The Doctor, May, issue 21

The magazine for BMA members

thedoctor

Issue 21 | May 2020

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Not in vain Fayez Ayache, 1943-2020 NHS doctor for 47 years Died after testing positive for COVID-19 ‘Loved by all who knew him’ Honouring and learning from fallen colleagues

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thedoctor

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

Email thedoctor@bma.org.uk

Editor Neil Hallows (020) 7383 6321

Call a BMA adviser

Chief sub-editor Chris Patterson (020) 7383 6978

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

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 Sarah Brown

The Doctor is a supplement of BMJ vol: 369 no: 8245 ISSN 2631-6412

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In this issue 4-5 At risk of ruin

Why the families of doctors who die during the COVID-19 pandemic need and deserve full death-in-service cover

Welcome Chaand Nagpaul, BMA council chair The coronavirus crisis has shone an exhausting and unending spotlight on our NHS. These testing times have reaffirmed what we have always known – that the health service is a remarkable institution, but that it has been left undernourished and allowed to fall into disrepair in too many areas. For years we have argued it needs more beds and more doctors – if only to match the resourcing of services of other major European nations – but politicians ignored those warnings, resulting in makeshift hospital wards hastily erected in conference centres and tower blocks.

For years we have called for the reversal of swingeing cuts to public-health funding, but politicians ignored our expertise, resulting in testing capacity vastly outstripped by demand and public health colleagues putting themselves at risk of burnout, working around the clock, to try to contain this disease.

While this crisis has exposed much of the flawed thinking of successive governments, it has also confirmed how proud we should be of our colleagues and our profession. It has been a great privilege to witness the remarkable determination, adaptability and professionalism showcased by doctors in taking on new roles, transforming services and protecting society from this disease.

In this issue of The Doctor we continue to investigate and explore some of the biggest issues facing doctors during this crisis – and advocate on behalf of our members as they go above and beyond to protect the public.

The issue includes features looking at continuing concerns around personal protective equipment, our demands for fairer death-in-service payments and a look inside the country’s new Nightingale hospitals – with testimony from the doctors who built services from scratch to provide care on this new front line.

We also speak to the daughter of Suffolk GP Fayez Ayache, who tragically passed away after contracting COVID-19. The feature also looks at one of the biggest issues arising from this crisis – the disproportionate adverse effect on the BAME workforce.

Among doctors this has been especially pronounced, as the piece highlights, with a recent review suggesting 94 per cent of deaths were of doctors from BAME backgrounds. I am deeply committed to addressing this.

6-9

In harm’s way

Many doctors are still being put at risk by inadequate PPE supplies, and fear repercussions if they speak out

10-13

‘A wholesale transformation’ Will some of the dramatic changes to GP practice endure for the long term?

14-17

Inside the Nightingales

The new NHS hospitals may never reach capacity, but the doctors involved say they have learned invaluable lessons

18-19

The ultimate price

The tragic deaths of doctors underscore the need to learn lessons and fight for better protection

20-21

Broken and exhausted

Doctors feel burnt out, anxious and unsafe, finds a BMA survey on work during the coronavirus outbreak

22-23

Public health revival?

After years of funding cuts can public health now recover its influence?

24-25

Too little, too late?

Testing might have increased, but doctors have strong concerns about delays, efficacy, and the safety of patient data

26-30

For want of support

An ‘exceptional’ doctor dies while under investigation

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The families of doctors who die during the COVID-19 pandemic need full death-in-service cover, rather than the basic level of compensation which has been announced. Keith Cooper reports

At risk of ruin T

SHARMA: Payment comes ‘nowhere near’

he health and social care secretary has pledged to pay all bereaved families of NHS and social care staff a £60,000 lump sum should they die from coronavirus, as more than 100 have so far.

Announcing the life assurance scheme, Matt Hancock said ‘financial worries should be the last thing on the minds of their families’.

But what does this mean for doctors? How far will it go to ease financial hardship in their families after such tragedy?

BMA pensions committee chair Vishal Sharma says the one-off payment might seem sizeable but comes ‘nowhere near’ what was needed for families who have lost lifetimes of income for the death of their loved ones on the front line.

‘Increasing numbers of families are dealing with the loss of a loved one as the death toll for frontline workers rises,’ he added. ‘They should not also face a future without financial security.’

Call for cover The BMA has long called for fairer DIS (deathin-service) payments for families of NHS staff.

Such calls intensified as the pandemic began claiming the lives of their colleagues. As payments are made through the NHS pension scheme they are subject to complex rules and qualifications. Unlike COVID-19, they do discriminate.

How much families receive depends on how long they’ve paid into pension schemes, whether they are still paying into it. For locums, it can even depend on whether they die on a day they’re at work.

During the pandemic, where so many doctors are putting their lives at greater risk, the BMA has called for an automatic extension of full DIS cover for all NHS workers.

Under the pension rules, families or dependants of doctors who have paid into their pension pots for fewer than two years will receive a lump sum payment. But they do

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not qualify for the regular monthly payments in the NHS pension scheme, the Government of a survivor’s pension. could do so much more and ensure eligibility This restriction automatically excludes for the existing DIS payments. tens of thousands of new doctors at work ‘If I were to die on a day that I had not been in the UK, the majority of contracted to work I would whom have come to work not get the same benefits ‘Increasing numbers here from abroad. GMC figures as someone in a salaried, show that 33,729 doctors have of families are dealing partner or officer role,’ joined the medical register in Dr Coley adds. ‘My benefits, with the loss of a the two years until the end of it seems, change on a dayloved one’ March 2020. Fifty-seven per to-day basis depending cent of new registrants in this on if I was booked or not. period are from abroad.

If Government wanted to provide the same cover to locum GPs it Families lose out could have done this by now. It has been BMA medical students committee co-chair asked often enough.’

Gurdas Singh points to the thousands of final-year medical students fast-tracked into Pensions penalties The BMA’s Dr Sharma said he is also foundation-year doctor roles whose families very concerned about the way the pension will not qualify for survivors’ pensions. rules disadvantage doctors who had left ‘There are quite a few medical students the pension scheme. Many had done so who have children. Those in more junior years very recently to avoid paying huge tax bills are more likely to receive lower amounts of because of the Government’s punitive benefit. Is this payment going to go very far? pension tax.

A lot of medical students take care of their Derbyshire GP Peter Holden is one of parents,’ he adds. ‘A few of my friends have another large group of ‘remainer’ doctors lost theirs. If they die, then the family loses forced to temporarily leave the NHS pension household income.’ scheme because their pensionable earnings Linking survivors’ amounts from had reached the lifetime limit. pensions to years of service or age ‘I left the NHS for a month could appear to be a form and then I came back to of age discrimination, ‘I have children work,’ he says. ‘People may Mr Singh says. ‘It shouldn’t who are still to finish say, well you’re quite well really matter how long we off and that’s true, when have been in this. It is a smack secondary school. am working. But I have in the face. It is grossly unfair.’

If I died, my household Ichildren who are still to finish Many of the fast-tracked income would secondary school. If I died, medical graduates are absolutely crash’ my household income would also working on lower-paid absolutely crash.’ agenda-for-change contracts Having left and rejoined to help battle COVID-19. Their the pension scheme in 2015, Dr Holden says families will also not qualify for survivors’ he no longer knows whether DIS payments pensions. for his family would be calculated on four Another group of doctors discriminated or 41 years of service. against by the rules are locum GPs. Their DIS Dr Sharma says the BMA would be payments are much reduced if they die on days they are not working. The BMA has called ‘examining closely’ the detail of the Government’s life-assurance scheme. for this rule to be changed, including taking ‘Losing a loved one during these horrific legal action in a case which it lost. times will be difficult enough for families, Stockport locum GP Mark Coley said he without the added pressure of losing what welcomed the announcement of the £60,000 may be their main source of income, leaving lump sum. ‘However, it seems odd to add in a them unsure of what the future holds.’ new level of assurance when for many of us

HOLDEN: Death-in-service calculations remain unclear

SINGH: ‘Is this payment going to go very far?’

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In harm’s way

The poor supply of personal protective equipment continues to place doctors at risk of death in the frontline fight against COVID-19 – and many feel pressured to stay silent for fear of repercussions.

Keith Cooper reports

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ISTOCK

‘I

have no confidence in the preparations the without adequate protection.

NHS is making. Mortality among medical There has been a big national push on PPE. staff looking after COVID-19 patients is It’s now headed by the Conservative peer who high. What support do we have? A quick fit test ran the 2012 Olympics, Paul Deighton, a former and off you go. I don’t recall signing up to a game investment banker. The Army’s been drafted in of Russian roulette.’ and a private delivery firm, Clipper Logistics, has This was the warning, blunt but clear, posted been contracted. in mid-March, to a BMA online portal – a week Yet there’s some way to go before the supply before the UK locked down to stem the spread becomes reliable, as our survey indicates. of the deadly virus.

The BMA has called for ministers to take ‘I have been asking for PPE [personal whatever action is necessary to scale up protective equipment] for the last six weeks,’ production in the UK. It has urged health said a GP, again, weeks before lockdown. ‘I’m very secretary Matt Hancock to explore overseas worried about getting COVID-19 and passing it suppliers and tap into EU joint-purchasing on to my son who has asthma,’ said another. arrangements.

‘The lack of clarity about PPE is alarming.’

It is still unclear if it will. In March, Cabinet Yet more than a month after lockdown began, Office minister Penny Mordaunt told Parliament despite these and repeated, the Government had ‘chosen similarly clear calls for other routes’. In response ‘I have been asking for to contested reports that it proper protection, reports of shortages continue to flood in. missed chances to tap them, personal protective The BMA snapshot survey the Department of Health and equipment for the at the end of April found a third Social Care told The Times it last six weeks’ of doctors working in high‘will consider participating’ in risk areas had experienced EU procurement. shortages or no supply at all With huge public support for of surgical scrubs and long-sleeved disposable NHS staff, their struggle and stress in accessing gowns.

PPE is a major political issue and headline news, One in five reported shortages of the FFP3 fuelled by a rising pyre of evidence. (filtering facepiece 3) masks worn in areas Poor fit where AGP (aerosol-generating procedures) As this wealth of evidence grows, under pressure are carried out. from this historic pandemic, some hidden gaps Another alarming finding was that one in in protective gear for the diverse NHS workforce three respondents had often or sometimes felt are revealed. pressured to see patients in AGP areas without Female doctors are struggling to find masks adequate protection. that fit, leaving some with sores and ulcers when ‘The PPE situation is an outrage for all staff. forced to work long shifts with those that don’t, Lives lost for want of visors, masks, and eye says BMA consultants committee deputy chair protection,’ one respondent said. ‘Senior Helen Fidler. management team have tried to shut me up ‘PPE is too often neither personal nor when I raised serious concerns,’ said another. protective for women. It doesn’t work as it should, Others told of their stress. ‘What is going to because the wearer is the “wrong” gender,’ happen to my kids if I die? Who will take care (see box, ‘Don’t say sorry for being female’). of them? I’ve no family here.’

Hundreds of female doctors have failed their Pressure to work ‘fit test’ for protective masks, they told the BMA’s These findings from the third regular BMA survey. While the proportion (8.5 per cent) who tracker survey point to some improvement failed the test is only marginally higher than in access to PPE following the Government’s their male colleagues (7 per cent), other recent well-publicised effort to tackle the supply-chain surveys point to a bigger divide. One by union fiasco. The first survey, in early April, found more Prospect, last month, found 16.7 per cent of than half of all respondents had experienced female respondents had problems with poorly shortages of FFP3 masks or felt pressured – fitting respiratory equipment compared with 7.6 per cent of men. often or sometimes – to work in risky AGP areas thedoctor | May 2020 07

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FIGURES: BMA COVID-19 TRACKER SURVEY

28%

reported worsening mental health during the pandemic

65

%

57%

of GPs have sourced their own PPE

of doctors felt partly or not at all protected from coronavirus at work

IZAGAREN: Struggle to obtain transparent masks

KOCHHAR: We don’t like to let the system down

protection often or sometimes. This compares NHS staff who fail ‘fit tests’ are often with 21 per cent who identified as white. BAME offered no alternative, according to many doctors were also more likely than white postings to the online portal. colleagues to cite ‘fear’ as a reason for not ‘Failed fit testing for the two types of reporting or speaking out about shortages. mask we had. Told we don’t have any more BMA staff, associate specialist and specialty respirator masks despite asking daily for a doctors committee chair week,’ one doctor said. ‘FFP3 Amit Kochhar says doctors won’t be suitable for me ‘Told we don’t have must be encouraged to as I wear a headscarf,’ said challenge managers who stop another. any more respirator them wearing PPE. ‘No alternatives have masks despite asking ‘We suffer too much from been given to me. We are daily for a week’ “presenteeism”. We don’t expected to work on COVID like to let the system down in wards during on-calls with any way. But we must ensure insufficient PPE.’ Fatin Izagaren, a paediatrics specialty trainee that we look after our own health too.’

Following a strongly worded letter from 5 at Frimley Park Hospital, Surrey, who is deaf BMA council chair Chaand Nagpaul, NHS and lip reads, has also struggled, so far in vain, England has told hospital employers to to get transparent masks. ‘Friends in other ‘risk assess staff at potentially greater risk hospitals are considering going off sick, and make appropriate they feel so stressed, and arrangements accordingly’ isolated,’ she says.

‘We are expected because of evidence BAME people are being Fear of repercussions to work on COVID disproportionately affected.

The BMA’s third tracker wards with As the politicians and the survey underlined a worrying insufficient PPE’ nation applaud NHS workers finding also seen in the each week, many are previous two: that doctors struggling to get the PPE with BAME (black, Asian, they need to help fight this deadly virus. and minority ethnic) backgrounds are Weeks and weeks into lockdown and disproportionately affected by shortages. months since the first clear warnings, many More than double the proportion of BAME are arriving at work in the sure knowledge doctors (44 per cent) have felt pressured to they still aren’t protected. see patients in AGP areas without adequate

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Don’t say sorry for being female Consider this paradox.

Most healthcare workers are, like me, female.

Yet the gear that we get to shield ourselves against a new, deadly virus has been designed for men.

And like me, you may have heard that your female colleagues have failed ‘fit tests’ for masks meant to seal on to their face for risky clinical settings. You’ll know they are sometimes left with no alternative protection, just the knowledge theirs doesn’t work.

Or like me, you’ve seen the sore or even ulcerated faces of doctors and nurses you work with every day as they pull fasteners too tight on ill-fitting PPE (personal protective equipment) masks for punishing 12-hour shifts.

You’ve heard from friends put in the invidious position of being called to help patients in extremis with COVID-19, with only a mask they’ve been told doesn’t fit to protect them.

One female friend even apologised for having a ‘small, funny face’. Some of us still do not recognise discrimination, which is what this obviously is. PPE is too often neither personal nor protective for women. It doesn’t work as it should, because the wearer is the ‘wrong’ gender.

This seems another example of what the author and journalist Caroline Criado-Perez describes in her book, Invisible Women – that a world designed on the male template is one that discriminates.

We shouldn’t apologise. We should be angry and demand immediate action.

We’ve known for three years, from a TUC survey in 2017 that PPE is often a poor fit for women.

From the BMA’s own surveys of thousands of doctors, we know that access to adequate PPE is already a problem for more than half of all doctors and now we are hearing that even when available it isn’t designed to fit the majority of the workforce. The Government was warned six years ago of the need for more research on PPE fit to protect staff against viruses.

There really seems no excuse for the situation we’re in. The Government must get a grip on the size of the situation its female workforce is in.

Helen Fidler is the deputy chair of the BMA consultants committee

Discrimination, it’s transparent As a paediatric registrar who is deaf, I rely on lip-reading to communicate with my team and patients. Lip-reading helps make sense of words that sound similar. With a lifetime’s battle to get to where I am now, it’s just been a thing to overcome, but not usually a huge problem.

Before COVID-19, people could pull masks down to talk. But we can’t do that since masks became part of our new national uniform.

As a registrar, I want to lead my team and support my junior doctors. Adding masks makes this difficult. It’s like being a given sheet music with occasional notes forgotten; reliance on lip-reading becomes obvious. The solution is a mask with a transparent window but there are no transparent masks manufactured in the UK. The procurement team at my trust and Surrey Heartlands clinical commissioning group have been searching for masks in the UK and abroad. The much-publicised transparent masks designed by a US student are not of the fluid-resistant standard required. I’m working with a small design company to develop mask prototypes but it’s a nowhere near a viable product yet.

We’re all in this for the long-haul. We need manufacturers to step forward to mass-produce transparent masks. These are not just needed for deaf healthcare professionals, but also for patients with hearing loss. Domain 3 of the GMC’s Good Medical Practice guidance highlights the importance of communication. We cannot ignore this issue and must all work together to push for a long-term solution.

Fatin Izagaren is a paediatric specialty trainee 5 at Frimley Park Hospital in Surrey thedoctor | May 2020 09

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The way consultations are conducted has been adapted to cope with COVID-19 but will some of the innovations change the way GPs interact with patients in the long term?

Tim Tonkin finds out

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EMMA BROWN

‘A wholesale transformation’

10/05/2020 12:22

SARAH TURTON

V

isits to surgeries for one-to-one consultations with GPs have long been the traditional starting points for people with health concerns.

As with so many other aspects of everyday life that were once taken for granted, COVID-19 has transformed the way general practice operates and provides care to patients in the communities it serves.

While the pandemic ‘The pandemic has has undoubtedly created seen a wholesale challenges for GPs, it has also presented opportunities for transformation change and improvements of how we work’ in the way care is delivered through innovations such as telemedicine and collaborative working.

‘It’s hard to know where to start,’ explains Sam Wessely, a partner at Amersham Vale practice in New Cross, London.

‘It [the pandemic] has seen a wholesale transformation of how we work.’

Like thousands of practices across the country, Amersham Vale has had to change its model for providing care to deal with the health needs of WESSELY: The two main ways of contact are through phone or online

COVID-19 and non-COVID-19 patients while protecting staff and patients from the risk of infection.

A component of this has been the use of telemedicine.

Prior to the pandemic, Dr Wessely says a typical session for a GP at his practice would see doctors having 13 to 14 face-to-face consultations with patients, along with three to four pre-arranged follow-up phone calls.

Patients with urgent problems would be added to a list to be followed up on by phone by a duty doctor, although Dr Wessely says that system would often be overwhelmed by patient demand.

‘We’re now completely triage first,’ he says.

‘We now discourage patients from physically entering the practice asking for an appointment, now the two main ways to contact the practice are by phone or through filling in an online consultation form.

‘We can get back to patients by phone, text message,

email or through a video consultation and can often deal with their problems that way.’

Planned rollout Dr Wessely says SMS-based services such as AccuRx, which enables practices to contact patients via text, have proved to be invaluable during the COVID-19 crisis and are something his practice will be continuing post-pandemic.

‘AccuRx has been absolutely fantastic,’ he says.

‘They’ve done incredibly useful things in developing their messaging app. You can now do things like arrange a video consultation with a patient and also allow patients to get back to you.

‘These sound like really small things, but they never existed before and they’ve completely transformed things.

‘Previously we would have to make a note to call back a patient and check they were OK. ‘It takes time to do that, the patient might not answer thedoctor | May 2020 11

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EMMA BROWN

HEATH: ‘COVID has actually fitted easily into our existing model’

‘We’re now talking more as a team and working more collaboratively’

or they might end up talking about two or three other problems – it’s messy. Now you get the information you need back from the patient in an automated way within seconds and added to the patient record.’

Another change embraced by the practice in response to the pandemic is the decision to dispense with GP sessions, something that Dr Wessely says has led to a more collaborative approach to providing care.

‘Doctors for decades have worked on a sessional basis,’ he says.

‘Whenever we’ve done workforce planning “the session” has always been the unit of work, but because patients are no longer waiting in the waiting room to be seen there and then, it makes a nonsense of the idea of sessions – you simply have a list of patients that have to be contacted.

‘We’ve now got one giant list of patients that we all do together, and when we get to the bottom of the list the

acute work is done.

‘That’s been quite revolutionary for us, it’s resulted in a huge amount of teamwork and seen us move from quite an isolated approach of individual sessions to a situation where we’re now talking more as a team and working more collaboratively.’

Combined resources The value of collaborative working in the face of the unprecedented challenge of COVID-19 is something East Sussex GP Jason Heath knows all too well.

A partner formerly at St Andrews surgery and now at the Foundry, a PCN (primary care network) made up of three practices in Lewes, Dr Heath says that combining the resources of three local practices has bolstered the response to the virus.

‘I have no doubt that the work we’ve done to become a PCN has massively helped us during the COVID crisis,’ he says.

‘COVID has required really rapid decision making on

where services are going to be placed, whether COVID or ongoing, like where we’ll deliver services such as necessary routine blood tests, diabetic reviews, childhood vaccinations etc.

All that is going to need to be streamlined. Instead of having to work out for three or four sites how you’re going to do that you just do it all in one place.

‘Had we had to organise all that as three or four individual practices you’d have to make the same decisions three or four times over.’

Prior to the pandemic the Foundry had introduced a system which filters patients into one of three workstreams based on their needs.

These include patients with overall good health who present with an acute need, patients with known conditions requiring continuing care and those patients with multiple conditions and complex care needs.

Early on in the pandemic, the Foundry was able to set up a hot site exclusively for treating patients with the virus and two cold sites that cater for non-COVID-19 patients with continuing care needs including cancer and mental health.

‘We’d already designed our services to deliver acute care from a centralised phone hub with consulting rooms we can bring patients to,’ he says.

‘COVID has actually fitted very easily into our existing model of working and organised phone triage system bringing [COVID-19] patients to one place.’

Despite their wellorganised set up, Dr Heath

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‘I can’t initiate a relationship with a new patient using telemedicine’

SARAH TURTON

‘COVID-19 has actually fitted very easily into our existing model of working’

admits that many patients with ongoing health issues are isolating themselves and avoiding face-to-face contact with medical services. He says it is in these cases that telemedicine services such as AccuRx for video calling are proving vital.

‘Paradoxically we’ve seen a significant reduction in the day-to-day demand for breadand-butter primary care services,’ he says.

‘People have got the message that we’re reducing face-to-face contact. We’ve been able to rationalise a lot of the work we’ve been doing yet it’s really important we minimise the risk of missing important non-COVID pathology.

‘New staff appointments facilitated by PCN opportunities like community prescribers and in-house senior pharmacists and paramedics have proved their worth.

‘The next challenge as we move into the “postpeak” phase is how we safely reintroduce ongoing work while trying to keep patients and staff safe. The flexibility across sites and staff mix that a PCN brings is invaluable.

Good teamwork and mutual trust is the key.’

BMA GPs committee chair Richard Vautrey says COVID-19 has forced GPs to revolutionise how they work in ‘just a few short weeks’.

‘Practices have rapidly moved both to protect patients and staff, and support social distancing, by introducing total triage arrangements with the vast majority of consultations now taking place by telephone or video, with face-to-face

WESSELY ‘You can’t form a human relationship as effectively on the phone’

consultations either in the practice or at home only taking place when clinically necessary,’ he says.

Greater reliance on remote working and technology in delivering healthcare in the face of having to reduce personal interaction have been revolutionary for GPs, but Dr Wessely warns there are also drawbacks that have to be considered.

‘You can’t form a human relationship as effectively on the telephone as you can face to face,’ he says.

‘I feel like I am continuing decent care for patients I know well already, but I can’t easily initiate a relationship with a new patient using telemedicine.

‘At the moment a patient contacts us with a problem.

We deal with that problem in a way that minimises harm and causes the least risk of infection to the patient or the practice staff, but that’s not necessarily the best way to practise medicine.

‘We don’t, for example, have the opportunity to pick up on cues and when you’re not face to face with someone, you might not notice certain aspects of their appearance or behaviour that

you might have noticed face to face.’

While a remote consultation will suit some patients, Dr Wessely says that telemedicine is often less suitable for the very elderly or vulnerable patients and those with multiple health issues.

He says that there would need to be at least a partial resumption of physical face-to-face consultations post-pandemic but stresses that he is confident that the majority of changes to general practice brought about by COVID-19 would remain in place.

‘If, before the crisis, a partner had gone to the team with proposals to change the way we practise to the way we are practising now, ie triaging patients first and having a greater reliance on technology, there is absolutely no way that it would have been taken on without a huge amount of resistance and a huge number of questions,’ he says.

‘Whatever we’re doing now is going to carry on to a large degree and it seems likely that similar changes are going to be replicated [by GPs] across the country.’ thedoctor | May 2020 13

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Inside the Nightingales The Nightingale hospital in London may be in ‘hibernation’, and the others unlikely to have reached capacity, but doctors involved say the experience of creating a hospital from scratch has given them invaluable lessons.

Peter Blackburn reports

O

GRIER: Patients treated as individuals not numbers

ne ambition was clear for Gareth Grier when he became involved with the Nightingale hospital at the ExCel centre in London: ‘This is not a factory for patients to sit on a ventilator.’

As with everyone else, Dr Grier, a consultant in emergency medicine and pre-hospital care at Barts Health NHS Trust, was aware of the headlines and the dominant narrative; up to 4,000 beds under the high roof of an echoing conference centre – a vast space to house the sick for whom London’s hospitals were too swamped to care.

At the time of writing, the Nightingale in London was heading for ‘hibernation’, its vast capacity thankfully not having been required.

However, for Dr Grier, building a new hospital from scratch – and one that

could end up dealing with huge numbers of patients in need of the most serious care – was an opportunity to ensure care and compassion were placed at the very heart of the COVID-19 crisis.

While headlines about NHS demand and daily deaths might be the order of the day, the patients and families touched by this deadly virus would not be left to feel totally alone and helpless, and the staff looking after them would know they were doing everything they could in medical and pastoral care.

What Dr Grier and his team have already achieved is, perhaps, as remarkable as the efforts of those who physically built this hospital from the ground up.

‘If I’m honest, I didn’t really have a definition of compassionate care when we started this,’ Dr Grier says.

‘But one of the palliative care consultants described it as the care of the patient as an individual not a number and when we talk about the ExCel having anywhere up to 4,000 patients that becomes even more important.’

Specialist team Dr Grier brought together a team of staff – some doctors left without much of their existing work, nurses involved in trauma and injury and volunteers used to dealing with the aftermath of major disasters – to provide the most comprehensive communication between doctors, patients and relatives possible. In April, 10 people were on shift during the day, and two at night, with scaled-up plans for shifts of 25 people should demand increase.

Families visiting patients are facilitated wherever

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PA

RAPID RESPONSE: Nightingale London was erected in record time

BANERJEE: Building patient records without interference

possible, particularly when patients are approaching the end of life, rather than ruled out as many areas have felt forced to do.

Dr Grier, who was watching a triathlon the last time he was at the ExCel centre, adds: ‘The Nightingale was a clean slate for us. We know in many places family are not getting calls and we said let’s work to a gold standard we would like to achieve. If demand grows significantly it will be difficult, but we have plans in place to continue this for the first few hundred patients.

‘It is really rewarding.

Many families are passing on their thanks and it’s become quite satisfying.’

Bypassing bureaucracy Ami Banerjee, associate professor in clinical data science at University College London and academic

cardiologist, had already had a significant role in the coronavirus crisis – delivering statistics and analyses which suggested the requirement for strict action to the chief medical officer, contributing to the Government’s decision to enforce lockdown measures in March. He was then seconded to help the clinical informatics team at the Nightingale hospital, as well as working there as a doctor.

And Dr Banerjee says the chance to build a good electronic patient record from scratch – without much of the interferences of usual NHS barriers and bureaucracy, a commonly enjoyed theme among doctors working in Nightingale hospitals around the country – is of ‘enormous’ interest and importance.

‘Our remit is to try to

make the electronic health record as easy to use as possible so that the data we have is high quality and usable for all of the extensive audit and quality improvement monitoring we need to do. [If the crisis gets worse] this hospital could be the biggest intensive care facility in Europe if not further afield. We need to get this right.

‘This is a disease we know very little about. We are trying to gather information and knowledge that will be useful here and then elsewhere in the country.’

Dr Banerjee adds: ‘It’s scary and exhilarating at the same time in equal measure – you wonder how the hell have we got here, that we are doubling and trebling intensive care capacity in a first-world country? And why didn’t we take heed of warnings? thedoctor | May 2020 15

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EAMES: An exhausting but inspirational experience

‘It seemed very daunting at the outset but it just felt like the right thing to do’

‘We are trying to gather information and knowledge that will be useful here and then elsewhere in the country’

‘But the other side is genuinely moving – that on the clinical side, the informatics side and the research side there is a level of speed, collaboration and working together that is incredible. I have not come across anything like that in 18 years as a doctor.’

The London Nightingale has been treating patients in a 42-bed ward which is divided into bays of six. It is staffed by healthcare professionals with a wide range of expertise – some of whom have intensivecare experience and others who don’t, such as GPs, obstetricians and research doctors. Intensive care and anaesthetic consultants are the senior decision makers.

new hospitals be needed for greater patient numbers could be a major issue.

Dr Banerjee says: ‘It is very much on people’s minds here… We are really stretched as a system and now with other Nightingale hospitals this is going to be an issue everywhere. We have had chronic shortages and we have not valued doctors and nurses as health professionals in the way that we should.’

There are also Nightingale hospitals in Birmingham, Manchester, Harrogate, Bristol, Sunderland, Exeter, Glasgow, Cardiff and Belfast, with capacity for thousands of beds should the COVID-19 crisis escalate or peak again.

Staffing levels

Paul Glover is the lead intensive care consultant at the Belfast hospital, which was set up in a tower block on the site of the Belfast City Hospital. The facility has 11 floors – with nine suitable for possible patient care and a maximum capacity of around 230 ventilated patients. At time of writing there had been up to 26 patients needing care at any one time.

‘It became clear that critical-care capacity across the region wasn’t going to be sufficient for the model numbers,’ Dr Glover says.

Dr Glover and colleagues drafted in staff from medical and surgical specialties which had decreased workload and immediately arranged basic critical care training. They split doctors into ‘pods’, each led by an ICU consultant and each with an anaesthetic consultant and trainee and a

Other staff at the hospital, who did not wish to be named, tell The Doctor that the process of setting up the hospital has been remarkable – and those involved are all overwhelmingly positive and supportive, but have concerns about staffing levels and the unwillingness of some London trusts to release staff who had volunteered.

Those concerns would become more severe, they said, should the Nightingale be needed to treat many more patients – and could potentially lead to unsafe conditions.

Staffing, in particular, appears to be a significant issue. The NHS is significantly understaffed in normal times and finding the numbers that would be required should these

Overspill

consultant and trainee from another specialty, with staff working 12-hour residential shifts with blocks of time on and blocks of time off.

‘It has been challenging,’ Dr Glover says. ‘These are different ways of working and the other specialties have had to learn a lot very quickly.’

Diary of a doctor Niall Eames is clinical director and consultant spinal surgeon at the Belfast Health and Social Care Trust and volunteered to take up a role in the Nightingale hospital – taking on his first 12-hour shift in years.

Mr Eames wrote a diary detailing his first seven days in the voluntary role: he worries about his mask not fitting tightly enough, his ankles and feet feeling vulnerable uncovered by scrubs and feeling dirty despite washing his hands seven times in 15 minutes.

He goes on to describe the high fives celebrating a stable patient, sleeping in his isolation room away from family, and the endless donning and doffing of PPE. ‘It seemed very daunting at the outset but it just felt like the right thing to do with the whole country in the middle of the pandemic,’ Mr Eames says.

For Mr Eames there have been lessons, as there will have been for so many staff in testing times: long shifts wearing PPE are exhausting and learning new expertise in unfamiliar areas is always challenging – but the opportunity to do so and see the work of other colleagues has been ‘inspirational’.

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PA

EXCELLING AT CARE: Staff who have been involved speak of their sense of pride

‘These are different ways of working’

‘I am surrounded by the most inspirational colleagues’

Can-do attitude Across these hastily erected Nightingale hospitals structures and systems have been very different to normal working life – with flat hierarchies and ‘can-do attitudes’ and a significant decrease in blockages and bureaucracy.

Several consultants told The Doctor that a simple computer tweak might result in a negative response that took six months to arrive, but anything required now is being carried out more or less instantly.

Those lessons learned have been almost unanimous in the conversations The Doctor has had with staff: this crisis has shown staff are willing to go to great lengths when the system unites in a common cause, that great things can be done without competition and strangling hierarchies and that clinicians, working

together, can provide genuine care and compassion amid crushing crisis.

Mr Eames adds: ‘We are being forced to work in the best, fastest way possible for the patient ultimately. We need to translate that into normal practice.’

BMA council chair Chaand Nagpaul says: ‘The NHS has shown its remarkable qualities at every stage of this crisis – staff have worked under relentless pressure to protect the public while also taking on different, unfamiliar, roles and transforming services.

‘Never again should this country be in a position where NHS capacity is so stretched that we must build intensive care units in tower blocks and conference centres, where cancer treatments are paused or where patients suffer serious illness at home rather than attending hospital.’

While the Nightingale hospitals have not yet been called upon to provide care for the sort of numbers the scientific advisers predicted, the future remains uncertain.

Another peak, a surge in cases, a period of calm – who knows? One thing that is not uncertain is the overwhelming sense of pride staff feel to be involved – seeing the work of their colleagues and the efforts of managers, clinicians and staff of all areas in uniting against the coronavirus threat.

Dr Banerjee adds: ‘To see this place go from a basically empty conference warehouse to a site where we are taking patients is amazing. This is not where anybody wants to be. Nobody got out of bed and said this is what we want – but everyone here is happy to do it. I am surrounded by the most inspirational colleagues.’ thedoctor | May 2020 17

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The ultimate price Still working in his 70s, Fayez Ayache was loved by his patients in general practice and secondary care. His death, having tested positive for COVID-19, underscores the BMA’s efforts to protect doctors and other healthcare workers and ensure lessons are learned.

Tim Tonkin reports

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SARAH BROWN

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A

patient walked into the consulting room. He was to assist employers to identify those doctors at high a Syrian refugee with a young son. Only recently risk and to take appropriate mitigating measures.

Following this letter, NHS England wrote to arrived in the UK, he spoke little English. employers acknowledging the disproportionate The patient was worried about his son’s condition, effect on BAME communities and recommending worried about being able to find the treatment he that they risk assess staff – however, the letter makes required, worried about being understood. no mention of how this might be done, and the BMA But he had the great fortune of choosing Fayez continues to press for a proper riskAyache as his GP. Syrian-born himself, assessment framework to be set up.

Dr Ayache was able to reassure the ‘The NHS is a lifeline patient, in Arabic, that his son would receive the treatment he required.

Messages of condolence for so many that ‘It was beautiful the way that dad Dr Nagpaul has also raised the issue in dad felt it his duty described it to me, his emotions so a BMJ article, in media interviews, and to serve within’ overwhelmingly apparent in recalling in a roundtable meeting set up by the the moment they had shared,’ says Labour leader Sir Keir Starmer.

Dr Ayache’s daughter Layla.

Everything on the political and ‘This is why the NHS was important to dad; because personal level needs to be done to honour the memory it brought people together, it gave a freedom that of those such as Dr Ayache, who came to the UK in some had never experienced before, and it gave hope 1973, working in general practice in rural Suffolk and as and light to those who were wandering a darkened an ENT specialist at Ipswich Hospital. Despite retiring path. The NHS is a lifeline for so many that dad felt it three years ago, and in his 70s, he returned to both jobs his duty to serve within.’ part-time.

He was still working at the age of 76. On 8 April, Ms Ayache says the outpouring of support from her six days after being admitted to the same hospital in father’s former patients and colleagues has been a Ipswich for which he had given a lifetime’s service, great source of support. he died, having tested positive for ‘He was a man who led by example.

COVID-19.

He was not just my father; he was a ‘He was a man who The more you hear about role model.

Dr Ayache, the more it underscores ‘As a family we have been led by example. He was overwhelmed by the messages of the efforts of the BMA to protect not just my father; he condolence and the memories that doctors and other healthcare workers, was a role model’ everyone has shared with us. and to ensure lessons are learned ‘It has been truly wonderful and a from their deaths. privilege to read how much dad was Discriminatory impact loved by all who knew him. They have brought us great One of the many disturbing elements of the more than comfort and they have helped us to realise that we are 100 healthcare workers who have died with COVID-19 not alone in our grief for him. is the evidence of the disproportionate adverse ‘The community he gave himself to were incredibly effect on the BAME (black, Asian and minority ethnic) important to him. They became his family too and he workforce. Among doctors, this has been especially cared for them as such. His colleagues became his pronounced, with a recent analysis putting the figure friends and he valued each of them with respect and at 94 per cent of those who have died. trust. He would visit people he knew were struggling, BMA council chair Chaand Nagpaul was he would be there when they needed him most and he instrumental in securing a Government review into the always went above and beyond to help others in need.’ high proportion of BAME healthcare workers who had Paying tribute to Dr Ayache, Dr Nagpaul says: died, and BAME members of the population who were ‘When Fayez Ayache left his home to come to this admitted to critical care. country almost 50 years ago, he came with a passion He said in a recent message to members: ‘It is vital and determination to make a positive contribution that this review is implemented rapidly so that we and difference to our health service and to the lives can understand why this is occurring and put in place of thousands of patients. mitigations to address this discriminatory impact of ‘A tragically heavy price has been paid by the medical the virus.’ profession and in particular among doctors from BAME Dr Nagpaul has also written to NHS chief executive backgrounds who have disproportionately lost their Sir Simon Stevens to call for a risk profile assessment lives in this struggle.’ thedoctor | May 2020 19

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The BMA has conducted the largest survey of frontline doctors during the COVID-19 crisis thus far – with more than 16,000 respondents.

Peter Blackburn reports what the findings tell us about the effect of the crisis on workload, staff wellbeing and patient care

Broken and exhausted ‘I 66%

of doctors are seeing an increase in workload

feel terrified that I will lose colleagues, friends or family. I am worried that I could become unwell myself and potentially infect my other patients… I worry about the impact of this trauma on the mental health of our profession.’

Those few words, from one doctor working on the front line of the COVID-19 crisis, illustrate the stress and strain of daily working life in this frightening new world.

Doctors sharing their experience with the BMA’s COVID-19 portal speak of ‘toxic cultures’ in their workplaces, ‘overwhelming anxiety’ and feeling ‘unsafe and undervalued’.

And these are far from isolated anecdotes.

A BMA survey, responded to by more than 16,000 doctors in just over 48 hours, has revealed a catalogue of concerns – with unmanageable demand threatening the wellbeing of staff and the future of services.

The survey shows that 66 per cent of doctors are seeing an increase in workload during the crisis – with staff redeployed to new roles, covering for sick colleagues or directly

dealing with the surge of COVID-19 patients.

‘This is unsustainable,’ BMA representative body chair Helena McKeown says. ‘Colleagues are feeling broken and are visibly exhausted.

Many have had little sleep in recent weeks, have had annual leave cancelled and rotas of 13-hour shifts imposed.

‘There has been very little rest – people just work and then try to go to sleep, and this has been their existence for weeks.’

Dr McKeown adds: ‘This is all going to be crucial planning as part of the Government’s exit strategies – we are going to have to work on sharing out rest and enabling people to take a proper break. We know people were already working under pressure and now they are even more emotionally and physically exhausted. And we need to be talking about a week or two off – three days is just not a proper break.’

Unhealthy environment The survey also found that redeployment of staff – which for many was not voluntary – is causing issues: 35 per cent of those redeployed say they were not given

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inductions, 32 per cent have not received training, 17 per cent feel they are working outside their area of competence and 74 per cent don’t know how long their new arrangements will last. Some doctors say they felt ‘bullied’ into changing job plans and working arrangements.

This could hardly be a less healthy working environment. It is perhaps as unsurprising as it is frightening that nearly a third of doctors (30 per cent) are more stressed and burned out than before the pandemic.

One emergency care doctor said they felt ‘dispensable’ – and described ‘hating every moment of work’, feeling ‘unsafe and undervalued’. They described their working environment simply as ‘dangerous’.

Another said: ‘Feeling unsupported and unsafe at the front line.’

For Dr McKeown one of the most ‘exhausting’ and worrying parts of working life under the COVID-19 crisis has been dealing with death in such great quantity. ‘It is a great concern for the service – this has just been exhausting for people,’ she says. ‘There are a few very special doctors in the world who choose to do palliative care and things like that but many of us aren’t used to several patients dying in a working day, and that’s a huge thing for people. It has been very difficult.’ feel they do not have At a time like this support access to the help services could hardly be that they need more vital – but 22 per cent of doctors feel they do not have access to the help that they need.

Dr McKeown says it is crucial that doctors are not made to feel guilty for leaving holes in service provision if they need time away from work – and urges regulators and NHS leaders to step back from buzzwords like ‘resilience’ when talking about staff under extreme strain.

She says: ‘Doctors may need to be given proper time off from working – not just

22%

occupational health while they continue the job. They need to be given permission to have time away and have therapy or find head space to get back to work. Burnout is absolutely horrible – some people never get back to work and it is absolutely crucial we take this seriously.’

‘Many of us aren’t used to several patients dying in a working day’

Collateral damage Ultimately, this is not just a huge problem in the present – but is storing up trauma and tragedy for the future.

It is the future that many doctors are worrying about. When asked which areas were most concerning them, respondents said the upcoming demand from patients and future working arrangements.

One doctor said they worried about ‘collateral damage’ and the future impact on services of missed diagnoses of cancer or illnesses like sepsis not being treated. He said: ‘There is a real sense of patients sparing the NHS for non-COVID issues.’

While the UK may be slowly passing the first peak of this crisis, a great deal of damage has already been done and there are many serious decisions still required. This significant survey shows doctors’ wellbeing – and the realistic capabilities of the service and its staff – must be placed at the heart of any plans made.

MA members who need help in the B current crisis can call and speak to one of our advisers on 0300 123 1233 (Monday to Friday 8am-8pm, Saturday 9am-5pm) or email membership@bma.org.uk

‘There has been very little rest – people just work and then try to go to sleep’

MCKEOWN: ‘Doctors need permission to have time away’

he BMA also has counselling and peer T support for doctors and medical students available. If you need someone to talk to in confidence – call 0330 123 1245 Visit NHS Practitioner Health www.practitionerhealth.nhs.uk

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ISTOCK: POWEROFFLOWERS

Funding cuts and reorganisation in the last decade to public health has meant the specialty has lost influence. Yet with the outbreak of COVID-19 its importance has become central once more.

Keith Cooper reports

Public health revival?

P ublic health medicine has been thrust into the limelight by the COVID-19 crisis.

Its practitioners are on national news, their practice the topic in daily press briefings with chief medical officers and ministers in UK countries and abroad.

It’s a far cry from bad funding and cuts – a specialty too often passed over for stronger pulls on tight budgets.

So how are its practitioners coping as they battle the virus? Will this sudden, intense interest make any difference?

Their views on the capacity of their specialty to tackle the virus are mixed, especially in relation to England whose

TOFF: Public health consultants have lost influence

22

budget was hardest hit by austerity. Public health funding has shrunk by £850m in real terms compared with 2015/16, according to research by the Health Foundation and the King’s Fund last year.

‘If you look at the current crisis there is certainly clear evidence that the whole public health family is not able to play its full role in terms of solving the crisis because of cuts,’ says retired public health director Heather Grimbaldeston.

Hampered BMA public health medicine committee member and past chair Penelope Toff says many public health

consultants in England lost ‘considerable’ influence and capacity when transferred in 2013 from NHS primary care trusts to councils.

‘The extent of public health input into commissioning decisions varies greatly across England in this more politically driven context,’ she says.

PHE (Public Health England) appears to have similar difficulties, Dr Toff adds. ‘Its civil service status curbs its ability to offer independent advice, influence ministers, and hampers the sharing of information to the wider public health community.’

The committee has long called for public health to be appropriately funded and for

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‘Public health is not able to play its full role because of cuts’

PHE to be fully independent of Government.

Not all public health practitioners agree that their capacity is so compromised.

Faculty of Public Health president Maggie Rae says many public health directors played a major role in the ‘highly effective’ programme of tracing contacts of early cases during the containment phase of the pandemic. It lobbied successfully with other organisations for testing to be extended to the many care homes affected.

Prof Rae points to the £3.2bn of extra local government funding as a welcome ‘short-term’ measure. ‘However, we are not aware how much has been allocated to public health priorities,’ she adds.

She doubts public health directors in England would support a switch back to the NHS. ‘They have to influence and have to take people with them,’ she says. ‘Just going back to the NHS would not make them more powerful. Directors of public health have to be able to influence health, local government and the communities they serve.’

Information sharing ‘Post COVID-19 outbreak, the function of public health will be discussed across the UK’

Most public health professionals would, however, likely agree that many lessons will be learned from the huge effort to tackle COVID-19 which could have a significant effect in the long term.

One lesson should be about data and other kinds of information sharing. The struggle to access health data from the NHS is a daily frustration for public health

practitioners. It’s a constant reminder of the uneasy degree of separation some feel from NHS colleagues since transferring to local authorities.

For instance, NHS lists of ‘shielded patients’ during the COVID-19 response have not been routinely shared with local authorities despite their role in offering social care and welfare support.

‘This is the kind of on-the-ground stuff that local authorities do,’ says Rob Green, a public health registrar in north west England. ‘If they had got those lists, councils could rapidly contact people for welfare checks. Instead they have to find workarounds, which leads to delays.’

Despite some frustrations, the crisis has prompted some novel practice, such as an agreement to avoid moving patients with COVID-19 to care homes from hospitals.

Dr Green points to other more positive lessons being learned from tackling COVID-19, as public awareness about the cost of health inequalities is heightened.

‘Health inequalities had become so obvious, it felt like they were becoming a political issue. Now, with this virus, people can see it’s those whose health is marginalised in other ways that are suffering the most.’

Like many trainees, he has had to step up and gained unique experience. He helped quarantine the first group of arrivals from Wuhan, China, where the virus began.

Links between loneliness and health outcomes, which were explored in public health

before the outbreak, will have more resonance after weeks or months of imposed social isolation, Dr Green adds.

Renewed purpose Despite some differences in views on the past, all practitioners we spoke to hope this spotlight on their specialty will ignite a debate on its future.

Dr Grimbaldeston says the last reorganisation in 2013 felt like an afterthought.

‘Suddenly, people are talking about public health, so let’s put some ambition into this and be the best in the world. If not now, then when?’

Public health bodies have already been discussing the future of the public health workforce, Prof Rae says.

‘It is likely post COVID-19 outbreak that the function of public health and its resources will be discussed across the UK. This needs to include the Association of Directors of Public Health and other key bodies.’

The BMA is calling for expansion to boost capacity and agencies have been lobbying for more investment in public health.

‘No one in public health is looking for a big well done and pat on the back,’ Prof Rae adds.

‘The public should be given massive credit for taking on the Stay Home, Protect the NHS, and other prevention messages,’ she says.

‘But we are looking to have the resources and influence across the four nations of the UK to marshal all the efforts of society to improve public health and prevent disease.’ thedoctor | May 2020

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BMA

SMALL: Highlights risk of false negatives

Testing for COVID-19 might have increased, but doctors have strong concerns about delays, efficacy, and the safety of patient data.

Jennifer Trueland reports

Too little, too late?

I

t was a Saturday, mid-April, when Amy Small noticed she had symptoms: headache, fever, a bit of dizziness but no cough.

The following day, her husband also had a headache and a sore stomach.

‘On the Monday, we got tested by NHS Lothian because I’m a key worker,’ says Dr Small. ‘Our swabs came back negative.’

Dr Small, a GP in East Lothian, is young and fit and otherwise healthy, but 25 days on, she still has symptoms of COVID-19, including a temperature, breathlessness and crashing fatigue. She has been unable to return to work so far – yet, according to the test, she should have been back seeing patients weeks ago.

The risk of false negatives, potentially sending clinicians such as Dr Small back into the workplace while they are most likely swarming with coronavirus, is just one of the issues to emerge around testing.

This topic has been a vexed one almost since the virus emerged in the UK, with policies on whether to test, who to test, and in what circumstances and quantities constantly evolving.

Most recently, the UK Government either met or didn’t meet its target of 100,000 daily tests in England, Scotland and Wales by the end of April (depending on whose calculator you use) and all four UK countries have announced they are moving to some form of test, track and isolate system, albeit with varying names, remits and methods.

‘A mess’ BMA council deputy chair David Wrigley probably sums up the situation around testing for a lot of people. ‘It’s been a total mess, hasn’t it? There have been mixed

PA

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WRIGLEY: No ability to get patients tested for weeks

messages: it was on and then it was off, Data concerns and certainly for me as a GP, there’s been no Penelope Toff, BMA public health medicine testing at all in the community in England committee member and past chair, until this week. welcomes the prospect of more widespread ‘So, we’re six to eight weeks into this and community testing but cautions that it has there’s been no ability for me to get my to be in the context of a proper strategy of patients tested. It’s only been test, trace, quarantine and hospital-based, so we’ve support. ‘It’s not about the ‘We’ve had a neglect had a neglect of general absolute number of tests practice and the community but how they are used,’ of general practice yet again. I’ve had personal she says. ‘Testing is being and the community protective equipment on piloted on the Isle of Wight, again’ for every patient I’ve seen but it’s been outsourced, because we have to assume with a centralised system that everyone has got it.’ of data collection, which is The situation in Scotland, where Dr potentially very concerning from a medical Small is based, is different. The Scottish ethics perspective. There is definitely a need Government has announced its own test, for assurance about data protection.’ trace, isolate and support approach, which She believes local public health teams are will test people in the community who have best placed to run testing and tracing and symptoms consistent with COVID-19. First that this presents an opportunity to reinvest minister Nicola Sturgeon said last week that in and recognise the importance of local more information was needed on the NHSX public health after years of cuts. app and how it would interact with digital ‘Unfortunately, it appears that the tools in Scotland. direction the Government The consistency and is going is outsourcing.

‘There is availability of testing in In order to make testing England is something that effective and sustainable definitely a need for at local level, it should be also exercises Peter Holden, assurance about public health-led, bringing in who leads on the COVID-19 data protection’ emergency response for the additional resources where BMA. necessary because directors of public health know their ‘Testing is a problem and populations.’ it’s very patchy – we’re struggling to get them done easily, and every area is doing Meanwhile Dr Small is still recovering – it slightly differently,’ he says. ‘Also, there’s despite having a second test that been a real problem with capacity.’ also showed negative. She also queries whether self-testing will work – as she The countries of the UK might now have the capacity to move to testing and contact points out, doing it properly is unpleasant, testing, but plans are still causing concern. and many people will struggle to get a suitable sample.

‘One thing that really bothers me is that in England, we’ve got the private sector – Serco Dr Wrigley seconds her warning about – involved,’ says Dr Wrigley. relying on the efficacy of the test itself, ‘I’m not happy about that at all. We’ve and stresses that people should not return to work if they have a fever, and that they got very good policy at the BMA opposing outsourcing and privatisation and this has should follow the latest guidance. actually been done without any bids or ‘I suppose it’s positive that things are tendering; it’s just been hot-handed to them happening now, but it seems a bit late down on a plate.’ the line. We might have missed the boat on this because the virus almost seems to be He believes it’s too early to say if the new testing policy will be effective, and echoes endemic in the population. We don’t know the concerns of those who worry about the where it is or who’s had it. That’s why I think there’s a feeling that we’re going to have data privacy issues with the contact tracing app being tested on the Isle of Wight. some restrictions until we get a vaccine.’ thedoctor | May 2020 25

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Sridharan Suresh was a consultant with an ‘exceptional’, ‘unblemished’ professional record and a doting father of two who took his own life while under police investigation.

His death raises concerns about the support offered to doctors by employers and professional regulators – and ‘a no-smokewithout-fire culture’ in the NHS. Peter Blackburn reports

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CATASTROPHIC CONTACT: Unwelcome news from the GMC came as a massive shock to Dr Suresh

For want of support ‘T

here was a feeling that the worst was gone,’ Visalakshmi Suresh told an inquest into her husband’s death, recalling the days before he died.

‘Everything was quietening down. He was consistently reassured there were unlikely to be any further actions and that he would be able to return to work as soon as possible… but then all of a sudden something lands on him and he was alone.’

On 2 May 2018, Sridharan Suresh, consultant anaesthetist at North Tees and Hartlepool Hospitals NHS Foundation Trust, received an email from the GMC informing him that he would be subject to an interim orders tribunal.

Just hours later Dr Suresh sent an email to his wife while she was at work, saying he had done nothing wrong, but could not go on any longer, and took his own life.

It was a ‘bolt from the blue’, a friend of Dr Suresh told the court. And it had a ‘significant impact’ on him, according to HM senior coroner for Teesside Clare Bailey.

A three-day inquest into Dr Suresh’s death, at Middlesbrough coroner’s court, heard that the weeks leading up to Dr Suresh’s death were littered with assumptions, misunderstandings and failures in communication. Questions were also raised about the support available to doctors, and whether the ‘devastating’ effect of GMC referrals can be mitigated or subjected to some sort of risk assessment.

Dr Suresh was under police investigation at the time of his death, following allegations of sexual touching made by a teenage patient undergoing sedation for dental extraction. thedoctor | May 2020 27

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PA

MIDDLESBROUGH CORONER’S COURT

The father of two, who lived in Ingleby Barwick, Stockton-on-Tees, vehemently denied the allegations and was questioned at Middlesbrough police station as a voluntary attender.

Bolt from the blue The incident was alleged to have happened during a private operation at the Grace Dental service, which is located on the site of the North Tees trust.

North Tees and Hartlepool NHS Hospitals Trust decided not to refer Dr Suresh to the GMC – the trust’s medical director, Deepak Dwarakanath, told the inquest that the drugs (midazolam and fentanyl) used to sedate the patient are ‘well known’ to produce hallucinations, sometimes of a sexual nature, and that the description of the alleged assailant did not match Dr Suresh ‘at all’.

Dr Dwarakanath told the coroner he hoped the case would be dealt with swiftly and thought little would come of the investigation – he reassured Dr Suresh that there would be no GMC referral and that he had the support of the trust.

However, a breakdown in communication left Dr Suresh in the dark.

While the trust was offering reassurance,

Cleveland Police had already decided to make a third-party referral to the GMC. They informed the hospital trust, but neither party informed Dr Suresh, with both assuming the other would do so.

On 2 May – two weeks after the trust had been made aware a GMC referral had been made – the email confirming notice of an interim tribunals order landed in Dr Suresh’s email inbox, with no warning.

The inquest heard that trust staff had failed to realise the significance of the referral and had not escalated the information to the medical director. The trust produced a number of documents outlining how gaps in communication should now be removed, to ensure a similar problem does not happen again. The trust also confirmed it would now automatically make occupational health appointments for staff referred to their professional regulator, in an effort to ensure support is in place.

At the inquest Ms Bailey said she was concerned about the trust’s failure to ‘recognise, communicate and escalate information about a third-party GMC referral’ and was concerned about assumptions made by police and the trust that meant Dr Suresh was not told.

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But Ms Bailey said she believed ‘very serious lessons’ had been learned and procedures and policies put in place to prevent similar failures in communication in future.

A spokesperson for the trust offered sympathies to the family and described Dr Suresh as a ‘highly valued colleague’.

He said: ‘Our trust is dedicated to ensuring that the health and wellbeing of all of our employees is an absolute key priority.’

the GMC to ensure it asks questions about whether a doctor is vulnerable in advance of sending future communications, and to edit communications to offer doctors phone calls to discuss referrals rather than the news having to come out of the blue in an email.

It is not the first time that the effect of a GMC referral upon doctors has come under scrutiny.

A 2014 review identified 114 doctors who died while under open GMC investigations between 2005 and 2013. Of those, 28 were Devastating impact recorded as suicide or The three days of the suspected suicide.

‘The drugs used hearing also focused around The report suggested that to sedate the patient the ‘devastating’ effect of doctors under investigation are “well known” GMC referrals for doctors, should feel they are treated and whether the regulator as innocent until proven to produce does enough to assess guilty and made a number of hallucinations’ the risk before sending a further recommendations, communication to doctors, including emotional informing them that their careers may be resilience training and staff training to under threat. increase awareness of mental health issues.

Joanna Farrell, the GMC’s assistant director Another report by Professor Louis Appleby, for investigations, was asked whether commissioned by the GMC to look into cases anything could be done to mitigate the effect where the doctors had died from suicide while on doctors. subject to investigation over an eight-year She said: ‘I think this is quite a tricky period, said the regulator must recognise ‘the question. We are all aware of the impact of vulnerability of any doctor facing a fitnessour communication on doctors and we are all to-practise investigation, whether or not aware that any professional being referred to they are known to have poor mental health’, their professional body will cause anxiety.’ suggesting ‘investigations can be punitive in Ms Farrell was asked whether alternative effect, even if that is not the intention’. options had been considered – informing Safeguards claim doctors in person or by phone, telling their responsible officers before and assessing any The GMC said it made a number of changes risk – but did not agree that the steps were following the review, including changing appropriate or feasible. tone of voice in correspondence to remove ‘We don’t think there is a perfect answer,’ legalistic wording and communicate more she said. sensitively, introducing Representing the family a process to pause ‘The description of of Dr Suresh, Leslie Thomas investigations to allow unwell the alleged assailant doctors to seek urgent QC questioned whether the did not match treatment, the creation of a GMC had conducted any specialist team to work with sort of risk assessment or Dr Suresh “at all”’ doctors who have health asked whether Dr Suresh was concerns and providing particularly vulnerable before sending the email. Ms Farrell said they had not. training to staff including an ‘awareness around suicide prevention’.

Mr Thomas also queried what happens after A spokesperson for the GMC said: ‘This was a doctor is told the news. ‘You do accept that if an extremely tragic case and our thoughts you notify someone of very serious allegations are with Dr Suresh’s family and friends at this by email, the sender has no idea how the difficult time. If we are aware a doctor may be information has been received, or the impact vulnerable we will always put safeguards in place on the recipient,’ he said. Ms Farrell agreed. to support them. However, for this to happen we Concluding the inquest Ms Bailey told thedoctor | May 2020 29

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that she desperately hopes a positive legacy for must be made aware of concerns, including if her husband could be a better system for other the doctor may be at risk of self-harm. In this case, our investigation was at a very early stage doctors.

She says: ‘The systems need to be and we had no information to indicate that the supportive for doctors – employers need to doctor was vulnerable or at risk.’ disclose all information of what is happening Dr Suresh’s friend and colleague, Vijay around a case, support systems need to be in Jagannathan, also a consultant anaesthetist, place and they all need to protect the dignity suggested that some of the issues the reviews intended to address remain – describing a ‘noand integrity of the professional and make smoke-without-fire’ culture – at the inquest. sure all options are explored until allegations ‘Any doctor will say the GMC never writes are proven.’ to you with good news,’ he said. ‘The regime An online petition – organised by a breaks you down – people start making Dr Suresh’s family supporter and the medicojudgements and determinations. legal adviser Rajesh Chaudhary, and calling for ‘It’s an emotional and mental trauma.’ greater protection of doctors being accused It is a feeling of overwhelming significance of misconduct – has gathered more than that the trust’s medical director Dr 20,000 signatures.

Dwarakanath recognised, too. Speaking at Summing up at the inquest, Ms Bailey the inquest he said: ‘I have yet to meet a described the circumstances that doctor who when referred to the GMC does surrounded Dr Suresh’s death as a ‘lacuna not feel anxious and stressed. It’s a careerin understanding’, and Mr Thomas spoke of defining moment for anyone. As we all know, ‘fundamental systematic failings’. it could be the end of their career if the BMA council chair Chaand Nagpaul says: worst happens.’

‘A GMC referral is a time of The petition calls for the exceptional stress and strain ‘The GMC should GMC to be made legally for many doctors – a constant have to provide responsible for the wellbeing nightmare which can be clear answers about of doctors who are under its isolating, stigmatising and investigation. worrying. what they did’ ‘It is of course important It says: ‘They should be held the regulator is able to ensure accountable for the loss of life of any doctor they are investigating. The health the fitness of staff to practice and to protect patients, but the reality is these processes secretary should bring about change to the often offer little or no insight into the emotional statute to achieve this, so that doctors’ lives state of the doctor involved and can potentially are protected.’ be as harmful as they are helpful.

Little progress ‘A “no-smoke-without-fire culture”, A family friend, who works as an NHS as it was described during this inquest, consultant in the North East, tells The Doctor worsens a brutal working environment that they do not believe the GMC is truly already characterised by blame, bullying and accountable. intolerable pressure – an environment which He says: ‘If a doctor dies while under weighs heavily on doctors and ultimately investigation, they will conduct their own impacts patient care and safety. internal inquiry and they may find some ‘It is crucial the GMC continues to look to lessons to be learned, but this keeps going refine its processes, to ensure that the welfare on and there does not seem to be any great of the vulnerable doctor is an integral part of acknowledgement or change in rules or the decisions taken by its staff, and to ensure processes. The family would like to see the the methods of communication used to explain GMC become more responsible for loss of life those decisions are compassionate and clear.’

– they should have to provide clear answers Ultimately, the NHS lost a talented doctor about what they did and what they are doing and a family their loving son, husband, father about it.’ and friend. Wherever lessons can be learned, Speaking to The Doctor, Ms Suresh says her lessons must be learned. family is ‘crushed’ by ‘excruciating grief’ – but bma.org.uk/yourwellbeing 30 thedoctor | May 2020

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

When a doctor found himself unable to return to the UK owing to the COVID-19 crisis, the BMA helped him secure a passage from India As a national medical Dr Nagpaul has since association, the BMA is written to foreign secretary blessed with a small army of Dominic Raab emphasising member relations staff, and the paramount importance their equivalents outside of the Foreign and England, who aim to do Commonwealth Office everything they can for prioritising seats on chartered doctors working in their flights for doctors stranded local areas. overseas.

When a doctor is in need, About a fortnight after first however, distance and contacting Mr Mason, Dr Misra MISRA: ‘Colleagues joked asking geography need be no barrier secured a seat on a chartered whether I swam home’ to providing support, as one flight from Delhi to Heathrow. acute medicine trust consultant from East Along with his fellow passengers, he faced a Anglia recently discovered. cramped and difficult journey having to wear a Having travelled to India in early March to face mask for the duration of the eight-and-avisit family, Sushil Misra found himself unable half hour flight back to the UK. to return to the UK as the rapidly unfolding After landing at Heathrow, Dr Misra was COVID-19 pandemic saw India locked down and reunited with family and was soon able to get international flights grounded. back to his post at West Suffolk Hospital in Despite appealing to the Foreign and Bury St Edmunds.

Commonwealth Office and British High Despite the delays and hardship he Commission for information and assistance, endured, Dr Misra said that he was extremely Dr Misra found his pleas for aid going effectively grateful to Mr Mason and all those at the BMA unanswered. who had worked to highlight his case and draw Fortunately for Dr Misra, being more than attention to the plight of doctors stranded 4,000 miles and five time zones away did not overseas. deter the BMA’s regional co-ordinator for the ‘People are very happy I’m back and some East of England Nigel Mason from fighting a of my colleagues joked asking whether I swam member’s corner. home,’ he said.

Mr Mason said that it seemed obvious that as ‘It felt great [to be back]. It felt like being an acute medicine consultant Dr Misra needed home and I want to again say thanks for to be at the front of any queue for a return flight everything the BMA did for me.’ to the UK. Mr Mason said: ‘It just brought it home to He said: ‘He contacted me saying that me the more I was in contact with Dr Misra and he was stuck in Delhi and if I could have any talking to other people that there was a wider influence on the High Commission in bringing issue of doctors being stranded abroad. back UK citizens stranded due to lockdown.’

‘Given how desperately we need doctors; to With Dr Misra still struggling to get his the point that we’re bringing people back from case acknowledged by the Foreign Office, retirement, getting doctors home seems the BMA council chair Chaand Nagpaul released obvious thing to do.’ a statement calling on the Government to The BMA has been alerted of other doctors do more to prioritise doctors and healthcare in India who are having trouble returning to the professionals stranded overseas in getting back UK, and the association has written to Mr Raab to the UK. to alert him to their case. thedoctor | May 2020 31

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