The Doctor, September 2020, issue 24

The magazine for BMA members

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Issue 24 | September 2020

Home alone Keeping shielding doctors safe

The COVID cash cow Private providers flourish despite their many failings Disclosure fears Disabled doctors and their fight for inclusivity Going virtual The BMA annual representative meeting 2020

07/09/2020 10:11

thedoctor

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

Email thedoctor@bma.org.uk

Call a BMA adviser 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.

Editor Neil Hallows (020) 7383 6321 Chief sub-editor Chris Patterson 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 photographer Ed Moss

The Doctor is a supplement of The BMJ. Vol: 370 issue no: 8259 ISSN 2631-6412

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In this issue 4-5 ARM 2020

Motions to watch out for at the BMA’s first virtual annual representative meeting

Welcome Chaand Nagpaul, BMA council chair These are extraordinary times.

This month, the BMA annual representative meeting will take place virtually – for the first time in our history.

We will not be interacting face to face amid the buzz of the packed conference hall. However, as our health service faces its greatest challenge for decades, we will still come together and continue to be a voice for the profession during this unprecedented period of history.

There is much to discuss. Not least, this Government’s lack of preparedness, an NHS run into the ground with little flexibility to cope, and the courage, leadership and flexibility of doctors who took on new job roles, worked well beyond the line of duty and even returned from retirement or stepped up from education to help fight this disease.

This month’s issue of The Doctor covers many of the issues we will debate at the ARM as we look at the effect of the pandemic on medical students, the plight of doctors who have had to shield during these difficult months, the response to the COVID-19 crisis from other countries and the Government’s seemingly obsessive use of private firms for its pandemic response.

Our forensic examination of the use of the private sector during the coronavirus pandemic highlights a consistent finding – that handing contracts and money to private firms has repeatedly resulted in squandering large sums of public money without effective delivery.

Whether it is in relation to the provision, and logistical managing, of personal protective equipment, the set up and running of laboratories and testing centres or the apparently ‘world-beating’ test, track and trace project – private firms have proved costly and inefficient and many serious failings have been exposed. The greatest tragedy of all, perhaps, is that this could have been an opportunity to invest in public health services, NHS expertise and local authority know-how – instead the Government doubled down on the ideology that has crippled the health and care system during the past decade.

Also in this issue of The Doctor we speak to emergency medicine doctor and MP for Tooting, Rosena Allin-Khan and profile esteemed surgeon, public health doctor and incoming BMA president Harry Burns.

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Outsourced and undermined The more the private sector under-performs, the more COVID-19 contracts it seems to win

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Lecture over Mixed fortunes for medical students during the pandemic

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Lived experience Doctor and MP Rosena Allin-Khan on her plans for improving mental health

18-21

Doctors can be vulnerable too Some doctors needing to shield themselves or others from COVID-19 are now finding themselves pressured to return to an unsafe workplace

22-23 Prepared for the worst How South Korea used the lessons from a different coronavirus to inform its response against COVID-19

24-27 Politics vs evidence Incoming BMA president Harry Burns comments on the handling of COVID-19

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Disabled and dismissed Disabled doctors face significant barriers, a BMA survey has revealed

30-31 On the ground How the BMA has tackled doctors’ changing working conditions

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The ARM, virtually

ARM2020

This year’s BMA annual representative meeting, where the issues of the day are discussed and policy for the year ahead is created, is taking place during extraordinary times.

Now a one-day event on Tuesday, 15 September, it will be held and run virtually – for the first time in the association’s history. While the event would usually see hundreds of doctors coming together to share experiences and debate the BMA’s response to the biggest issues of the day, this year the additional workloads and the restrictions brought by the COVID-19 pandemic have rendered that impossible.

Instead, doctors leaders will deliver speeches and motions on some of the most important issues, related to the pandemic and the profession and society in a wider sense, online.

Here, we profile motions which will be debated during the ARM.

ISTOCK

UNDER STRAIN: COVID-19 has heaped pressure on frontline staff to tackle growing waiting lists

Follow the BMA annual representative meeting 2020 on 15 September online at bma.org.uk/arm

In July, a BMA report revealed the sheer scale of the hidden effect of the COVID-19 pandemic – with millions of patients not receiving planned operations, treatments and appointments.

It is a problem followed by great consequences. NHS England data for June shows waiting lists for treatment increasing and unmet care rising, with the number of people waiting more than one year for treatment 46 times its normal value in June. And the statistics suggest the majority of patients are likely now waiting more than four months for treatment.

A motion at this year’s ARM aims to address some of these problems. It notes this extraordinary backlog of planned care and the likely effect on NHS waiting lists and calls for the BMA to work with governments to develop a public information campaign on timescales for the NHS’s return to normal routine services, to demand adequate funding for the NHS to increase capacity, to seek the return of public funds paid to the for-profit private sector and to promote the invitation of all patients on waiting lists to opt into a rescheduled appointment and potential primary care review.

Motion 13: Public health scapegoats Last month, the Government appeared to place PHE (Public Health England) in its sights as the fall guy for wider failings and questionable political decision making – with health secretary Matt Hancock announcing the creation of a new National Institute for Health Protection, which would combine parts of PHE with the struggling NHS test-and-trace system. It was news first conveyed to public health staff over Twitter on a Sunday evening.

The BMA has repeatedly warned of the effects of substantial budget cuts and deep fragmentation of public health services.

In response to the announcement, BMA council chair Chaand Nagpaul demanded the Government not seek to blame PHE and its staff and urged the return of a fully integrated public health and NHS, locally and nationally, with proper resourcing and protections for staff who need to be able to speak out.

A motion at this year’s ARM says the global PA

ARM2020

Motion 12: Waiting list explosion

HANCOCK: Replaced Public Health England

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pandemic has demonstrated the need for a wellresourced national health protection function and calls for a Government review of the fitness for purpose of the UK’s current systems, PHE to be reconstituted as a fully arm’s length, independent, NHS ‘special health authority’, the establishment of a national public health infection service as part of PHE and for all consultants in public health to be employed on contracts equivalent to NHS consultants with guarantees of freedom to make professional advice public.

Motion 14: Inquiry demands The UK has suffered more than almost any other country during the COVID-19 pandemic. The UK has had more deaths than any other country in Europe and the fourth most in the world behind the USA, Brazil and Mexico.

The UK has the greatest number of excess deaths in Europe and the highest case mortality rate from 15 May to 10 August. And on top of that UK GDP fell by 20.4 per cent in the second quarter of 2020 – more than double the fall in the USA and significantly higher than France, Italy, Canada, Germany and Japan.

It has been a pandemic response characterised by hamstrung public services struggling to cope, monumental PPE (personal protective equipment), testing and logistical failings and endless Government U-turns.

At this year’s ARM doctors will consider a motion which demands a public inquiry into the UK Government’s management of the pandemic – urging a remit which would include the mismanagement of care homes, the provision and logistical management of PPE, testing strategy, health and care staff wellbeing and the timing of interventions and easing of restrictions.

Other prioritised motions at the ARM Motion 15: Calls for affirmation of the rights of transgender and nonbinary individuals to access healthcare and live their lives with dignity.

Motion 16: Asserts that the COVID-19 pandemic and the Black Lives Matter movement have demonstrated the importance of addressing health inequalities and racism in the UK. Motion 17: Asks for a mandate for the BMA’s council and committees to pursue policies which would see a return to pre-COVID contractual requirements and job plans, proper remuneration for additional work, protection from future long-term changes to job plans or contracts and an additional reward for healthcare staff who made personal sacrifices during the pandemic.

Motion 19: Urges the BMA to support continuation of the home use of mifepristone with remote consultation support for abortion Motion 20: Demands that any trade deal between the US and UK does not result in a rise in UK drug prices, does not weaken the ability of the NHS and related bodies to negotiate drug pricing with US companies and does not adversely affect the safety and regulation of drugs and medical technologies distributed in the UK. Motion 24: Calls on the BMA board of science to examine the evidence base on the use of digital consulting and when it can be appropriately used.

Motion 25: Calls for a reduction in GMC regulation and an independent audit of the processes of appraisal and revalidation.

Motion 26: Demands a survey of members on the Review Body on Doctors’ and Dentists’ Remuneration pay recommendations and whether the BMA should take steps to tackle real-terms pay erosion.

Motion 27: Raises concerns about the adverse effect of the pandemic on mental health of healthcare workers and carers – and insists that governments and NHS departments make resources widely and rapidly available.

MATT SAYWELL

‘This year’s ARM is a first – it will be our first annual meeting taking place virtually and our first during the grips of a global pandemic which has changed so much for all of us. With clinical workloads and restrictions related to COVID-19 we cannot meet face to face, but it has never been more important for us to come together. The impacts of coronavirus on doctors, patients, the NHS and wider society are clear for us all to see

Keep in touch with the BMA online at

– and the voices of doctors, who face so many of the immediate impacts of this crisis – must be heard.

‘With so much to discuss and so many issues to tackle this year’s event will be as important as ever. Please get involved through watching the event live online or following on social media using the hashtag #ARM2020.’

Helena McKeown is BMA representative body chair

instagram.com/thebma

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Outsourced and undermined The private sector has been the winner in the Goverment’s response to COVID-19 in England – but why, given the growing and predictable litany of mistakes it has made?

Peter Blackburn reports

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he prime minister has admitted there may be ‘some lessons to be learned’ from his Government’s handling of the coronavirus crisis.

It is perhaps a rare moment of understatement from Boris Johnson. In truth, it is hard to know where to start. But when the inevitable public inquiry takes place, there is one area of deep concern which must not be neglected – the Government’s reliance on the private sector.

New contingency measures have been put in place during the pandemic which circumvent normal tendering processes, and now large parts of the overall response are in the hands of the private sector.

Among the deals which have been struck: DHL, Unipart and Movianto to procure, manage logistics of and store PPE (personal protective equipment); Deloitte to manage the logistics of national drive-in testing centres and super-labs; Serco to run the contact tracing programme; Palantir and Faculty A.I. to build the COVID-19 datastore and Capita to onboard returning health workers in England.

‘Since the passing of the Health and Social Care Act in 2012 the NHS in England has been forced down a route of increased marketisation and privatisation – and the Government has accelerated its aggressive outsourcing to private firms during the COVID-19 pandemic,’ BMA council deputy chair David Wrigley says.

The Westminster Government’s dependence on private firms during the pandemic follows a decade

of health system reorganisation and marketisation combined with severe funding cuts to public services and local authorities in England. The result has been weakened and fragmented NHS services and local councils’ public health departments – with the country’s ability to respond to COVID-19 hampered. This environment may have allowed the private sector to flourish during the crisis – but publicly owned facilities, services and staff could have been invested in and utilised rather than, in many cases, feeling ignored.

Many of these issues were problems identified during a simulation exercise carried out in 2016. Exercise Cygnus uncovered crucial gaps in the UK’s ability to plan and prepare for a pandemic at the local and national level. The recommendations from the report on the exercise appear to have been largely overlooked by the Government which meant the UK started out at a significant disadvantage, with inadequate resources and resilience mechanisms. And cost-cutting and austerity can only have exacerbated these problems.

Speaking to The Doctor, in June, the former health secretary and now chair of the Commons health and social care select committee Jeremy Hunt admitted mistakes had been made under his tenure.

He said: ‘The main mistake was that we focused our preparation on pandemic flu rather than a SARS-like virus, all our thinking was geared to the way flu-type viruses behave – that there was no need to increase PPE stocks or testing capacity.’ thedoctor | September 2020

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to supply PPE. The contracts awarded by the Ministry of Justice and Department of Health and Social Care are reportedly worth between £25m and £120m. It is a web of structures which could hardly be more complex.

In May, amid concerns around supply of PPE across the NHS, the Westminster Government appointed Deloitte to develop a new procurement plan to boost the production of PPE and source stocks from the UK and abroad. While, separately, trusts were told by NHS England that a new data collection process was being rolled out nationally to establish an equitable distribution of PPE. This information pertaining to stock levels is being gathered by US data mining company Palantir.

The result of all this complexity?

Unsurprisingly it is fragmentation, bureaucracy and uncertainty where the healthcare workers putting their lives on the line desperately The background to a reliance on aggressive needed simple structures and effective outputs. outsourcing is clear – a health and care system starved Even after the decision was made to give Deloitte of resource and expertise left uncared for. Whether responsibility for leading on boosting stocks, there were ideology or incompetence underpins these decisions is ongoing concerns with delays in PPE supplies and how not totally clear, but the results well this new procurement have been painful.

‘We are seeing outsourcing system has been managed, At the top of the damning with some UK manufacturers being carried out with list of these painful results pointing out that offers to minimal oversight, governance help provide PPE were not are problems with the supply or transparency’ responded to – the BMA alone of PPE. During the initial was contacted by 70 companies willing to supply PPE COVID-19 outbreak these issues were well documented with many healthcare workers reporting they were not but unable to communicate with the Government. provided with adequate PPE, leaving them exposed to the virus.

Home testing failings In recent years large parts of the management and Delays with PPE have further highlighted issues logistics of procuring and stockpiling items such as PPE around the level of oversight and governance of these for the NHS in England have been outsourced to a web processes in Whitehall. Delegating large parts of the of private companies. management of procurement processes and supply Although NHS procurement is ultimately the chains to a complex web of external companies has left responsibility of NHS Supply Chain Coordination Ltd the Westminster Government less able to respond in an – a publicly owned company responsible for sourcing, agile and rapid way to the dramatic increase in demand delivery and supply of healthcare products across for PPE caused by the pandemic.

England and Wales – in reality, most of the management It is not only in the supply and management of PPE and coordination of procurement for items such as PPE that the Government appears to have almost entirely has been outsourced. relied on the private sector, with the approach to the DHL has responsibility for finding wholesalers to building up of testing capacity following the same trend. supply ward-based consumables, including PPE kits.

A contract of undisclosed value was secured by Unipart manages supply chain logistics, overseeing the Deloitte, one of the ‘Big Four’ consultancy firms, to set delivery of PPE, and Clipper Logistics was contracted up and manage a network of 50 off-site testing centres in England and Scotland. The firm has been responsible by the NHS supply chain to deliver PPE. And the PPE for managing logistics across these sites as well as stockpile is sub-contracted to Movianto. In addition, there are a growing number of examples of firms with no booking tests, sending samples to laboratories and former appropriate experience or expertise – in one case communicating test results.

Fitting with the general theme of complexity, Deloitte including a pest control company – being contracted WRIGLEY: ‘We should not be continually running to the private sector’

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of test results in understanding the spread of the virus then nominated Serco, Sodexo, Mitie, G4S and Boots to inform national policy, and has left NHS staff, who to staff and manage operations at the testing sites. have reportedly waited up to seven days to receive their Those unable to access the testing sites were advised results, unaware of their COVID status. Conversely, local to request home testing kits produced and processed NHS laboratories were able to determine the results in by diagnostics company Randox (in a contract worth just six hours. £133m) and dispatched by Amazon.

The concerns have been held for some time. At the In July it emerged that the swabs in some batches start of July Jo Martin, president of the Royal College of of these home testing kits were not up to standard Pathologists, said: ‘It is really important that the data and, embarrassingly for the Government and health is easily accessible by those secretary Matt Hancock, had who need to be able to deal to be withdrawn. with infection in both primary And last month and secondary care, but also The Guardian revealed that those who need to trace hospitals had asked to take ‘England has been forced down a related infection. I would like over the running of Deloitte’s route of increased marketisation to see very close collaboration testing centre at Chessington and privatisation’ between any new endeavours World of Adventures, in Surrey, and existing providers of after failings led to the test pathology services to the results of NHS staff being lost NHS.’ or sent to the wrong person.

And in June doctors and public health leaders At the same time a network of Lighthouse told The Doctor they face difficulties in delays of Laboratories was developed through a partnership test results, a significant lack of data availability and with the DHSC, Medicines Discovery Catapult, UK regular communication failures between Serco, Public Biocentre and the University of Glasgow. Deloitte was Health England nationally and local teams. handed further responsibility for coordinating these Delays in delivering test results have been labs, located in Milton Keynes, Glasgow, Cheshire and compounded by reports of lost test samples, leaking Cambridge and the centres were built over several test vials and incorrectly labelled samples at testing weeks to cope with testing on a mass scale, processing sites and laboratories. And the BMA believes standards 75,000 tests of the Government’s 100,000 target.

The moves were met with great concern from clinical vary greatly between the Lighthouse labs, with reports that labs have been disposing large proportions of staff working in and around the NHS – with a growing batches of tests and others not being fully utilised, sense that a parallel system bypassing the existing with dozens of shifts cancelled as a result of a lack of network of NHS labs was being built, encouraging test samples. competition for supplies and effectively reducing the capacity of the established labs. A former director at the World Health Organization, Anthony Costello, said the 44 NHS labs were left ‘under used’ and major centres such MARTIN: ‘I would like to see as the Francis Crick Institute and Oxford University were collaboration between any new endeavours and existing providers’ ignored when offering expertise and resources.

Mistakes repeated Speaking in July Allan Wilson, president of the Institute of Biomedical Science, said the Government was repeatedly making the same mistakes but seemed ‘determined to continue using the same model’ and that the NHS should be given a chance to bid for contracts.

Outsourcing the coordination of testing appears to have resulted in significant adverse effects. The Lighthouse laboratories were reportedly taking three days from the time they received the samples to process the results and national leaders in pathology have indicated that this delay limits the usefulness

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Further problems encountered with IT systems and data protection also meant that during the first two months of lockdown, GPs and local authorities were unable to receive timely, detailed information on tests conducted in privately-run sites, despite the commitment in ‘pillar two’ of the Government’s testing programme to link data with patient medical records.

The Deloitte contract does not oblige the company to share detailed data with PHE or local authorities. It is a basic failure which, according to many, contributed to an extended lockdown in Leicester.

The procurement of logistical and IT support for the test and trace strategy has been a hugely problematic area – with serious issues involving the use of the private sector, too. Serco and Sitel were bypass normal tendering processes. The contracts awarded contracts valued at £108m to support the that cover testing centres, laboratories, PPE Government’s test and trace strategy – recruiting procurement and staff recruitment are agreed without 25,000 contact tracers to work in remote call centres competition or public scrutiny making it difficult to – but Serco accidentally shared the email addresses demonstrate value for money. of 296 contact tracers and Emergency procurement is there have been warnings said to have enabled a rapid that call handlers were response to the crisis but has ‘There is no ability to inadequately trained. reduced transparency around In the first week of scrutinise these deals and the contracts signed with COVID tracking in England, taxpayer money is haemorrhaging private firms. This was also government figures from the treasury’ the case with the Nightingale suggested that approximately Hospitals, where it is still one third of positive cases unclear how the sites were transferred into the system procured. The hospitals have were not contacted by call cost up to £350m for three months but treated fewer handlers, leaving patients potentially unaware of than 100 patients. their illness. Meanwhile, contact tracers were left with minimal or no work for several days, waiting to be Better prepared allocated cases that did not arrive.

There has been an absolute litany of problems – Money wasted and there are a host of lessons to be learned and Given the mounting – and expensive – evidence, a safeguards required to protect the NHS and the public BMA report into outsourcing during the pandemic in future, whether in further waves of this pandemic or draws some serious, but seemingly quite clear, in preparation for another. conclusions. It suggests that public resources are Ultimately, the BMA has consistently called for being wasted on unnecessary private outsourcing, a publicly funded, publicly provided and publicly that outsourcing is being used to fill gaps created by accountable NHS. The best chance of a speedy underinvestment and that decisions to outsource and comprehensive response to a pandemic is a have caused fragmentation of services, disabling a properly resourced health and care system. And, the coordinated response. result of an over-reliance on outsourcing carries a On top of that there are huge, and legitimate, risk of removing crucial elements of major incident concerns with transparency and the robustness of management – such as the ability to command and procurement processes. The contracts awarded to control. Successful major incident management private providers under special pandemic powers depends on the capacity to adapt any and all 10

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responses rapidly with complete agility, a situation that may be limited when private companies are contracted.

Beyond that, the BMA report calls for any public inquiry into the Government’s handling of the coronavirus outbreak to scrutinise the role of outsourcing.

The evidence of the need for this seems incontrovertible. In August virologists across the UK wrote a letter criticising the UK’s handling of the testing strategy and with detractors and failures mounting handing out further contracts and taxpayer money to private firms could result in yet more concerning consequences. And moving forward the Government must be more transparent about the private sector outsourcing ‘The health service that has taken must be protected and place during the returned to being a publicly funded system’ pandemic – with details of contractual arrangements with private companies published. The Government should, the BMA asserts, also pursue a much more robust governance system under NHS control that has oversight of the management and coordination of procurement in England or at a UKwide level.

Dr Wrigley says: ‘The BMA has been lobbying against this dogged policy in England of outsourcing for many years but the current level and nature of the contracts being handed to these corporations

is becoming increasingly concerning. We are seeing this outsourcing being carried out with minimal oversight, governance or transparency. There is no ability to scrutinise these deals and taxpayer money is haemorrhaging from the treasury while a health and care system in desperate need of investment and resource is ignored.

‘Urgent action is required to protect the NHS and ensure taxpayer money is being spent in a responsible manner. In the long term the health service must be protected and returned to being a genuinely publicly funded, publicly provided and publicly accountable system.

‘That must include a substantial year-on-year realterms increase in funding for the NHS, local public health departments and a genuinely reformed and properly financially supported social care system.’

Dr Wrigley adds: ‘We should be empowering and expanding our NHS to undertake additional health related work and not continually running to the private sector who have shown time and time again that they are not able to undertake and fulfil contracts to a satisfactory level.’

Private matters A BMA paper outlining the Government’s use of private providers in its pandemic response sets out the following recommendations: – A publicly funded, publicly provided and publicly accountable NHS – The role of private outsourcing in England to be scrutinised in any future public inquiry on the UK government’s handling of the Covid crisis – A substantial increase in funding for the NHS and local public health departments – Transparency of private contractual agreements – A more robust governance system under NHS control that has oversight of management and coordination of procurement.

At the BMA annual representative meeting, taking place online on 15 September, doctors will debate a call for the BMA to ‘seek the return of public funds paid to the for-profit private sector to retain capacity which was under-used during the pandemic’.

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The pandemic has brought mixed fortunes for medical students. Some have had to miss out on vital clinical experience, while others, drafted in early as doctors, got far more than they bargained for. Jennifer Trueland reports

LECTURE OVER

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ISTOCK

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s medical schools grapple with the challenge of opening their doors to unprecedented numbers of future doctors this month, the effect of COVID on existing students is still felt.

With face-to-face teaching and placements coming to an abrupt end at the start of lockdown, it’s been a mixed picture for students depending on their personal circumstances, the stage they had reached – and the decisions taken by their medical schools.

Students at some universities have had a better experience than others, says Gurdas Singh, co-chair of the BMA medical students committee, who is studying medicine at King’s College London.

‘It’s been disparate – from what I hear, universities reacted in different ways. For example, King’s did really well – my friends said that the way they handled it was absolutely excellent. They got increased webinar teaching, they got out-of-hours teaching which they wouldn’t normally have had. They actually got so much more teaching than they necessarily would have on clinical placements, so they felt really supported.

But other people said they had virtually no teaching in their medical schools and that was quite unfortunate,’ he says.

Second-hand experience Even where the online teaching was top-notch, the situation was far from ideal, says co-chair Chris Smith, a student at Southampton University, who is now based in Jersey for his final year.

‘From what I’ve been hearing from my peers, we [at Southampton] got a pretty good part of the deal. We got semi-regular lectures, semi-regular tutorials, which is a lot more than a lot of other people got, but it still wasn’t enough. It didn’t make up for actually seeing people and actually being on placement. It didn’t make up for being in the room and sitting in the tutorial.’

As with other students going into their final years, Mr Smith experienced the cancellation of a placement,

MATT SAYWELL

SINGH: ‘Universities reacted in different ways’

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MATT SAYWELL

MATT SAYWELL

DANGERFIELD: ‘I get a feeling a lot of them missed out on the formal teaching’

SMITH: ‘We had to buy new routers, we had to buy desks, we had to buy chairs’

in his case, psychiatry. He confesses he wasn’t completely broken-hearted about this, but he is now a bit fed up that, in order to make up the hours, he will not be able to do his elective placement.

‘I was supposed to be doing oncology, which is the career that I’d like to go into,’ he says. ‘It was a bit of an unfortunate turn of events, but it’s just one of the things that we’ve had to adapt to with COVID.’

Home study drawbacks There were other, more practical considerations as well. ‘I’ve been living with a shielding parent and haven’t been able to volunteer to work in the NHS,’ says Mr Smith. ‘I just studied at home and used the virtual learning, including lectures, provided by the university. We did sit our exams, but they were online and automatic progression.

‘There were four of us working from home trying to use the internet, and we didn’t have a good internet connection. We had ‘We got semi-regular lectures, to buy new routers, we had to buy desks, semi-regular tutorials, which we had to buy chairs. is a lot more than a lot of other I hadn’t lived at home people got’ for a prolonged period of time for more than eight years so it took a bit of getting used to, settling back in. We were lucky in that we had some outside space, but it wasn’t easy.’

Even for those who were able to volunteer to work in the NHS, experience varied. ‘I have friends in Bournemouth who felt really fulfilled by what they were doing. They felt they were part of a team and that they were contributing something. Whereas I had other people at busier, bigger hospitals who said there were so many people there that it was difficult to find shifts and they didn’t feel that they were being properly utilised a lot of the time. I also know students who applied to be foundation year 1s early but they weren’t needed.’

Closed canteens, long hours Medical students who had taken time out of their courses to complete an intercalated degree were also affected. Mr Singh, who was working on an intercalated master’s in hand surgery at Oxford, found himself back in his childhood bedroom rather than in the lab or library as he tried to finish his course work.

The start of the pandemic was a ‘weird time’, he says. ‘All my flatmates started to leave. It was quite upsetting to be honest – it felt very isolating. It was also very difficult because all of the facilities in Oxford shut down – normally you rely very much on catering, eating in halls, because it’s so much cheaper even than going to a supermarket and cooking your own. So, expenses went up, you couldn’t see people – because it was classed as a communal area you couldn’t even sit with people on the college grass.’

His research involves patient-identifiable data, so when he realised he would no longer be able to go to the data lab, he had a ‘mad panic’ extracting all he could that wasn’t patient identifiable, while ensuring that governance arrangements were in place.

‘I was working very long hours getting the data in a state where I could take it with me – working overnight, 30 hours [at a time]. I had to get permission from the information commissioner’s office to take it out. Obviously, it wasn’t ideal – I basically became sort of a zombie.’

He also had limited contact with his supervisors, two of whom were clinicians and required to work in hospital, while the other two were told to shift their research to coronavirus. ‘They really didn’t have time to start looking at my thesis, for example, or my modelling or anything like that.’

‘Mixed bag’ Peter Dangerfield, co-chair of the BMA’s medical academic staff committee and senior lecturer at the University of Liverpool, says it’s been a tough time for

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‘I worry about the strain this is causing all through medical school’ students at all stages, but that experience has varied.

‘One gets a feeling that it’s been rather a mixed bag – some have done quite well out of it, and others don’t seem to have had as good an experience as they would have liked. I get a feeling as well that a lot of them missed out on the formal teaching they would have expected to come up to standard at the end of the year.

‘A lot of them were pushed out in March when they’d normally be there until June, continuing studies and possibly exams and everything else.’

Some students fared better than others with formal teaching cancelled.

For those from more affluent backgrounds, there were comfortable working conditions, working highspeed wi-fi and perhaps even a doctor mum or dad to help with home-study.

Others weren’t so fortunate – which runs the risk of baking in alreadyexisting inequalities. ‘It’s partly the luck of the draw and if you know the right people,’ says Prof Dangerfield.

On the whole, students – the future medical workforce – have done us proud during the pandemic, says Prof Dangerfield. But he adds: ‘I worry about the strain this is causing all through medical school – we have enough problems with anxiety and depression and mental issues with the students as it is, and it is a constant worry.’

PATERSON: ‘As long as people are supporting each other, it really gets you through’

A flying start For one student, beginning her career early was a hugely positive experience, and she even had a graduation of sorts For Amy Paterson, the pandemic meant starting work as a doctor earlier than planned.

A final-year student at the University of Dundee, she opted to join the GMC register early and take up a post as an interim foundation year doctor. At first, she had been told she would be working on the COVID ward – which she admits was a ‘daunting’ thought – but in the event, the reduction in cases meant she was allocated to the general medicine ward at Perth Royal Infirmary. PRI – part of NHS Tayside – was designated as a ‘clean’ hospital, that is, there were no positive cases of COVID. ‘At the start it was very quiet but as the weeks went on a lot of patients coming in were very sick – I think because they hadn’t wanted to come in because of COVID so they had delayed seeking help. About three weeks in, it started to get very busy so they were very grateful to have extra hands.’

She found the medical staff at PRI very helpful. ‘I learned a huge amount, and one thing that sticks in my mind is the teamwork aspect.

It seemed the most important thing – as long as people are supporting each other, it really gets you through. I really enjoyed it, and everyone pulled together.’

Being allocated that role was particularly good for Dr Paterson, because it was where she was to start working in her first substantive post – this time as a ‘real’ rather than interim FY1. ‘I feel much better prepared,’ she says. ‘I think the registrars recognised that this was actually a very good opportunity for us because they remembered feeling very overwhelmed on their first day, even when doing things like prescribing paracetamol, but we’ve been doing that for months now so it won’t seem as daunting, I think.’

She felt appreciated, she says. ‘They even had a fake graduation ceremony for us when we left – they got us a card and Prosecco; it was so nice of them and they were very kind to us.

‘I’m pleased to have got through medical school when I did – I think we were probably the best of the five years, because we were able to start work. I have friends in the year below and they still aren’t really sure what their final year is going to look like and how their scores will be calculated, so I’m glad to be through.’ thedoctor | September 2020 15

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ALLIN-KHAN: ‘I fought so hard to be a doctor’

Lived experience The daughter of a single parent in south London, Rosena Allin-Khan was told medicine wasn’t for the likes of her. Turns out it was. The A&E doctor, MP and shadow mental health minister talks to Keith Cooper about deprivation, inclusivity and the benefits of belligerence

R ‘There’s still a resounding stigma attached to [mental health]’

osena Allin-Khan, emergency medicine doctor and Labour MP for Tooting, London, began her national political career in turbulent and tragic times.

She was elected on 16 June, 2016, the day Yorkshire MP Jo Cox was murdered, as the country prepared to vote to leave the EU, decades after it joined.

‘My children at the time were a baby and two and a half,’ she recalls.

This April, after winning her seat for the third time in the 2019 election, she was appointed shadow minister for mental health, as COVID-19 cases climbed to their first-wave peak, and while shifting at NHS Nightingale, London, as a link between patients and families.

Now, five months into the new role, Dr AllinKhan is telling The Doctor about her plans to shape party policy with her experience in medicine, life, and humanitarian aid. With NHS Nightingale shut, she’s back at St George’s, south London, and finished her latest shift the weekend before we speak. ‘I’m really committed to my medical career,’ she says.

‘Ifought so hard to be a doctor.’

‘I am pushy and belligerent’ is how she describes herself but it’s not how she comes across in our interview. Thoughtful, open,

and unafraid to admit of her own frailties, are more like it. They’re qualities many might welcome in mental health care – alongside that belligerence and pushiness for better and kinder care.

‘I know how hard an area this is to tackle,’ Dr Allin-Khan says. ‘I’ve had first-hand experience. There is so much to cover. While there has been some great strides forward made in mental health in recent years, there’s still a resounding stigma attached to it.’

Social deprivation Dr Allin-Khan sees her role and mental health policy as broad in scope, extending beyond NHS services. ‘Mental and physical health don’t sit in siloes in a health department,’ she says. ‘There’s issues of housing, of drug and alcohol abuse and the drivers behind that’.

With a master’s in public health, she’s a keen interest in prevention and the ‘bigger picture’.

‘All of the inequalities we see feeds into that,’ Dr Allin-Khan adds.

This bigger picture is played out, she adds, ‘in technicolour’ in her constituency surgeries in Tooting, where people bring her their problems, and in the emergency department, where she still works as a doctor.

‘People come in with breathing difficulties

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but when you dig deeper you realise they’ve got this because they live in a mouldy flat and have been on the housing list for years.

All of these things form a very fine interplay of experiences and people’s life situations which really help frame how I can be the best possible advocate for them.’

She has nothing but praise for staff who work in mental healthcare.

‘They work tremendously hard. They do the best job that they can, given the lack of resources,’ Dr Allin-Khan adds. ‘We have a huge issue with retention of an already stretched workforce. Everyone I speak to in the mental health sector are saying that workforce is really strained and they need more help, more workforce, more resources.’

She wants to work ‘in partnership’ with colleagues, those already involved in mental health care, and the NHS, and sees a boost in the workforce, especially in the community, as a key means of improving the service.

‘Sometimes people report having to wait so long to see somebody to support them with their mental ill health that they deteriorate to the point where they need to become an inpatient,’ Dr Allin-Khan adds.

‘I saw colleagues cry’ She is keen too, however, to hear from those whose concerns are yet to be acted upon.

‘I very recently had a roundtable with LGBTQ+ charities. I took a lot away from that,’ she says. ‘There is a disproportionate amount of homelessness, they say their mental ill health started at school.’ Such points prompt conversations with party colleagues, she says.

‘Reducing mental health inequalities requires working across departments, education, equalities and justice.’

Her first big policy push as shadow mental health minister was a call for a Care for Carers package to better support the mental health of NHS and care staff through the COVID-19 crisis. It was driven by her experience on the front line during COVID-19. ‘I saw many senior colleagues break down and cry,’ she adds.

‘It definitely affected my mental health and the mental health of most people I know.’

She’s working with trade unions to see what other employers can do to help staff feel safe enough to call in sick with mental health issues, like anxiety and addiction. ‘People don’t feel that they can do that. They fear losing their

job. I want to see an attitude shift so that there is compassion and empathy towards those suffering from mental ill health so that we can all support people in recovering faster.’

Once the COVID crisis has passed, Dr AllinKhan expects to focus on three main policy areas: child and adolescent mental health services, suicide, particularly in young men, and stigma.

She wants to ‘bring everyone into the conversation’. ‘When you look at suicide in young men, you can talk to LGBT men, you can talk to black, ethnic minority, and Asian men, engaging with different groups so they have a voice.’

Threats and abuse As a female, Muslim MP of mixed heritage, what she calls her ‘tri-factor of doom’, she receives much abuse, even death threats that, understandably, have their own impact.

‘I’ve had months where I’ve lost sleep, where I’ve really had to manage my feelings.’

Just being an MP, of course, joined her to a stigmatised, untrusted profession as she continues a medical career, ‘We have a huge issue one of the most trusted.

For all its challenges, with retention of an Dr Allin-Khan says Parliament already stretched would benefit from more workforce’ MPs with professional experience. She’s the only doctor on the Labour benches. ‘I’d love to see more doctors, nurses, porters, everyone, because lived life experiences make you an incredible advocate. We’ve got to support one another to get there.’

Being a politician, for her, seems in a way an extension of her medical career or what moved her towards it.

As the daughter of a single parent, working three jobs to survive, she was told ‘medicine wasn’t for kids like me’. She became an emergency medicine doctor ‘to meet the kids like me to change the path for them’ and a politician to ‘improve people’s lives in a way that my life needed improving when I was growing up’, Dr Allin-Khan says.

Now, with this shadow ministerial post, she’s the chance to alter some paths and make some improvements on the national stage. thedoctor | September 2020 17

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Doctors can be vulnerable too Some doctors needing to shield themselves or others from COVID-19 are now finding themselves pressured to return to an unsafe workplace. Tim Tonkin finds out how they’re being supported

T

he lockdown instituted in March was a hugely challenging, albeit necessary, disruption for many people’s daily lives – and one which they were eager to move away from, with the gradual easing of restrictions during June and July.

For those who have to ‘shield’ themselves or others from the threat of the virus, returning to normality has not been as straightforward or necessarily as eagerly greeted a prospect.

Shielding refers to the extra level of precautions needed to be followed by people deemed clinically extremely vulnerable to infection from the virus, with the measures applying to atrisk individuals and to those living with them.

With doctors among the most at risk of coming into contact with the virus as a result of their work, personal shielding – and shielding by proxy to protect vulnerable family members – was a reality for many members of the profession from March.

However, following a reduction in community transmission rates, the Government announced on 6 July that the national policy on shielding would be ‘paused’ from 1 August, meaning

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that thousands of those most at risk, including doctors, suddenly faced the prospect of having to return to their workplaces.

In the latest BMA COVID-19 tracker survey, a total of 405 doctors reported having been shielding, of whom 128 were doing so owing to personal clinical vulnerabilities, with the remaining doing so because of a vulnerable member of their household.

Of this total number, 147 reported having returned to work.

For those doctors shielding who have not yet returned to work, 20 told the survey they had an agreed date to return to their normal roles, 23 had a date agreed for a return to different roles and 69 had no agreed return dates.

One of those not set for an imminent return is Bristolbased anaesthetics clinical fellow Carly Webb.

Dr Webb had already been effectively shielding even before the pandemic, having been classed as extremely vulnerable owing to issues affecting her personal health.

She says that once COVID-19 took hold her employer had been accommodating in agreeing

KEMP: ‘The NHS response to the need for risk assessment, I think that’s been inadequate’

a phased return to working remotely, doing auditing work and other non-clinical tasks from the safety of her home.

‘COVID-secure’

DAVE NELSON

With the Government’s advice to those formerly shielding that they should only return to work if they are confident that their workplace is ‘COVID-secure’, Dr Webb says that, for doctors as exceptionally clinically vulnerable as herself, she is sceptical that any kind of healthcare environment would be able to reach such a standard.

‘My consultant and medical team have said that I still shouldn’t be in the hospital and are not confident that even an elective hospital can be COVID-secure enough for my risk level,’ she says.

‘I know that other doctors are going back into elective procedures with patients who have been tested [for the virus], but there is still risk that you end up working with colleagues who have seen patients in non-secure locations.’

Dr Webb says that while she has been well-supported by her trust in terms of being able to continue to work from home past the 1 August pause, she feels there are other doctors throughout the UK who have not been as fortunate.

She says she knows of doctors emerging from shielding who are being pressured into working in inappropriate, non-COVID secure on-call environments.

‘I know of multiple people who have been asked for

letters from lawyers waiving their right to safe working, which wouldn’t be valid as far as health and safety law goes, so that they can cover on-call rotas for departments,’ she says.

‘People feel a lot of guilt about not being in work and therefore when they’re then pressured to come in, they can feel that they are perhaps being over-anxious when, actually, a lot of us have a very real increased risk of dying from COVID.’

‘People are being pushed to work in unsafe environments and it is so inappropriate’

Pressured Prior to the shielding guidance being paused, doctors unable to work for health reasons had continued to have their pay premiums for on-call work protected.

Dr Webb says she knows of instances where a formerly shielding trainee doctor had returned to the workplace having rotated to a new trust, with their new employer unwilling to honour these payments, despite the fact individuals continued to be clinically vulnerable.

This is contrary to the BMA’s position which is that no doctor should be financially penalised for not being able to undertake certain types of work due to the risk doing so would pose to their health.

‘I know of trusts that are fighting this and are trying to not pay doctors who are still needing to be in a COVID-secure environment,’ she says.

‘It’s quite horrifying.

People are being pushed to work in unsafe environments and it is so inappropriate.’

The Government’s advice to people who have been

‘I know of trusts that are trying to not pay doctors who are still needing to be in a COVID-secure environment’

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‘We hadn’t even heard of shielding and we were wondering how we were going to protect her’ shielding is to continue home working if their workplaces are not COVID-secure.

Employers must either assist staff in continuing to work from home or make necessary changes to allow them to transition back to work as safely as possible.

The BMA’s 13 July tracker survey gave enhanced focus to the issue of doctors in shielding and their experiences.

The survey found that, of the 560 doctors who reported being in shielding, 198 were doing so because they were personally extremely clinically vulnerable, with the remainder living with someone who was classed this way.

When asked whether they had received support from their employer while in shielding, 58 per cent of respondents reported receiving satisfactory support, but a significant minority of 30 per cent said they had either not received support, or it had been unsatisfactory.

Risky calls WEBB: ‘My consultant said I still shouldn’t be in the hospital’

Greater Manchester-based neurology specialty trainee 4 Mike Kemp entered shielding back in March to protect the health of his clinically ED MOSS

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extremely vulnerable daughter.

Working from home since then, he was told in July following a risk assessment by his employer that he could continue home working at least for the duration of August, but potentially for longer.

As with Dr Webb, his own experiences of shielding and home working have been positive and productive.

However, he feels the approach to shielding, particularly risk assessments, has been widely inconsistent.

‘If we look at the NHS response to the need for risk assessment, I think that’s been inadequate,’ he says.

‘A lot of the people who have been shielding are having to do a lot of the legwork themselves, to make sure risk assessments are being done. It shouldn’t be that the employee is having to seek risk assessment [ahead of returning].’

He says that some assessments took a comprehensive, scorebased approach, while other assessments appeared to be more arbitrary and at the discretion of the staff member administering it.

‘The people being tasked with doing these risk assessments are generally clinical supervisors or managers who have no training in occupational health or in how to quantify and manage a risk, so they are reliant on the tool they’re provided with.

‘There are some very good risk-assessment tools out there, and I am fortunate that my employer’s is a particularly good-quality one, but with

other employers that’s not the case.

‘Why are we relying on individual trusts to create their own risk assessments?

The risk for a doctor in one hospital versus a doctor in another hospital might be working in different environments, and the assessment needs to be made about their workplace, but the tool used to make that assessment shouldn’t be different.

‘I don’t understand why NHS England hasn’t created one tool and mandated its use for everyone.’

Speaking to The Doctor in late July, he said he knew of some people in shielding who were due to return to work on 1 August who had still not undergone a risk assessment.

‘We’ve known about shielding since March, so I don’t understand why it took until July for anyone to get around to thinking about setting up a risk assessment tool for when these staff eventually return to work.

‘This is work that could have been being done gradually over the last couple of months, instead it is being done in a rush.’

Planned returns The BMA has sought to give advice and support to doctors returning to the workplace following shielding.

A briefing paper published in July outlines staff’s rights and the responsibilities of employers and training bodies in areas such as how to perform individual risk assessments, how these should help to inform a plan for an individual’s return and what can be done to make

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workplaces safe.

The paper also explains what can be done to support vulnerable staff who can’t return to the workplace post-1 August.

Bristol-based anaesthetics registrar Sethina Watson was one of those involved in drawing up guidance on workplace shielding for doctors at higher risk who were working in anaesthesia and critical care.

She went into shielding early owing to her daughter being clinically vulnerable, and has since been able to return to work.

She says she feels she has been extremely fortunate in her shielding experience, in that her employer has facilitated everything without questioning or negotiating with the terms of her arrangements.

‘At the beginning there was a certain amount of uncertainty as to what impact the pandemic was going to have. We hadn’t even heard of shielding and we were wondering how we were going to protect her, which caused us quite a lot of stress prior to shielding being announced,’ she says.

‘The first six to eight weeks were very difficult.

Dealing with feelings of guilt, isolation and uncertainty while watching the pandemic, coming to terms with being stuck at home and then wondering when it is all going to be over.’

Wellbeing checks While at home, she was able to use her time effectively through work including teaching and developing training programmes for

WATSON: ‘Dealing with feelings of guilt, isolation and uncertainty while watching the pandemic’

‘There is a lot of uncertainty about whether a second wave of the virus is coming’ doctors working in ITUs. Her employer also stayed in regular contact with her to check on her wellbeing and making sure she was being adequately supported to work from home effectively.

Aware of the fact that not all doctors’ experiences of shielding were as positive as hers had been, Dr Watson used part of her time while working from home to set up the Shielding Doctors group on Twitter. Initially aimed at fellow anaesthetists, the group quickly broadened to include doctors from all specialties and levels of experience.

‘I started getting contacted by other doctors who said they were eager to talk to someone in the same position as them,’ she says.

‘Through the group, a lot of experiences [of shielding] have been shared, some of which are really bad examples of

unsupportive employers.

‘Even now that people are returning to work, there’s a great deal of variability in terms of people’s experiences of things like risk assessments and support.’

Following discussions with her employer and her daughter’s medical team about how her return could be most safely facilitated, Dr Watson was able to return to work in early July.

Although happy, she remains wary. ‘I think there is a lot of uncertainty about whether a second wave of the virus is coming,’ she says.

‘The numbers of infections at the moment are OK and I’ve taken some reassurance from that, but it’s still very much in the back of my mind that those numbers might start to change and we [shielding doctors] will all be in a different situation again.’ thedoctor | September 2020 21

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TESTING REGIME: South Korea was carrying out far more tests than the UK in the early days of the pandemic

Prepared for the worst

South Korea learned from the experience of tackling a different coronavirus pandemic to inform its effective response against COVID. Keith Cooper reports

S

‘We never had a lockdown.

No business or hospitals shut’

outh Korea is famed for its efforts against COVID-19; it quickly abated its spread early on and saved thousands of lives.

Only 309 of its 51 million inhabitants had died from the virus by late August since its first case in February – compared with 41,429 COVID19-related deaths among the UK’s 66 million population.

So how did this east Asian powerhouse – known for its hi-tech cities and high-street brands, such as LG and Samsung – and its doctors flatten the curve with such speed?

South Korea’s approach to COVID-19 was helped by its experience in 2015 of MERS (Middle East Respiratory Syndrome) – another coronavirus, that claimed 38 lives, its doctors say.

‘The way we dealt with MERS wasn’t satisfactory,’ says Ducksun Ahn, president of the Korean Institute of Medical Education and Evaluation and professor of plastic surgery at Korea University Medical College.

‘It was very embarrassing,’ Professor Ahn adds. ‘It created a great fear in society. With that fresh in their memories, people hearing of this epidemic were anxious and followed what the Government asked [of] them.’

Experience counts ‘MERS helped humongously,’ agrees Hyunmi Park, a UKtrained colorectal consultant surgeon, now a visiting professor in robotic surgery

at Korea University Hospital.

‘It’s helped in the track and trace but also in the regulations that were introduced for small and medium pharmaceutical companies to produce test kits very quickly,’ Prof Park adds.

‘As soon as we had a sample of the virus they were able overnight to start making test kits. We produce and even export as many as we need.’

This measure meant 120,000 tests could be carried out daily almost straight away, says Prof Park, as the UK struggled to hit its initial target of 10,000.

On the front line, patients with any symptoms are tested in pre-assessment areas, away from hospital front doors. Any booked for elective surgery – and their families – are tested too. Results return in hours.

‘We didn’t cancel anything,’ says Prof Park. ‘We never had a lockdown. No business or hospitals got shut.’

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‘We had maximum protection. But I’ve been feeling very guilty when messaging my friends in the UK’

‘We were worried about a slippery slope towards totalitarian surveillance’

Social-distancing advice was issued by its Government to reduce meetings, travel and contacts and to encourage hygiene measures.

AHN: ‘The way we dealt with MERS wasn’t satisfactory’

Supply in swing South Korea avoided the worldwide shortages of PPE (personal protective equipment) that hit the UK so hard, alarming and distressing its health and care staff.

Such was its supply, each citizen could buy two N95 masks weekly for the equivalent of £1.

‘Koreans demanded to have N95 masks and they got them,’ says Prof Park. ‘They were all wearing it. They still do. That’s the norm.’ They’re delivered to the door of anyone aged over 65. Healthcare staff had advanced respirators.

‘I never felt unsafe,’ says Prof Park. ‘We had maximum protection. But I’ve been feeling very guilty when messaging my friends in the UK. All I hear is, “we don’t have enough PPE”. That was really sad for me. I felt really bad.’

Prof Ahn says ‘avoidance of uncertainty are one of the characteristics of Koreans’.

‘Whatever the evidence shows they want the best model, the guaranteed model,’ he adds. ‘In hospitals, highlevel PPE is very cumbersome, particularly in this hot weather, but people preferred to have the more secure ones.’

South Korea also made use of a track-and-trace system which filtered huge volumes of personal data from citizens’ mobile phones, credit cards, and CCTV footage to pinpoint their movements. Anyone located near a new COVID case was flashed warnings on a disaster alert app which

PARK: ‘I never felt unsafe’

almost everyone has on their mobile phones.

Prof Ahn says doctors in South Korea are concerned about the right balance between access to personal information and the benefits of the track-and-trace system.

‘We were worried about a slippery slope towards totalitarian surveillance.

We’ve been through a nondemocratic regime and we don’t want that again.’

For all its measures, South Korea has suffered outbreaks, some requiring a national response. The largest so far was traced to a religious group, which Prof Park describes as a ‘cult’, in Daegu, a city with some 7,000 cases among its 2.5 million citizens. More than two-thirds of the country’s 309 COVID-related deaths are here.

Another escalation in cases, in August, has also been traced to its followers.

Some 1,000 young doctors who were on public health duty for national service were mobilised to deal with the first outbreak, which peaked in March. Universities despatched respiratory specialists.

Hundreds more doctors volunteered, says Prof Ahn. ‘They admitted every single patient to hospital,’ he adds.

‘That’s why the mortality rate was so small.’

Potential disaster A significant outbreak in the capital, Seoul, could test them further. Cases there were hovering at 100 a day in June when these interviews were carried out but more than doubled during the outbreak in August.

‘If we had a heavy number of cases, like the UK, we probably couldn’t handle it either,’ says Prof Ahn. ‘The Korean Medical Association is very worried that many health professionals are already burned out. If something happened in Seoul, could we manage here?’

Like all countries, there are also concerns about the economy. The industry which kept hi-tech supply chains of PPE and testing kits healthy has suffered, as export income fell. And now, some months into summer, doctors fear people will feel less and less like COVID-19 is just another ‘big snowy day’.

‘It has started to get really hot and nice,’ says Prof Park.

‘During the wintertime, people don’t mind staying at home.

They now want to go out and enjoy themselves. We’re worried about that.’ thedoctor | September 2020 23

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Why does the new BMA president Sir Harry Burns often want to throw something at the TV when a politician appears?

Jennifer Trueland finds out

POLITICS VS EVIDENCE W

hen Harry Burns decided to leave surgery and move his focus to public health, there were some who couldn’t believe it – not least his colleagues.

As a trainee then consultant surgeon at Glasgow Royal Infirmary, he had worked with a prestigious team that included such luminaries as Sir Andrew Kay, David Hamilton, and Sam Galbraith (later to become Scottish health minister).

He decided to leave this – in medical career terms – gilded existence to do a master’s in global public health.

‘Lots of guys thought I’d gone crazy, bonkers, and asked why I’d do that,’ he reminisces. ‘A lot of folk thought I’d taken leave of my senses. I was never interested, at all, in private practice or anything like that – it just didn’t interest me.

‘I’d been a consultant for five years at that point, and I thought, OK, I know how to do this.

What else can I challenge myself with? Do I want to do this for another 30-odd years – let’s go and see what else I can do. I was attracted by the science of public health. I don’t think they think I’m mad now.’

Fighting inequality Since completing that master’s degree in 1990, Sir Harry has had a varied career, including a stint as director of public health with Scotland’s biggest health board, Greater Glasgow, and as chief medical officer for Scotland – a post he held between 2005 and 2014. He is professor of global public health at the University of

Strathclyde, and, this month, he takes up a new role as president of the BMA. This is usually a one-year post, which begins at BMA annual representative meetings, although the timing of this year’s ARM means Sir Harry will have a shorter term than his predecessors, through to the next meeting which is scheduled to take place in June next year.

All the while – even while he was a consultant surgeon – he has been driven by an interest in the science of wellness, of health inequalities, of the factors that determine whether someone will have a long and healthy life – or a life cut brutally short.

Colleagues – including Sam Galbraith – had suggested that he take up a career in politics, but this is something that never attracted him, he says. Nevertheless, there is something inherently political about health inequalities – so has it been difficult to remain outside the political arena?

‘I have tried all the time to shape my opinions on the science that I see before me,’ he says.

‘The classic thing is that inequality in health is socially determined. Well actually, there’s a biology associated with that, and unless you understand the biology, then you’re never going to come up with the answer to fix it. I keep saying to folk when I talk about this that this isn’t a political view, this is the science of inequality.

And unless you can get that across, particularly to those on the right of the political spectrum, who tend to believe that people are struggling because of poor choices they’ve made, unless

‘A lot of folks thought I’d taken leave of my senses’

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BURNS: ‘I was attracted by the science of public health’

‘I have tried to shape my opinions on the science I see before me’

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you can show them that there are actually some biological aspects to why they are where they are, then they’re never going to want to sit down and try to address these problems.

‘I try to stay out of politics, although at the moment, I don’t know why I’ve still got a working television in the house because I keep wanting to throw things at it whenever I see certain politicians on pontificating about coronavirus.’

Political interference Sir Harry – he was knighted in 2011 – has not been directly involved in the COVID-19 response at either a UK or Scottish Government level, although the latter has asked him to chair a group to look at emergency planning with a particular focus on winter.

Does he wish he was still there, standing next to the first minister as she gives her briefings?

‘No,’ he says very definitely. ‘Been there, done that. It’s someone else’s turn. Gregor [Smith, interim CMO for Scotland] is doing a great job.

You move on. They’ve asked me to do a specific thing and I’ll happily help them out, but I want to have what they’ve asked me to do done and dusted quite quickly so that I can get on with doing other things.’

Given that he wants to ‘throw things at the television’ when watching UK COVID-19 briefings, what would he want to see done differently? He speaks carefully: ‘If England had done what Scotland has done…’ he says with evident regret. ‘Eventually, Scotland imposed lockdown and I think that was out of a sense of, um, frustration over what was happening – or the fact that nothing much was happening.

It was very, very clear that England was much more interested in just letting it ride because they didn’t want to disturb the economy, and eventually – I think – the Scottish Government just said “we’re shutting schools; we’re shutting down”, and England just went immediately after that.

‘If you remember, the chief scientific adviser, [Sir Patrick Vallance] when asked about Liverpool versus Atletico Madrid football match came away with something about there being no evidence that having a mass gathering like this, or having a crowd at a football match

FIRM HAND: Sir Harry in 2006 when he was chief medical officer for Scotland at a meeting about the outbreak of H5N1 bird flu

would increase the risk of getting this virus. I thought “Really? Does he really believe that?” and you know, technically speaking he was correct because no one had ever done a randomised controlled trial of football matches versus no football matches, but you put 50,000 football fans [there], and you don’t see that all the singing and dancing and jumping up and down is going to spread a virus? No. It was pretty clear there was a lot of political interference there.’

Sir Patrick said in response to a question from Boris Johnson at a briefing that there was a very low risk of infecting a large number of people at a stadium, and that most transmission tended to take place with friends and colleagues in close environments ‘not the big environments’.

A spokesperson for SAGE, which Sir Patrick chairs, says: ‘At no time has SAGE advised on specific sporting events. The role of SAGE is to provide government with science advice. It is for ministers rather than SAGE to make policy and operational decisions.’

As an internationally known leader in public health, constantly invited to talk at conferences and to share his perspectives via the media, does Sir Harry feel a weight of responsibility?

He thinks carefully before responding: ‘I don’t say things unless I believe them to be true and I don’t believe them to be true unless I’ve seen some evidence that they’re true.

I don’t express an opinion without having some scientific reasoning behind it – which again is

‘I don’t know why I’ve still got a working TV in the house because I keep wanting to throw things at it whenever I see politicians pontificating about coronavirus’

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another reason why I’d never be a politician, because they express opinions because they’ve got opinions, and I like to have evidence.’

Public health wins

CHEERS: Sir Harry with Scottish first minister Nicola Sturgeon

THE SCOTSMAN

Even though Scotland has a far lower prevalence of the virus, he does not think that is a reason for closing the border – yet. ‘If you get a sporadic outbreak, yes I’m in favour of local lockdowns, but if England started to have a second peak, if the whole of England started going up and up and it wasn’t happening in Scotland, that might well be a reason for restricting movement. But we’re still going to need to have food deliveries, we’re still going to need to survive, and we’d need to make sure there would be a way of making these happen safely.

‘So, there would be an alternative to just mindlessly closing the border in those circumstances.’

In his time as CMO for Scotland, there were some major public health initiatives, including legislation to ban smoking in public places, and to oblige minimum unit pricing for alcohol.

Asked what he is most pleased with, however, his answer is a little unexpected.

‘I think the most interesting stuff that I was involved with was the improvement stuff – the patient safety programme, the Early Years Collaborative [a multi-agency improvement programme designed to ensure that children get the best start in life and that families are supported] and so on.’

He has, he says, as the son of a physicist, always been interested in systems and how things work. ‘Systems thinking, systems change – looking at the delivery of healthcare in a different way, and recognising that the way to change things, the way to improve things, is not shouting at people, but getting people to work differently: giving them permission to determine what makes the outcome better,’ he enthuses.

‘Get them to suggest how you improve systems, get them to test it, then once they have tested it, and seen that it works, then you put it into practice. It’s that sort of thing that I get really very exercised about and interested in.’

He was, he stresses, ‘absolutely’ pushing for

the public health legislation on smoking and alcohol, but that’s not the end of the story.

‘These are steps in the process. But it’s about giving people control. It’s not telling people that it’s bad to drink and it’s bad to smoke and we’ll make it really difficult for you to smoke and all that sort of stuff. It’s about gradually showing people that they can make small changes in their lives that will add up to a big change in their wellbeing. It’s a different kind of approach that you need.’

So is he looking forward to taking the BMA presidency? ‘Well I’ve just got on to the email system and there are a hell of a lot of emails flying around,’ he laughs.

‘It’s a great honour to be asked. My medical colleagues have covered themselves in glory over the past few months and health workers in general have shown themselves to be quite heroic in the way in which they’ve exposed themselves to great risk, and as we know, many of them have succumbed to the virus. So, it’s an honour to be asked to do this and I’ll do it to the best of my ability, to support them and to help the medical profession support the population at large.’

Sir Harry Burns is in conversation with the current BMA president, Raanan Gillon, in a podcast on the BMA website.

‘My medical colleagues have covered themselves in glory over the past few months’

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Disabled and dismissed Doctors with disabilities have revealed the barriers they face through a BMA survey.

Tim Tonkin reports

‘I

was told that “doctors don’t get sick”, making me feel weak and a failure at a time when I needed support.’

This experience, reported by one doctor to a BMA survey of disabled doctors and medical students, paints a damning yet sadly not untypical experience of the kind of dismissive attitudes faced by many healthcare professionals in the NHS. The survey, which was carried out between November 2019 and January this year, sought to shed greater light on the challenges and inequalities affecting disabled people by highlighting their experiences across a range of issues.

Incredibly, in a profession

‘They face unique barriers and challenges as they study, train and work’

that places care and compassion at its heart, there appears to be a strong perception that medicine is frequently not inclusive in its approach to disability and ill health among those who practise it.

Of the more than 700 doctors and students responding to the survey, just 36 per cent reported feeling comfortable at the prospect of telling their employers or colleagues about their disability, because they believed their workplace or medical school was disability friendly.

Added to this was the fact that 77 per cent expressed fear of being treated unfavourably were they to reveal their health conditions,

with just 41 per cent saying that doing so had resulted in them receiving improved support for their disabilities.

‘I felt I had to disclose information I did not wish to, and my trainers have felt it is reasonable, due to my health condition, to behave in questionable ways such as questioning my capabilities,’ one doctor told the survey.

‘Making judgements on my lifestyle outside of work, on my character and so on.

They have used my health and disability as a weapon.’

Seniors targeted Disability-related bullying or harassment is disturbingly common for doctors. It is more likely to be experienced among senior doctors with

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Unaware of help Despite the fact that NHS England’s recent Workforce Disability Equality Standard found the majority of trusts had disabled staff networks (63 per cent) in hospital and a disability champion (65 per cent), fewer than 10 per cent of doctors taking part in the survey said they were aware of these resources being available in their workplaces.

In presenting its findings, the BMA has also used its

MATT SAYWELL

42 per cent of consultants and 38 per cent of staff, associate specialist and specialty doctors reporting such experiences to the survey compared with 33 per cent of junior doctors and 24 per cent of students.

Challenges faced by disabled people in the workplace can also be amplified by intersecting issues around ethnicity. While 38 per cent of white doctors and students with a disability reported feeling comfortable in disclosing it, just 20 per cent of BAME (black, Asian or minority ethnic) doctors and students felt similarly.

Additionally, while 58 per cent of those from a white background said they had succeeded in obtaining adjustments for their disability, only 39 per cent of BAME staff said the same.

This must also be considered in light of the fact that only 55 per cent of survey respondents said they received reasonable adjustments, while just 26 per cent felt their workplace or schools’ sickness absence policies took proper account of their disabilities or health conditions.

MCKEOWN: ‘A system not designed with their needs in mind’

‘They have used my health and disability as a weapon’

survey to set out eight recommendations aimed at improving the day-to-day working and cross-career experiences of disabled doctors and students.

Among these are increasing awareness of disability in the workplace, by confronting discrimination and promoting positive and visible role models.

The association is also calling for trusts to create centralised budgets and simplified processes for funding reasonable adjustments, and to improve access to occupational health services for all doctors and students.

The BMA is also backing efforts to make career and training pathways more flexible, in part by utilising services such as telemedicine and remote working, both of which have proved invaluable during the pandemic, and by ensuring that sickness absence policies are updated to properly reflect the needs posed by disability or longterm ill health.

‘Disabled doctors and medical students are a valuable part of our medical profession, bringing unique perspectives and insight

into patient experiences and healthcare,’ says BMA equality, diversity and inclusion advisory group chair Helena McKeown.

‘They also face unique barriers and challenges as they study, train and work in a system that was not designed with their needs in mind.’

Dr McKeown says the survey findings, and more recently the pandemic, have emphasised the extent to which the health service needs to reform ways of working to better serve and protect those with disabilities and demonstrate effective change can be made with sufficient will.

‘The response to COVID-19 has also involved unprecedented changes to the way that health services operate and creates an opportunity to re-think healthcare delivery and job design,’ she says.

‘Some of the changes that happened at the peak of the virus show that things that disabled doctors and medical students have been calling for, for many years, such as more remote working opportunities, can in fact be implemented at large scale and at rapid pace, if the will is there to do so.’ thedoctor | September 2020 29

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

Doctors’ working conditions have been put under intense pressure during the pandemic. BMA staff tell how they have continued to support them, often adapting to changes in their own lives ‘I’m absolutely impressed by the members’ resilience and sheer determination to continue to care for their patients and their colleagues.’

And Clare Kellett should know. From a union background and a BMA employment adviser for two years, she is one of a UK-wide network of advisers who work both individually and collectively for BMA members, often during their most stressed and vulnerable moments.

To give an idea of the range of work, recently covered in the On the Ground section of The Doctor, a group of junior doctors had inferior working conditions imposed which left them demoralised and exhausted, a consultant desperate to return to his patients found himself stranded abroad, and a doctor working nights with inadequate PPE (personal protective equipment) was forced to choose between a patient at serious risk or exposure to COVID-19.

All were resolved with the input of the advisers, who often need to show immense persistence and ingenuity through dozens of calls, emails and face-to-face meetings to

resolve members’ problems.

As with every part of the BMA, they have changed with the pandemic.

Perhaps the most obvious change is that they are even busier. New cases were up 12 per cent, calls up 11 per cent, and emails up 48 per cent between January and June.

Opening hours expanded to 24 hours a day for urgent COVID-related enquiries.

But there have been other changes too.

Ms Kellett says: ‘When COVID started, the cases were very much about rota changes, pay changes and PPE; now I’m seeing issues with incorrect pay following those rota changes and changes to job plans which are being made without due process being followed.

‘My sense is that everyone worked incredibly hard to deal with the immediate concerns, to cover the rotas and to protect those who were vulnerable but there wasn’t any precedent to follow in terms of changes to rotas and pay, and guidance was constantly being issued and amended. Inevitably, though, that all has to be worked out in time, which is

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TOUGH TIMES: Isolation has become an issue for members

what we’re doing now.’

She and other advisers have also been giving a lot of advice to members on shielding, now that the guidance for those with certain conditions to stay at home has been lifted.

Other cases, such as long-running pay disputes or difficult professional relationships, have not gone away, even if the members agreed to put them on hold at the start of the crisis.

Working lives of staff have also changed.

Ms Kellett, like many of her colleagues, was already home-based and finds virtual meetings efficient but misses the human contact of team and one-to-one meetings.

George Milne, a team manager with the BMA’s first point of contact team, also misses the social interactions, and had to adjust from office-working to being at home.

‘I have a small one-bed flat, but have managed to make a great office set-up in my living room and have kitted it out well.’

‘Who needs a dining table?’, he jokes.

While meetings can often be easier to

arrange, thanks to the now omnipresent Zoom and Teams, the pandemic has made some of advisers’ work more difficult to resolve.

‘The cases that are definitely taking longer are the ones that involve investigations and speaking to colleagues; there just isn’t time for in-depth meetings it seems,’ says Ms Kellett.

She says there are often long delays in obtaining occupational health appointments, which can determine whether, for example, a member’s application for early retirement or a change in working conditions is successful.

This adds to members’ stress and anxiety at this difficult time.

More than ever, it’s a job that requires empathy.

Mr Milne says: ‘This has been a very difficult time for members and many have faced challenges with either their working or personal arrangements. We’ve had many difficult conversations with our members around issues such as self-isolation/ quarantine rules if having to see sick family members abroad. Being able to provide an empathetic listening ear has been crucial.’

Working so closely with doctors and medical students, often at their most vulnerable times, allows BMA staff to indentify with them. This has if anything been enhanced by the experience of the pandemic.

Ms Kellett says: ‘Although there are stresses and difficulties, not least of which must be the incredible discomfort of working in full PPE in the summer heatwave, members have shown huge resolve to keep going – whether on-site or from home, coming back early from maternity leave, moving into hotel accommodation for weeks on end, returning from retirement or clinical research, or remaining in their training placements when they had expected to be moving on.

‘I can only say that whatever difficulties and frustrations I’ve felt in doing my job, it’s as nothing compared with our members’ daily experiences and I’m very proud to say that I can support them by working for the BMA.’ thedoctor | September 2020 31

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