The Doctor, issue 33, July 2021

The magazine for BMA members

thedoctor

Issue 33 | July 2021

20210200 The Doctor, Issue 33 July – p.1.indd 1

GMC inquiries The harsh impact on career and personal life A sting in the tail How long COVID's impact could be felt for decades

Bearing the brunt

‘Unappreciated’ Overseas doctors hurt by NHS leader’s comments

Tackling violence against doctors

12/07/2021 09:46

In this issue 3 At a glance A new section illustrating the key features of topical issues

4-7 Three little letters A GP describes the devastating impact of a GMC inquiry

8-9 A missed opportunity Why a report into racial and ethnic disparities fails to reflect the lived experience of doctors

10-11

Wrong words, wrong time A senior NHS figure’s call to reduce the ‘reliance’ on overseas doctors shows a lack of support and appreciation

12-13 Because they’re worth it GPs call for occupational health services to be extended to the whole primary care team

14-15 Sting in the tail The effects of long COVID could be felt for decades to come

16-21 On the receiving end The constant and unacceptable threat of violence faced by doctors

22 Your BMA Creating a stronger dialogue between BMA members

Chaand Nagpaul, BMA council chair Kicked in the chest. Volleys of verbal abuse and profanities. Threats to kill family members.

It was hard – albeit tragically not totally surprising – to read the experiences of doctors from across the profession who fear and face attack and abuse every day of their working lives, in this issue of The Doctor.

The latest NHS staff survey, published last November, found that more than a third of who had frequent face-to-face contact with patients said they had experienced bullying, harassment or abuse from patients, their relatives or the public in the past year. Almost 15 per cent reported at least one incident of violence.

Anecdotally, doctors have reported a steep rise during the pandemic – and some frontline staff have suggested incidents have spiked further in recent months. In a survey by BMA Scotland in May, almost nine in 10 GPs in Scotland said they or their practice staff had suffered verbal or physical abuse in the past month.

The BMA has long campaigned for the NHS to recognise violence against staff – and to provide adequate support for those who have been victims. There has been progress, and the Government is consulting on an increase to the maximum sentence for assault on emergency workers, but clearly more must be done.

This issue of the magazine also features heart-breaking reflections from a West Midlands GP who, responding to our piece about the tragic suicide of Sridharan Suresh in the June edition, details the personal and professional effect of the GMC fitness-to-practise process. The GP, protected with anonymity, tells a familiar story of finding himself practising defensive medicine, his mental health deteriorating and a growing desire to leave the profession.

It is time for another look at the systems which cause such fear and distress for frontline staff. It is vital the GMC makes every effort to ensure its processes are conducted as humanely as possible – and that no doctor is made to feel guilty at the onset of an investigation.

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

23 Viewpoint The Government can no longer afford to take doctors for granted 02

Welcome

Keep in touch with the BMA online at twitter.com/TheBMA

instagram.com/thebma

thedoctor | July 2021

20210200 The Doctor, Issue 33 July – p.2-3.indd 1

12/07/2021 09:30

AT A GLANCE A severe shortage of doctors has huge implications for workload, safety and practitioners’ health, according to a new BMA report on workforce. Here are some key findings Under-doctored

A state of exhaustion One-in-five doctors indicated they will leave their career in the NHS altogether post-pandemic – although clearly a worst-case scenario, extrapolated to the whole medical workforce, if one in every five doctors did leave their post the NHS would lose 31,820 FTE doctors

Just under two in five doctors said their health and wellbeing is ‘slightly’ or ‘much worse’ now compared with wave one

Just under three in five said their level of exhaustion or fatigue is ‘higher than normal’

Almost one third have undertaken additional unpaid hours

Over two in five had felt ‘slight’ or ‘significant’ pressure to work additional hours from their employer

2021

It will take until 2046 before the NHS has the number of practising doctors per 1,000 people required to match today’s OECD EU nations’ average.

We are therefore 25 years behind where we should be to sit on par with comparator nations.

2046

Source: BMA analysis of OECD data and NHS Digital General Practice and Secondary Care Workforce Statistics

Source: BMA COVID-19 Tracker Survey, April 2021

Unpaid work

A hard act to replace The shift in GP working patterns combined with the concurrent loss of partners means we need to train around three more GPs to replace the hours lost when one GP partner leaves their partnership

52.5%

Shortages lead to burnout and moral injury. When asked what factors contribute to moral distress, a recent BMA survey found ‘insufficient staff to suitably treat all patients’ was the most common response (52.5%)

See the report in full at bma.org.uk/staffing Source: BMA analysis of NHS Digital General Practice Workforce Statistics

bma.org.uk/thedoctor

20210200 The Doctor, Issue 33 July – p.2-3.indd 2

Source: BMA Moral Distress and Moral Injury Survey, June 2021

thedoctor | July 2021 03

12/07/2021 09:30

Three little letters ...

GMC – the email heading no doctor wants to see.

A GP describes how an inquiry had a devastating effect on his career and personal life, leading him to be an ‘emaciated version of his former self’

egend has it a doctor’s worst fear is relayed in the significantly clinically and biochemically thyrotoxic form of an A4-sized envelope. and subsequently advised a small-dose reduction in In my case, however, it was one particular email, her thyroxine replacement.

buried within my inbox that had caught my Several months passed before I became embroiled attention. It was titled ‘Re: General Medical Council’ – in the investigation. Although the GMC had closed the and it had an ominous serial number attached in the case against the patient’s usual practitioner, there header section. As I took a deep breath, and with my were concerns expressed regarding the unilateral heart pounding frantically, I knew the contents of the decision I had taken in reducing her Levothyroxine email would make this particular downcast December dosage. I had not at the time fully appreciated the day, somewhat darker. importance of complete I learnt that I was subject TSH suppression, to a provisional inquiry from ‘I knew the contents of the email would for differentiated the GMC regarding a clinical thyroid cancers. make the day somewhat darker’ decision I had taken some Furthermore, the GMC months earlier. In short, wanted to establish whether I had seen a lady privately who relayed numerous I had knowingly contravened specialist advice in symptoms on the background of a past history of altering her replacement dose. After an independent thyroid cancer. She appeared irritated in clinic and expert reviewed my clinical notes, I was eventually her frustrations, in particular, were directed towards exonerated of the latter charge, as it was clear that her NHS general practitioner. She revealed she had I was not in receipt of any hospital correspondence made a complaint to the GMC about the care she had when reviewing the patient. received from her doctor. Although slightly taken Most importantly for me, no harm had come to her aback by this, I tried my best to address her concerns. as she was advised to remain on the lower thyroxine As part of my assessment, I noted that she was replacement dose after specialist review. I was 04 thedoctor | July 2021

20210200 The Doctor, Issue 33 July – p.4-7.indd 1

12/07/2021 09:31

bma.org.uk/thedoctor

20210200 The Doctor, Issue 33 July – p.4-7.indd 2

thedoctor | July 2021 SIMON 05 GRANT

12/07/2021 09:31

obviously relieved by the decision of the GMC to end the investigation at the preliminary stage after six weeks.

Consumed by fear

Put another way, there is a reasonable chance that a doctor might expect to have their practice called into question at least once in their career.

Those few weeks, though, had felt like nothing short Defensive medicine of an eternity as time around me lost its linearity. I While there was of course immense relief on my part, had become so consumed with fear that I managed to that I would not be subject to any further action, the conjure up a reality where being struck off, penniless expectation of a rapid transition to normal duty did and destitute was an inevitability. I was unable to not materialise. In the subsequent months, I found motivate myself to leave myself naturally gravitating the house and my appetite ‘As the ruminations became towards the practice of and sleep had become defensive medicine. even more unpleasant, interrupted.

I was now starting to so did my mind’s ability Prior to my GMC inquiry, subconsciously overto catastrophise’ I was fortunate to have only investigate my patients ever received one frivolous complaint in the preceding and was referring more of them into secondary care 12 years. I did not – naïvely perhaps – think of myself services. I was not prepared to deal with uncertainty as someone who would fall foul of the regulator as I and found the concept of risk extremely anxiety prided myself on being conscientious, reflective and provoking. Indeed, my greatest asset as a generalist extremely patient-focused. Given the wide knowledge had now become a significant weakness and with that base required in being a competent generalist, I my confidence to do the job effectively had all but had always been receptive to the dangers of the deserted me. unconscious unknown. With that at my forefront, As my irrational thoughts grew, I started to my armament was attempting to stay up to date ruminate on clinical encounters from many years where possible across all areas, as well as completing before. Had I undertaken the correct management numerous and varied clinical diplomas. plan for patient X? Did I refer patient Y on in a timely Furthermore, I had always thought the GMC’s remit manner or did they fall into the ether? Why did I ever was only to investigate issues of probity that might choose to prescribe remotely for an online pharmacy bring the profession into disrepute, or reprimand all those years ago and will it come back to bite reckless doctors who repeatedly cause patient harm. me? These whispering thoughts did not just limit But I believe the threshold is lower than that. In the themselves to the clinical arena, but also transgressed last few years, the GMC has considered around 8,000 into my private life. to 9,000 FTP (fitness-to-practise) inquiries each year, As the ruminations became even more unpleasant, so did my mind’s ability to catastrophise. On seeing with around 1,500 proceeding to a full investigation.

The GMC

8,000 9,000

considers to fitness-to-practise inquiries each year

With around

1,500 proceeding to a full investigation

06 thedoctor | July 2021

20210200 The Doctor, Issue 33 July – p.4-7.indd 3

12/07/2021 09:31

an ambulance blue light in the vague direction of my primary care practice, I would presume the paramedics were attending a desperately ill patient that I had misdiagnosed. If a patient did not come for their review appointment as instructed, then they must have died owing to my gross negligence.

Desparate need of help

groups in FTP referrals is perturbing.

I, like many of my colleagues from minority ethnic backgrounds, worry incessantly about complaints arising, including the possibility of unconscious biases playing out.

Fairness in question

In the case of a recent ruling of discrimination I was not capable of offering myself any kind of brought against the GMC by a surgeon of mixed racial logical explanation to circumstances that I had no heritage, the tribunal found that ‘there was a level of control over. A seed of doubt would quickly snowball complacency about the operation of discrimination into an obsessional intrusive thought, and with that in the work of the GMC’ and that they were ‘looking a compulsion to seek reassurance at the earliest for material to support allegations, rather than fairly opportunity. Like the itch-scratch cycle, any relief assessing matters’. was short-lived, before the This will not surprise many next implanted seed would of us who have long felt perpetuate the same cycle that doctors from minority ‘I was now on a downward of futility. backgrounds are not always slope into the abyss’ I was now on a downward treated in an even-handed slope into the abyss and it manner. And finally, as we was my family who would ultimately bear the brunt as negotiate our way out of the pandemic, an already the self-consumption translated into my absence as a demoralised profession faces unprecedented dad, husband and son. In short, I became a dishevelled challenges after many years of underfunding.

General practice is no exception as demand for and emaciated shadow of my former self and would ruminate on everything until I reached what I can only primary care services has never been greater. Juggling describe as some sort of ‘pseudo-catatonic’ state. increasingly complex medical problems with ever I was in desperate need of help and was put in touch diminishing resources, coupled with longer waiting with NHS Practitioner Health, a confidential free service lists has unsurprisingly culminated in diagnostic delays and the potential for patient harm. tailored for doctors and dentists with mental health problems. I was reassured to Given my own particular learn that I was not alone and ‘Doctors from minority obsessive personality trait, that many doctors had felt a working within such a backgrounds are not similar crisis of confidence fragmented health system on always treated in an evenwhen being the subject of a a full-time basis feels entirely handed manner’ GMC inquiry or investigation. unsustainable going forward.

It has been nearly three years since my brush with This has led me to contemplate working abroad or the GMC and although I was scathed by the process, I leaving the profession altogether – a situation I could am glad to have been able to finally close this particular never have envisaged just a few years ago. chapter. As I reflect upon my experience, I feel a sense of sadness as well as surprise that I had allowed my The GP, who is from the West Midlands and mind to wander into such depths of despair; especially wishes to remain anonymous, worked with over a provisional inquiry that never escalated.

Peter Blackburn on this piece Clearly my perceived resilience was in short supply given my inability to cope with the fallout. Clichéd as The BMA is also supporting legal action taken it may sound, it truly is enlightening what one learns by the family of Sridharan Suresh, who took his about themselves during their darkest days. own life when facing a GMC investigation.

While I recognise the GMC’s statutory role to Read the story at bma.org.uk/newsandprotect patients through the regulation of doctors, the opinion/a-lack-of-compassion over-representation of doctors from minority ethnic bma.org.uk/thedoctor

20210200 The Doctor, Issue 33 July – p.4-7.indd 4

thedoctor | July 2021 07

12/07/2021 09:31

SARAH TURTON

A MISSED OPPORTUNITY

SHANBHAG: ‘Racism should not be accepted as an occupational hazard for the NHS’s ethnic minority staff’

A Government-ordered report into racial and ethnic disparities fails to reflect the lived, everyday experience of doctors and underplays the presence of systemic and structured racism in the health service.

Tim Tonkin reports

R ‘When racism occurs the health and care system’s approach to dealing with it is often awkward and ad hoc’

adhakrishna Shanbhag still recalls painfully the incident which led him to consider walking away from a successful, 20-year-long career in the NHS. A highly experienced associate specialist in trauma and orthopaedics, Mr Shanbhag describes how a patient under his care asked him if a white doctor could perform his operation instead of him.

It was an experience which BMA council member Mr Shanbhag said left him feeling worthless, but which was sadly far from being an isolated experience of workplace racial discrimination, either for him or for many other ethnic minority doctors and healthcare staff in the NHS. ‘I know from my own experiences, as well as colleagues across the NHS, that the reality is when racism occurs the health and

08 thedoctor | July 2021

20210200The Doctor Issue 33 July – p.8-9.indd 1

12/07/2021 09:42

care system’s approach to dealing with it is often awkward and ad hoc,’ says Mr Shanbhag, who firmly believes that workplace racism blights the lives of so many doctors, nurses, and healthcare staff in today’s health service.

‘It is not just reflective of racist individuals but rather shows a system that has processes and attitudes which are not fully equipped to deal with racism. Denying this is terribly damaging and sets us back by 20 years. Racism should not be accepted as an occupational hazard for the NHS’s ethnic minority staff.’

Flawed review One consultant psychiatrist told the BMA: ‘I will never forget a patient complaining about not wanting to be treated by Africans – openly using the “n” word and demanding to be seen by a white clinician.

‘Very often patients and colleagues, who I’ve not worked with before, address junior, white medical staff and hardly acknowledge me, claiming I don’t look like a doctor. This is what I find the hardest. The constant microaggressions, insidious comments and behaviours which are just subtle enough you feel powerless to call it out but no less hurtful.’

As a professional organisation, the BMA has sought to do much to highlight and address the corrosive effect of racial discrimination in the health service welcoming, and later contributing to, the Sewell commission – a Government ordered root-and-branch examination of racial and ethnic disparities in the UK. It was much to the association’s disappointment and consternation therefore that the prevailing narrative and conclusions of the report published by the commission in March this year appeared to be at stark odds with the lived experiences of doctors such as Mr Shanbhag.

Three months on, the association has now published its own in-depth response to the commission’s analysis: A missed opportunity: BMA response to the Race Report – and what it says is a failure to reflect doctors’ experiences or to identify possible solutions to racial discrimination.

Chief among the BMA’s criticisms is that bma.org.uk/thedoctor

20210200The Doctor Issue 33 July – p.8-9.indd 2

‘The report ignores the lived experience of many ethnic minority healthcare workers’

NAGPAUL: ‘The documentation of racism occurring at a systemic level within the NHS is enormous’

the report seeks to downplay the presence of systemic and structural racism in the health service, despite the BMA having documented evidence to the contrary, to fit a politicised narrative.

Discrimination ignored Outlining the association’s refutation of the report, BMA council chair Chaand Nagpaul points to the findings of one BMA survey submitted to the commission, showing that almost three times as many staff from ethnic minority backgrounds (17 per cent) reported experiencing discrimination in their workplace compared to their white colleagues (6 per cent).

He says sweeping statements made by the report’s authors, such as the NHS enjoying a ‘significant overrepresentation’ of ethnic minority staff in ‘high status, professional roles’, were incredibly short-sighted, and difficult to comprehend given the well-documented extent of racism reported by health service staff.

‘The NHS has always been more racially diverse than the UK population itself,’ says Dr Nagpaul.

‘While the report celebrates this diversity, it ignores the lived experience of many ethnic minority healthcare workers as well as the wealth of evidence which shows that for these staff working in the NHS has been, at best, unfair and unequal.

‘The documentation of racism occurring at a systemic level within the NHS is enormous, tough to process, very often not addressed and assumed to be part of the job for ethnic minority doctors and healthcare workers. This should not be the case and it is hard to comprehend how the Commission on Race and Ethnic Disparities race report failed to see this.’

He adds: ‘Having missed an opportunity with this report we’d strongly urge the Government to take the BMA’s response seriously and begin to tackle structural racism within the health service so that the values of fairness and equity we ascribe to patient care applies equally to those that work within the NHS.’ To read the BMA’s response in full, search for ‘race inequalities and ethnic disparities in healthcare’ at bma.org.uk thedoctor | July 2021 09

12/07/2021 09:42

I

n the weeks following the vote to leave the EU in June 2016, NHS England chief executive Simon Stevens penned an opinion piece in The Daily Telegraph imploring the Government to reassure all overseas staff working in the NHS of their continued welcome.

Describing such a move as ‘completely uncontroversial’, Mr Stevens acknowledged that while he wished to see an improvement and increase in opportunities to access training for health professions, the health service was ‘still going to need committed health professionals from other countries’.

With his tenure set to end on 31 July, potential successors to his role as leader of the NHS are being considered.

One candidate, head of the NHS Test and Trace programme Dido Harding, has already struck a rather

different tone on foreign staff in the NHS, stating that she would seek to end the health service’s ‘reliance’ on overseas staff should she be appointed.

While increasing the numbers of and access to medical school and foundation programme places is something that is universally welcomed, the COVID-19 pandemic and the startling level of staffing shortages within the NHS are stark proof of how invaluable the continued contributions of overseas doctors and health professionals are.

According to recent data published by the House of Commons library, NHS staff reported as having a non-British nationality account for 14 per cent of the health service’s total workforce.

Meanwhile, just three years ago, the GMC reported that the number of overseas qualified doctors joining

Wrong words, wrong time A leading NHS figure has said she wants to end the health service’s ‘reliance’ on overseas doctors.

For the many thousands working under intense pressure, it showed a lack of support and appreciation.

Tim Tonkin reports 10 thedoctor | July 2021

20210200The Doctor Issue 33 July – p.10-11.indd 1

12/07/2021 09:42

the UK’s medical register had outstripped UK graduates for the first time.

DAVE: Diverse workforce a benefit to the NHS

Let down Consultant child and adolescent psychiatrist and medical director Ananta Dave came to the UK from India in 1995 and has spent more than two decades working in the NHS. She says it was disappointing to hear such comments from a potential future chief executive of the health service.

‘I think it just shows the lack of a compassionate culture which acknowledges the contributions of staff from diverse backgrounds,’ she says.

‘I think that while ensuring that we are training enough doctors and nurses in this country is a laudable aim it should not be done at the expense of dismissing the contribution and role that international healthcare workers play in the NHS. ‘I think it was particularly insensitive in the context of COVID because we have seen over the last year and a half the contributions made by international workers to keep the NHS going when [many] were at higher risk from the virus, coming from ethnic minority backgrounds.

‘What we’ve been through as a country over the last year and a half with COVID, I thought those comments were ill-timed, insensitive and showed a lack of understanding and acknowledgement of the role of international workers in the NHS.’ bma.org.uk/thedoctor

20210200The Doctor Issue 33 July – p.10-11.indd 2

Setting the tone Dr Dave says that having a diverse workforce encompassing doctors with different skills and experience from different parts of the world was in fact a huge benefit to the health service as has been shown by research and analysis.

‘If she were to become the chief executive of the NHS then it is worrying as to what tone and culture will be set right from the top.

‘The culture of any organisation or institution starts at the top and the attitude, values and behaviours of those at the very top. If we have somebody at the helm of the NHS who is unable to understand the contribution and unable to acknowledge or appreciate the role played by international workers, I think that sets a dangerous precedent.’

The vital role of overseas doctors and healthcare staff within the NHS was something that BMA council chair Chaand Nagpaul reiterated in his response to Baroness Harding’s comments, emphasising that the health service would simply be unable to survive without them.

‘Non-UK doctors, nurses and healthcare workers have and continue to play a critical role in supporting the

NHS, and their contribution to saving lives and caring for patients during the pandemic has been invaluable,’ he says.

‘With serious staffing shortages within the NHS, we must be doing all we can to attract and retain hardworking doctors and healthcare workers both from overseas and within the UK as that is what is needed to care for patients amid an

‘We have seen the contributions made by international workers’

enormous backlog of care.

‘Quite simply, the NHS would not survive without the contribution of overseas healthcare workers and we should be celebrating their contribution and thanking them for the difference they have made to our healthcare service.

‘Their contribution is every bit as integral as that of UK healthcare workers.’

STEVENS: Overseas staff welcome

‘We must be doing all we can to attract and retain hardworking doctors’

thedoctor | July 2021 11

12/07/2021 09:42

Because they’re worth it GPs are calling on occupational health support to be extended to the whole primary care team as a matter of common sense and justice. Tim Tonkin reports

S

taff stress and burnout in the health service are not new phenomena.

However, COVID-19 has seen demand for occupational health and other support services surge in the past 18 months.

While the NHS provides support to all staff across secondary care, service access at primary care level in England is not as straightforward.

A policy framework standardising the commissioning of occupational health services was introduced in 2016, and while some aspects of support are funded by the NHS, other services need to be paid for by the user.

Other forms of support at primary care level such as those provided by NHS Practitioner Health are only available to GPs. By comparison, the NHS in Scotland has provided full occupational health services to all

12 thedoctor | July 2021

20210200The Doctor Issue 33 July – p.12-13.indd 1

12/07/2021 09:43

SANFORDWOOD: ‘We all work as a team’

‘For the sake of possibly a few hundred pounds of counselling time to support one of these health practitioners, they [NHS England] could potentially lose somebody in whom they’ve invested tens of thousands of pounds in training.’

A recent report into workforce resilience published by the Commons health and social care committee ruled that burnout has become ‘a widespread reality in today’s NHS’ in England.

In its recommendations the report called for integrated care systems to be made responsible for enabling access to wellbeing services for all staff, and for the COVIDera investment into such services to be maintained and regularly reviewed following the pandemic.

Burnout risk

‘They are being told to “get on with it” effectively’

staff working in primary care since the end of 2016, while the Welsh Government pledged as recently as last September to explore means by which all staff will have access to health board-provided occupational healthcare.

Denied help This inequality of access to occupational support is something the BMA GPs committee has criticised for a number of years and, according to GPC deputy chair Mark Sanford-Wood, it needs to change.

‘We all work as a team so it is completely iniquitous that if I [as a GP] start to suffer stress because of work, I can get help, but my nurse practitioner, paramedic or social prescriber colleague can’t, and they are being told to “get on with it” effectively,’ Dr SanfordWood explains.

‘It is insanity for a system like ours, that invests huge amounts of money into training all of these people, and then watches them break and get crushed without bothering to step in and help,’ he adds. bma.org.uk/thedoctor

20210200The Doctor Issue 33 July – p.12-13.indd 2

‘Watching them break and get crushed without bothering to help’

While acknowledging the pandemic had placed an unprecedented level of pressure on healthcare professionals, the report explicitly cited opaque NHS workforce planning, personnel shortages and failure to retain staff as the biggest drivers of burnout.

Shortfalls in staffing in primary care remain a challenge, in spite of national efforts to increase numbers of GPs. Findings from the BMA’s latest workforce report Medical Staffing in England – Now and for the future reveal that, although there are now greater numbers of GPs, there are 1,307 fewer fully qualified full-time equivalent GPs in England today than in 2015.

Manchester GP Samira Anane says that making occupational health services universally accessible to primary care staff would make a huge difference to the wellbeing of individuals and for the state of the general practice workforce as a whole.

‘Having that feeling that you can access services and get help is a huge burden off people’s shoulders, and it also means that we can better retain people in our GP workforce,’ she says.

‘It is great to see GP trainee numbers going up but the biggest issue we face is retention.

We know people are leaving [primary care] for various reasons be it burnout or retiring on grounds of ill health.

‘I think extending these services would make a more productive and happier and healthier workforce as well.’ thedoctor | July 2021 13

12/07/2021 09:43

Sting in the tail The effects of long COVID could be with us for decades. Its nature, prevalence, and what patients will need in support was discussed by leading researchers at a BMA event. Neil Hallows reports

A

lmost 400,000 people in the UK are still suffering the symptoms of COVID, more than a year after contracting the virus.

The implications of this insidious ‘tail’ left by the virus are profound, but they should not have been entirely unexpected.

In fact, says BMA medical academic staff committee co-chair David Strain, it would be unusual if such an epidemic did not have long-term consequences.

He cited the film Awakenings, based on the famous intervention by the neurologist Oliver Sacks, in which patients who had survived the epidemic of encephalitis lethargica between 1915 and 1926 were briefly roused from a catatonic state with the drug L-Dopa.

The patients were treated in the late 1960s, more than 40 years after the epidemic. Its causes are still debated. The most severe outbreak coincided with the 1918 influenza pandemic and Sacks and others argued that the influenza virus potentiated the effects

of the causative agent of the encephalitis or lowered resistance to it in a catastrophic way.

COVID is different, and the world is different, but it is not unreasonable to ask whether there will be patients in 40 years still suffering from the consequences of the virus, in ways we don’t yet fully know, even if successful vaccination programmes keep the acute effects under control.

Dr Strain was co-chairing a BMA board of science discussion event on long COVID last month, with the board’s chair Professor Dame Parveen Kumar.

Leading researchers gave updates into longitudinal studies, predictors of long COVID, and recovery and rehabilitation.

Drained and fatigued The most moving presentation was undoubtedly by East Lothian GP Amy Small, who contracted COVID in April last year and suffered months of utterly

14 thedoctor | July 2021

20210200The Doctor Issue 33 July – p.14-15.indd 1

12/07/2021 09:43

GETTY IMAGES

STRAIN: Surprised if COVID did not have long-term consequences

SMALL: A day’s work left her devastated

than 12 weeks varies between 1.3 and 41.1 per cent. debilitating fatigue.

Primary care coding shows even lower prevalence, and ‘Every last ounce of energy is drained away from you,’ she says. For an energetic and hardworking GP, the he and others at the event stressed the importance of effect was devastating. An attempt to return to work for long COVID being correctly coded in primary care to aid understanding of and planning for the condition. a full day left her so tired she could not even move her Other speakers included Leicester professor of jaw muscles to talk or drink.

The only way she could avoid terrible relapses was to respiratory medicine Chris Brightling, who is carrying out a study on the outcomes of people who have been discover how to pace. To prepare a meal she would peel hospitalised with COVID, and Leicester professor of the carrots, go and rest. Cut the carrots, go and rest. pulmonary and cardiac rehabilitation Sally Singh, who ‘For someone used to whipping up a stir-fry in presented on the rehabilitation needs of patients, and 10 minutes, this is an incredibly different way of the ‘Your COVID Recovery’ online resource for those doing things,’ she says. ‘It taught me I had to plan my who are experiencing continuing symptoms. day. If I was picking up my kid from school, I probably couldn’t take him there.’

Holistic approach needed A clause in her practice agreement meant that she King’s College senior clinical lecturer and consultant was expelled from it, having not been able to work geriatrician Claire Steves is using data from the COVID for six months. She has now recovered sufficiently to symptom study app, in which 4.5 million people have be doing full-time locums. She needs to be careful participated, to help predict the nature about how she uses her energy but is of the disease, estimate prevalence gradually improving. and predict hotspots, hospitalisations With such long and varied effects, ‘Every last ounce of and other outcomes. the need for good population studies is energy is drained away She gave an example of how the vital. But as Bristol professor of medical from you’ NHS had to adapt to COVID. While statistics and epidemiology Jonathan Sterne says, researchers were trying to some with long COVID had a single create definitions, design treatments condition that was driving most of the symptoms, others had problems and learn how to manage the condition with a number of systems. while still knowing very little about it. ‘We are building ‘If people are going to have to see multiple different the aeroplane as it takes off,’ he says. professionals, then it is going to be very burdensome Estimates vary on individuals who have fatigue and it’s also going Professor Sterne is part of a large collaborative study, to lead to multiple different doctors having different which is seeking to establish the nature of long COVID, suggestions for treatments.’ and its risk factors and outcomes, using data from There have been many predictions of COVID’s electronic health records and population-based legacy, ranging from a renewed commitment to the cohort studies. environment to a more atomised society resistant to Establishing prevalence is difficult, he says. ‘You can public gatherings. But for all the mix of idealism and pessimism in the other predictions, it is a certainty that see huge variation in the estimated prevalence of long hundreds of thousands of people will be going into the COVID depending on the age of people studied and the future with enduring symptoms of long COVID. And, as severity of their symptoms.’

Dr Steves suggested, the health service will need to find The percentage of people with COVID experiencing new and imaginative ways of looking after them. symptoms from four to 12 weeks has been recorded at between 3.3 and 23.2 per cent of the population. Data Listen to the discussion at www.youtube.com/ on the percentage of those having symptoms for more watch?v=hE-6ARjT3QQ bma.org.uk/thedoctor

20210200The Doctor Issue 33 July – p.14-15.indd 2

thedoctor | July 2021 15

12/07/2021 09:44

GETTY IMAGES

‘This can become so normalised that for some staff it’s seen as part of the job’

16 thedoctor | July 2021

20210200The Doctor Issue 33 July – p.16-21.indd 1

12/07/2021 10:05

GETTY IMAGES

Doctors face the threat of violence every day, the risk fuelled by system pressures and patient expectations, which are not of their making.

Seren Boyd reports

On the receiving end T

he patient was reclining on a trolley in a cubicle in the emergency department when Cathy Wield came to assess him.

She knew he had been agitated: security staff were in the cubicle. But he appeared calm when she approached.

The flying kick to her chest was so hard it flung her against the wall.

Dr Wield immediately reported the assault to a senior colleague but no one checked how she was.

She continued to tend to the patient for the next two hours.

‘I was in shock so I carried on working, and nobody suggested I shouldn’t,’ says Dr Wield, a Dorsetbased specialty doctor in emergency medicine.

It was only at the end of Dr Wield’s shift that a manager asked if she was OK. By now, she was very sore and bruised. ‘They said, jokingly, “Do you want to join the sixhour wait to be seen?”’ She declined. She didn’t sleep that night. bma.org.uk/thedoctor

20210200The Doctor Issue 33 July – p.16-21.indd 2

Dr Wield logged an incident report and reported it to the police. But an assessment of the patient’s mental state meant no charges could be brought.

Unreported Levels of aggression and abuse aimed at healthcare workers are hard to quantify.

In the latest NHS Staff Survey last November, more than a third of staff (35.4 per cent) who had frequent faceto-face contact with patients said they had experienced bullying, harassment or abuse from patients, their relatives or the public in the past year. Almost 15 per cent reported at least one incident of violence.

Nuffield Trust analysis found that levels of abuse and aggression reported in the 2015/2019 staff surveys remained fairly stable over that timeframe. Yet, much abuse goes unreported and national annual data on physical assaults has not been collected since 2017.

Anecdotally, doctors have

WIELD: ‘I carried on working, and nobody suggested I shouldn’t’

‘We all become desensitised over time in order to cope’

thedoctor | July 2021 17

12/07/2021 10:05

CHARLIE BIRCHMORE

CAMPBELL: ‘COVID has pushed us over the edge’

JANJUA: Sworn at for a full ‘15 minutes of chaos’

an appointment. Another turned up to the surgery with a hammer.

Political climate

‘Even patients who were on our side turned overnight’

reported a steep rise during the pandemic – and another spike in recent months.

In a survey by BMA Scotland in May 2021, almost nine in 10 GPs (87.7 per cent) in Scotland said they or their practice staff had suffered verbal or physical abuse in the past month.

The abuse has reached such a pitch that the Institute of General Practice Management has produced a video compilation of threats made to surgery staff, entitled ‘If I die It will be your fault’.

It recounts how one patient slashed the tyres of three staff members’ cars because, on phoning at 5pm, he was told he would have to wait till the next day for

Adam Janjua’s GP practice in Lancashire had to call the police recently to deal with a woman who had been declined a referral for a ‘cosmetic issue’.

She overturned a chair, thumped the desk, then screamed and swore for a full ‘15 minutes of chaos’, in the consulting room and waiting area, leaving only when she realised the police were coming.

Dr Janjua took to Facebook Live to ask patients to treat NHS staff with more respect – and to set the record straight over suggestions that GP surgeries have remained closed to patients during the pandemic. He believes the recent onslaught of passive aggression and abuse has been fuelled by tabloid headlines and health leaders.

‘It’s mainly people taking shots at us: “When are you going to start seeing patients? You’re just pocketing the money and not doing anything. Why don’t you help the hospital out?”

‘It’s very unfair because

we never stopped doing face-to-face: we’re a training practice and we have lots of appointments. We get people blaming their medical problems on us, even if they’ve been referred. One child’s father threatened to come down and show us what he could do to us.’

NHS England’s letter in May telling GP practices to ‘ensure they are offering face-to-face appointments’ sparked what Dr Janjua calls ‘a full-blown forest fire’.

Patients have ignored smallprint provisos recognising ‘clinical reasons’ to refuse appointments in person, such as acute COVID symptoms.

‘Even patients who were on our side turned overnight,’ says Dr Janjua.

‘We’ve been firefighting ever since. Unless there’s an apology from NHS England on every newspaper’s front page, people won’t pay heed. They’ve damaged the reputation of the profession.

The goodwill built up over the last year seems to have evaporated overnight.’

All part of the job?

As a consultant in emergency medicine, Roddy Campbell now expects to be in the firing

18 thedoctor | July 2021

20210200The Doctor Issue 33 July – p.16-21.indd 3

12/07/2021 10:05

‘Patients assault staff and make significant, and at times scary, verbal threats to harm you’

line. He’s sanguine about the fact that he experiences violence or aggression ‘every other shift’ these days. Most of it is fuelled by drug and alcohol misuse or mental health issues; a small proportion is down to people with poor coping strategies.

Things have been bad for ‘two or three years’ in his emergency department in southwest England. It is frequently overcrowded, sometimes with twice or three times the number of patients it was designed for. The hospital is near full occupancy, or over, most of the time. Staffing levels are inadequate for the level of demand.

‘We recently had a patient in the emergency department for several days, waiting for a suitable place to go,’ says Dr Campbell.

‘They abused and assaulted several staff members and caused huge disruption. It was very frightening for other patients and an overcrowded emergency department is a totally unsuitable environment for people with mental health conditions.

‘The worst part is knowing we’re not giving our patients bma.org.uk/thedoctor

20210200The Doctor Issue 33 July – p.16-21.indd 4

‘We get people blaming their medical problems on us’

the best care we can.

We’re trying to manage the corporate risk and spread our care across a large number of patients without enough staff or space.’

The recent reopening of hospitals to a backlog of medical concerns and pent-up frustration means patients have become even more agitated.

‘We were already on the verge of decompensating, but COVID has pushed us over the edge,’ says Dr Campbell.

Mavi Capanna, a core trainee 2 general psychiatry doctor in London, says incidents in psychiatry are so common they’re seen as ‘normal’.

‘Patients assault staff and make significant, and at times

CAPANNA: ‘When you go home, and talk to people who aren’t in your profession, you realise how wrong and damaging it is’

scary, verbal threats to harm you, and this can become so normalised that for some staff it’s seen as part of the job,’ says Dr Capanna. ‘But when you go home, and talk to people who aren’t in your profession, you realise how wrong and damaging it is.’

Becoming immune It’s clear something has to change, not least for team morale and staff retention.

Feeling part of a supportive, close-knit team is ‘the saving grace’ for Dr Campbell. But he worries he has become so inured to aggression he may fail to spot its effects on more junior staff.

‘If, like me, you’ve seen a lot of abuse and assault in thedoctor | July 2021 19

12/07/2021 10:05

your career, it’s harder to appreciate how awful it is for a brand-new junior doctor who has just seen something unpleasant, because we all become desensitised over time in order to cope,’ he says.

‘They might be feeling utterly deflated and vulnerable, and maybe blaming themselves for what’s happened, which is a sort of moral injury.’

The impact on patient care, too, makes a pressing case for change.

As both Dr Wield and Dr Campbell point out, any form of rudeness inhibits people’s ability to treat patients safely for a time – a point emphasised by the Civility Saves Lives campaign.

‘It absorbs your emotional bandwidth so you have a great deal less emotional energy for all the other things you’re supposed to be doing,’ says Dr Campbell.

Dr Wield worries that a secondary consequence is medical staff becoming hardened towards people behaving badly.

‘The risk is they value less people who behave like this,’ she says. ‘Unfortunately, a lot of these are people whose chances of dying young are much greater.’

Taking responsibility Policy is hardening against aggression and abuse. The first NHS violence reduction strategy, launched in 2018, aims to ‘better protect staff and prosecute offenders more easily’. A national Violence Prevention and Reduction Standard for NHS organisations was published in January.

SHAH: Staff need training in conflict de-escalation techniques

The Government is looking at increasing the maximum sentence for assault on emergency workers, including doctors, from 12 months in prison to two years – something for which the BMA has lobbied hard.

June saw the start of a rollout of bodycams across 10 ambulance trusts in England to record, and thereby reduce, abuse.

The number of physical assaults on ambulance staff in England last year was ‘30% more than five years ago’, according to NHS England.

Since April 2020, it has been possible to deny treatment to patients who are abusive, as well as to those who are aggressive or violent, unless they need emergency care.

But ‘zero-tolerance’ will remain an empty slogan without effective sanctions.

Hospitals’ red card system – barring offenders for two years – is unenforceable, says Dr Campbell.

‘If somebody has taken a significant overdose or has a

head injury that suggests they have a bleed on their brain, you really can’t enforce that,’ he says.

But people should be supported to take responsibility for their actions.

‘If you’re delirious with an encephalopathy, it’s not your fault if you’re badly behaved.

‘If you’re drunk and disappointed because you had a fight and you lost, and you don’t like waiting, then it probably is.’

Drawing that line can be hard, especially in psychiatry – but some fear the pendulum has swung too far.

‘I worry that we’re medicalising psychosocial problems and we are increasingly tolerant of bad behaviour,’ says Dr Wield. ‘If people aren’t held to account, it doesn’t help them to resolve issues.’

Culture shift Doctors’ suggestions for tackling aggression and abuse are wide-ranging: more staff, more space, more security, more sanctions.

20 thedoctor | July 2021

20210200The Doctor Issue 33 July – p.16-21.indd 5

12/07/2021 10:05

More ‘detox units’ providing medical checks for the intoxicated, to relieve pressure on emergency care. A national awareness day highlighting the problem.

Dr Wield has been trying to help improve support for staff experiencing abuse in her own trust.

‘There have been times when I’m not sure I want to do this anymore,’ she says.

‘That’s why I needed to speak up, make something positive happen as a result of my bad experiences.’

Dr Capanna, a member of the BMA’s North Thames junior doctors committee, says that there should be a national benchmark for safety standards. Poorly performing trusts need to be held accountable and supported to improve.

Shobhna Shah, a Londonbased anaesthetist and aviation medicine specialist, says even low-level workplace violence and abuse should not tolerated.

She refers to criminology’s ‘broken window theory’ that links disorder and incivility within a community to subsequent serious crime.

Dr Shah believes there is a place for security systems with a deterrent effect, including trained security staff, CCTV, fixed alarms, personal alarms and communication systems.

Employers need robust safety protocols and they must be enforced.

And, she says, staff at all levels need proper training in recognising warning signs, interpersonal skills and deescalation techniques.

Dr Shah feels patients need support too, recognising their anxiety can be fuelled by bma.org.uk/thedoctor

20210200The Doctor Issue 33 July – p.16-21.indd 6

‘I worry that we’re medicalising psychosocial problems and we are increasingly tolerant of bad behaviour’ issues such as lack of choice, lack of information and lack of space. Creating a calm environment where people are kept informed and noise is minimised is key.

But equally important is building non-acceptance of abuse among staff.

Less than half (48.4 per cent) of participants in the 2020 NHS Staff Survey said ‘they or a colleague reported harassment, bullying or abuse

at work the last time they experienced it’.

Dr Shah understands why people don’t want to report.

‘People might not want to relive their experiences.

But we must make sure incidents are reported so we know the true extent of the problem. Abuse and physical risk should not be an intrinsic part of the job of a health worker.’

STANDING UP TO VIOLENCE The BMA has cast a spotlight on aggression and violence towards healthcare workers for many years, including through regular data collection and awareness raising through its surveys.

It collaborated with the Social Partnership Forum to support the development of the national strategy and standard on violence prevention and reduction.

It continues to hold trusts to account, including by raising awareness of the legal requirements for employers set out by HSE (the Health and Safety Executive). It also highlights HSE guidance on reducing workplace violence, for employers and doctors. The BMA offers guidance on removing patients from a GP practice list.

Search for ‘preventing and reducing violence towards staff’ at bma.org.uk

thedoctor | July 2021 21

12/07/2021 10:05

MATT THOMAS

Your BMA I’m here to enable you, BMA members, to become more involved with the work of the association to help make a difference to doctors’ lives I have recently been appointed as your new acting representative body chair.

As your representative I would like to take this opportunity to say hello.

I was elected as your deputy RB chair in 2019 having previously taken on a number of local and national roles in the association, including on the BMA medical students committee, junior doctors committee and agenda committee.

Very few people outside of the BMA know what my role as RB chair means. I think that is a shame – and it’s something I would like to try to address during my time in office. The first part of my job is to represent the RB; the medical students and doctors who come together once a year for the annual representative meeting, where we make policy for the BMA to act on. That is a group of around 600 people who represent our 159,000 members from across the UK and the profession.

The other main part of my role is to represent the views of the wider membership – to make sure your voices are heard as widely as possible. My role requires me to be neutral. I will take the experiences, reflections and ideas of members to branches of practice committees, to the BMA council or the board of directors.

And I will support the BMA to amplify your views in the wider society.

While the BMA has many representative structures – and increasingly diverse representation – the reality is that even with all the different regional and national committees only a fraction of the membership is directly involved. These are important, powerful, structures – but they are only the tip of the iceberg when it comes to involving our membership in our work.

My foremost priority in this role is to talk to members, and for that to be a two-way conversation – not just me speaking at you. Whenever my time in the position comes to an end it would be my proudest achievement if I had been able to listen, to engage and to amplify the views of as many of our members as possible. To increase our membership footprint.

I know from my communications with members – through this column, features in this magazine, social media and emails – that people who are not necessarily active in BMA structures do wish to engage with us and

@drlatifapatel do have stories to tell and experiences to share. I want you to help me understand how I can best facilitate that process. How would you like to talk to us? Do you want the continued use of surveys, which have been so useful during this pandemic? Is the best way of communicating through our FPC (First Point of Contact) system where you can leave us messages? Would you like us to hold surgeries? Or should we utilise social media more – with ‘ask me anything’– type slots, for example? I want our methods of communication to be the ones that offer you the best opportunity to have your say. Please get in touch and let me know how I can help your voice to be heard.

I’d also like your views on the BMA’s ARM. The association is reviewing it – looking at the way it works and whether things need to be changed to ensure we are representing members as best as possible. I want to hear your reflections so we can feed those into the process.

I want to know if members understand how the ARM works, whether you know who represents you there and how policy made at the ARM influences the BMA during the rest of the year. I want you to tell me how the voices of members should influence decisions the BMA board and council make outside of the ARM when they have to react to events.

I firmly believe the greatest attribute of this association is our strength in numbers. In every forum, in every meeting, and on every stage we are a trusted voice for 159,000 doctors across the country and across the profession.

We are a powerful pool of talent, experience and expertise and we must make the absolute most of that collective strength. To do that to the best of our ability I want to make sure we are constantly looking to improve our communication and engagement. And the best way to do that is if you tell us how we can be better. Please get in touch and let me know.

Latifa Patel is acting chair of the BMA representative body

22 thedoctor | July 2021

20210200The Doctor Issue 33 July – p.22-23.indd 1

12/07/2021 09:45

viewpoint

Why doesn’t my grandson want to become a doctor?

MACHERLA: The Government thinks it can take doctors for granted

More needs to be done to attract and retain doctors to the NHS, otherwise the next generation will simply not be interested ‘Ninety pounds for the first half-hour to assess and diagnose the problem. Then £75 per half-hour after that.’

I have no great skills in plumbing so I sighed, agreed to it, and switched the TV on. The news item was about doctors’ reaction to the Department of Health’s recommendation of a 1 per cent pay rise for NHS staff in England.

After all the sacrifices they and their NHS colleagues have made in the last 18 months, it seemed cruelly unfair.

I looked up the starting salary for an NHS consultant, and it is around £80,000 per year for 40 hours a week, although hardly any doctor works only for these hours, and none would leave a sick patient in the lurch.

To become a consultant in the NHS it takes at least 13 years from the start of medical school. It entails a number of rigorous examinations, assessments and extensive training. After all this, a consultant’s basic pay equates to around £20 for half an hour.

Compare this with that of £90 per half an hour I was charged by the plumber. I respect their and other skilled work, and how much they charge is up to them. But if you have to attract people into the medical profession, such societal perspectives cannot be ignored.

We have seen recruitment problems and attrition, with more than one in five doctors considering leaving the profession altogether, and a third planning to leave early, according to recent surveys.

One problem is that the NHS has a strange business model. While the service as a whole is not profit-making, it has the culture of profit-driven enterprise hard-wired into its obsession with targets, and the financial

bma.org.uk/thedoctor

20210200The Doctor Issue 33 July – p.22-23.indd 2

penalties for missing them. It feels like the service responds by squeezing as many units of activity as it can out of every doctor, who tend to view the world instead through the lens of providing the best patient care.

But even in the most profit-driven of private companies, there is an understanding that they need to take care of workers’ well-being otherwise they leave. The NHS does not seem to have grasped this.

I was talking to my 13-year-old grandson the other day, and asked him what he wanted to be in the future. An astronaut, perhaps, he said. Law, he suggested, or architecture, the performing arts, flying planes. Very good, I said.

And then I waited. Both of his grandfathers, his dad and his uncle are doctors.

‘And… medicine?’ I asked. He smiled.

‘Grandpa, hearing everyday about how awful and miserable life is being a doctor why would I choose to become a doctor?’

There’s a lesson there for we doctors.

Our children barely get to see us sometimes, and, when they do, we bring our troubles home with us. There’s a lesson for the Government too. It assumes that enough people will still want to do this job, and then when they’re doing it, they’ll be happy to live off fresh air and platitudes. It is complacent to assume that.

Perhaps my grandson’s choice is a right one. But then it is sad for the society if such young aspiring students are deterred by the unenviable state the medical profession is in the UK. Radhamanohar Macherla, now retired, was for more than 20 years a consultant physician with Barts Health NHS Trust thedoctor | July 2021 23

12/07/2021 09:45

ADVERTISEMENT

There’s always someone you can talk to…

It’s vital that you look after your own mental and physical health, especially while looking after others Free face-to-face counselling for doctors and medical students In addition to our existing in-the-moment support and telephone/video counselling, you can now also access a structured course of up to six face-to-face counselling sessions from one of over 1,800 counsellors across the

UK, with our partner Health Assured. All counsellors offer a safe and confidential COVID-secure space where you can talk to a BACP accredited professional about the challenges you face.

Wellbeing support services C O U N S E L L I N G | O N L I N E | P H O N E | FAC E TO FAC E 030 123 1245 | bma.org.uk/yourwellbeing

thedoctor

For face-to-face counselling, please visit our website for information on COVID-19 secure arrangements and availability, as Government restrictions are eased.

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

Editor: Neil Hallows (020) 7383 6321 Chief sub-editor: Chris Patterson

Email thedoctor@bma.org.uk Call a BMA adviser 0300 123 1233 @TheDrMagazine @theBMA

Senior staff writer: Peter Blackburn (020) 7874 7398 Staff writer: Tim Tonkin (020) 7383 6753 Scotland correspondent: Jennifer Trueland

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 July 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 July be obtained from the publishers on written request.

Feature writer: Seren Boyd Senior production editor: Lisa Bott-Hansson Design: BMA creative services Cover photograph: Charles Birchmore Read more from The Doctor online at bma.org.uk/thedoctor

The Doctor is a supplement of The BMJ. Vol: 374 issue no: 8300 ISSN 2631-6412

20210200The Doctor Issue 33 July – p.24.indd 1

12/07/2021 10:44