Doctors Association UK (DAUK) has written to health secretary James Murray urging the introduction of clear national standards to ensure patients referred to hospital by a GP are assessed by a doctor.

DAUK GP co-leads Dr Sarah Jacques and Dr Steve Taylor wrote to Mr Murray following coroners’ reports into the deaths of nine-year-old Dylan Cope and eight-year-old Ethan Hanson.

They were both urgently referred to hospital by their GPs with suspected appendicitis but, according to the coroners’ findings, were not assessed by a doctor after arriving at hospital.

The letter has been featured by The BMJ, Pulse and Doctors.net.uk

In it, Dr Jacques and Dr Taylor called on the government to introduce national standards requiring patients urgently referred to hospital by a GP to be assessed by a doctor.

The letter also asks to ensure that no patient with undifferentiated symptoms is assessed or discharged without doctor oversight.

DAUK has invited Mr Murray and Department of Health officials to discuss the proposals.

Read the letter in full.

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A total of 791 final year medical students were placed on the reserve list for the UK Foundation Programme (UKFPO) last week, after not being allocated a placement for FY1.1 This is the largest reserve list to date and an increase of 300 from last year, despite official figures showing that the NHS in England is short of almost 8,200 doctors.2 It costs £230 000 to train a single medical student.3 So why, in the context of an understaffed NHS with worsening rates of workforce attrition due to the covid-19 pandemic, can we still not provide timely job security to all final year medical students?

Ten years ago, the General Medical Council (GMC) stated that: “students who enter medical school have a legitimate expectation that if they pass their examinations and graduate, they should have the opportunity to qualify as a doctor.” For the hundreds of students on the reserve list, this is not the case, and they have been left waiting for posts to become available. In previous years everyone on the reserve list was eventually offered a place, but faced uncertainty while they waited to find out.

The Doctors’ Association UK (DAUK), a grassroots advocacy group for doctors and medical students, received numerous accounts from final year students expressing their distress and frustration at being placed on the reserve list last year. Listening to these testimonies, revealed that students who applied for special circumstances, due to ill health, caring responsibilities, or financial constraints, appear to be disadvantaged. Even if a post becomes available for them, if it is not within the geographical area they selected, they face the predicament of choosing medicine over their personal circumstances, and are left unsure of where they will be living and working.

The UKFPO says it expects all applicants will be allocated a post this year “as in previous years” but these promises fail to address the existing flaws in the system, and risk compounding the mental health crisis facing junior doctors.

One final year student with carer responsibilities told DAUK that their special circumstances were not considered because the application form stated they were the “main carer” instead of the “primary carer.” A subsequent appeal was rejected. The DAUK has heard from other students with family responsibilities, which make it impossible to move away from home, who have said that they feel overwhelmed with the uncertainty.

For students who do not get allocated a foundation job and have to take time out of training, the financial strain is untenable for many. The average medical graduate has £70 000 of student debts and cannot afford a year out of training with no steady income. There are many existing barriers for students from financially strained backgrounds to complete medical school.4 Lack of an appropriate post is an obstacle to postgraduate training and does not recognise the challenges that medical students face trying to combine their responsibilities as carers alongside their medical training.

For final year students, who have worked tirelessly for half a decade, being placed on the reserve list is hugely undermining and anxiety provoking.

Unless action is taken, the UKFPO will remain oversubscribed and students who require special circumstances will continue to be disadvantaged if we do not address current flaws in the system.

As the NHS recovers from the covid-19 pandemic, there is no better time for change. The current recruitment issues need to be addressed swiftly, to optimise the local workforce and for fair treatment of candidates.

Footnotes

• Competing interests: EW and FR none declared. AB was a reserve list candidate last year.

The recent case of Toombes vs Mitchell made legal history and the medical profession have been considering the potential implications ever since.

read the piece by DAUK, The On-Call Room, NHS Million and GP Survival here

NHS staff who work directly with patients should have routine access to face masks that offer high protection because covid-19 infections threaten to overwhelm services, doctors’ leaders have said.

Three national organisations said that filtering facepiece respirators (FFP3s) should be made fully available because of the increased transmissibility of the omicron variant. The BMA, the Hospital Consultants and Specialists Association, and the Doctors’ Association UK, concerned at rising hospital admissions and rates of staff sickness, cite growing evidence that airborne transmission of SARS-CoV-2 is a major driver of infection.

They want better protection for all healthcare staff who work with or around patients who have covid-19, saying that the current guidance on FFP3 use and the NHS’s reliance on usual surgical masks leave staff at increased risk of infection.

Jenny Vaughan, who chairs the Doctors’ Association UK, said that staff were deeply concerned that the NHS could be overwhelmed by high numbers of patients needing beds in wards and critical care. “Our frontline workers must be protected,” she said.

Research published earlier this year showed that FFP3 masks for healthcare workers on covid-19 wards reduced hospital acquired SARS-CoV-2 infections.

The NHS is required to follow UK national guidance on infection and prevention control, which was updated by the UK Health Security Agency on 21 December. This says that an FFP3 respirator (or equivalent) must be used by staff when they care for patients with a suspected or confirmed infection that is spread wholly by the airborne route, and when performing aerosol generating procedures on a patient with a suspected or confirmed infection spread wholly or partly by the droplet or airborne route.

FFP3 masks can be used more widely when transmission risk remains unacceptably high, after local risk assessments that should include “evaluation of ventilation in the area, operational capacity, and local prevalence of infection/new SARS-CoV-2 variants of concern.”

But doctors’ leaders said the guidance did not do enough to minimise the risks to all staff who may be exposed to the virus, nor did it guarantee an adequate supply of FFP3 masks.

In an open letter to the UK Health Security Agency, published last week, the Doctors’ Association UK said the distinction between normal patient care and “aerosol generating procedures” was “artificial” and that the latest guidance would confuse NHS trusts over how to fulfil their health and safety responsibilities.

The letter said, “We now know that breathing is sufficient to generate airborne coronavirus capable of infecting others who are breathing the same air. With omicron rates doubling roughly every two days we must treat every patient we see as being a potential carrier of covid. We believe it is necessary to provide FFP3 masks for all staff working indoors where exhaled air from patients is circulating.”

Read the full article here

GPs have called on the government to update the official list of covid-19 symptoms after seeing patients shun tests to check their infection status because they don’t believe they have been infected by SARS-CoV-2. They also said that a public communication campaign was needed to inform the public about the limitations of lateral flow tests and vaccination.

The website of the Covid Symptoms Study being run by the health science company ZOE and King’s College London said the most commonly reported covid-19 symptoms were now headache, runny nose, and sore throat and not fever, cough, and loss of sense of smell or taste, as listed by the government.1

Lack of information about this changing profile of symptoms is making dealing with patients difficult and could thwart efforts to control the pandemic, GPs have told The BMJ.

The Cumbria GP Ellen Welch said, “I work entirely remotely, both in and out of hours, and the vast majority of people contacting out-of-hours services with coughs or fevers still express surprise and frustration when a covid-19 test is mentioned. People ‘know’ it’s not covid-19.

“If we end up referring people on for face-to-face appointments via out-of-hours [services] or NHS 111 we ask the standard covid questions about any symptoms, and I would say almost every single person responds to the ‘do you have any covid-19 symptoms’ question . . . with, ‘Oh, I’ve had both my vaccinations,’ as if this means it doesn’t apply to them any more.”

The Nottinghamshire GP Prakash Kachhala said, “I’m struggling to recall anyone I have spoken to at an urgent appointment having done or arranged a PCR test. We saw this even before delta with straightforward coughs and fevers, but obviously it’s more complex with delta and broader symptoms. While access to testing is much better than last year, it seems that fewer people who contact the GP are doing it. Lateral flow tests don’t help, and I wonder if access to them is reducing those going for PCR.”

Lateral flow tests, which are now available to the public for twice weekly testing, are supposed to be used to identify asymptomatic cases. This means that a negative result does not rule out infection. However, the communication about the use of these tests has been poor. A BMJ investigation found that only one third of local authorities that rolled out these tests made their limitations clear to the public.2

The Hertfordshire GP Neena Jha also said she had seen such problems at her practice. “I don’t think the blame is with the patients at all. I think it’s poor public health messaging, and patients have misunderstood the role of the lateral flow tests and what the results mean.”

However, Jha said that some patients became angry when they were advised to get a PCR test. “I think there is this backlog of frustration and misunderstanding,” she said, “which I think has been driven by some of the media outlets that have [spread] this rhetoric that GPs have been closed and we’re using covid-19 as an excuse not to see patients, which couldn’t be further from the truth.

“We set up covid community hot sites, we’ve been seeing covid and non-covid [patients] face to face throughout. There has just been a tele- or remote appointment first [policy], and that was at the direction of NHS England. But the way it’s been spun has been really damaging. And we’ve seen a huge increase in aggression from patients since then.”

GPs now want to see a public communication campaign, led by the government, to tackle these misunderstandings around symptoms, testing, and vaccination.

Read the full article here.

The volume of patients, the complexity of illnesses, and the unrelenting nature of the covid pandemic are having a huge impact on morale among our junior doctors, many of whom are experiencing their first winter in the NHS, write Nikki Nabavi and Clara Munro

A winter surge in hospital admissions is not unfamiliar. However, Public Health England’s annual flu and covid reports1 show that the current pressure on hospitals is not comparable to the usual winter influx. The difference in healthcare staff’s morale between the start of the pandemic and now is palpable, not least among those who are experiencing their first winter in post.

The nervous energy that characterised last spring has been replaced by chronic exhaustion. Natalie Ashburner, vice chair of the Doctors’ Association UK, says that doctors feel “battered by the unrelenting experience of caring for those with the virus.” And the idea of “just a bad day on call” is replayed without any opportunity for recovery.

Pushpo Hossain, a junior doctor in London, says, “When you are doing everything you can and you reach the ceiling day after day, morale falters.”

Alone

One major difference is that, during the first wave, doctors weren’t also providing routine care. This has now changed, and in addition there are long backlogs of patients, some of whom have had their treatment delayed for over eight months. It’s created an additional pressure on the NHS that wasn’t there during the first wave.

The Faculty of Intensive Care Medicine surveyed its members in November 2020, before the peak of the second wave, and reported that only 18% of respondents agreed that staffing levels in intensive care units were adequate.2At the peak of the second wave in January, junior doctors and medical students were being asked to volunteer in intensive care, sometimes through call-outs on social media.3

The BMJ heard concerns about staffing levels from several junior doctors around the country. “Staff are constantly having to isolate, which leaves us so understaffed,” says Amelia Seifalian, a foundation doctor in Watford. “Often at 9 pm we are asked on our hospital’s foundation year 1s’ WhatsApp group if anyone can go in and cover a night shift, as they are short of around four doctors.

“These shortages mean that juniors are left with more responsibility than usual, and things that you would usually ask your senior house officer for support on or double check with them, you are unable to, which makes us feel less confident.”

In a 2019 study published in the Journal of the Royal College of Physicians, 66.4% of doctors reported “feeling part of a team” as being the most important factor affecting their morale.4 Bethan Markall, a junior doctor based in Birmingham, told The BMJ that rota gaps also affected doctors’ sense of team support and camaraderie: “Juniors no longer have a team—it’s not unusual to work four different shifts, each with completely different teams.” This leads to a lack of team identity and reduced support.

Markall adds, “First year foundation programme teaching has only been online, meaning we have had less of a chance to meet our cohort or socialise with them, which can be quite isolating.”

This trend of isolation is highlighted by the stark contrast between the culture of free team meals and social support, as seen during the first wave of the pandemic, and the new socially distanced canteen booths that Seifalian describes, allowing for little to no mealtime debriefs with colleagues after difficult days. She emphasises the importance of reflections with colleagues. “I don’t want to talk about it to my family or housemates,” she says. “I don’t want to share the burden.”

Infantilised and ignored

Morale may be further eroded by feeling “infantilised” by colleagues. Freddie Stourton, a foundation doctor in the south of England, says that it can feel frustrating and exhausting to be thrown in at the deep end and then be “told off” for things that are out of your control. Senior staff can expect juniors to be familiar with their surroundings or a ward’s logistical practices, even though they are sometimes working with completely different teams on different shifts. Some reported being shouted at for “standing in the wrong place” five minutes after arriving at a new ward and while trying to help a patient.

While all doctors will be familiar with the “bad shift,” those who spoke to The BMJ said that the covid pandemic had brought an increasing frequency of these shifts among junior staff who lack the experience to contextualise these encounters.

The Doctors’ Association UK is among those who have called for greater provision of accessible mental health services for doctors. A spokesperson told The BMJ, “We have grave concerns about the effect that this pandemic is having on the mental health of NHS workers. We urgently need more specialist mental health services that are well funded, adequately resourced, and accessible to those who need them.”

The BMA, meanwhile, has called for medical staff to be prioritised for covid-19 vaccination to help reduce the absences that are leaving rotas short5 and subsequently affecting junior doctors’ ability to attend vaccination appointments themselves, while changes to shift patterns and night shifts6 make this challenging.

Stourton says that, in some ways, the shunting of junior doctors reflects an attitude that’s persisted throughout the recruitment process: doctors who have undergone years of training being “treated like numbers on a page, with patchy communication and changes in the process with little or no notice.”

Partha Kar, consultant in diabetes and endocrinology and a BMJ columnist, says that “what junior doctors have taken on in this pandemic has been nothing short of astonishing. Stepping into areas way outside their comfort zone, with specialties not being a barrier or given a second thought—their desire and determination to help without any hesitation has been fabulous to see and be part of, as well as inspiring.”

He concludes, “The least as seniors we can do is to find some time, if possible, to have a kind or caring word, or even a simple thank you, for their efforts in these extraordinary times.”

Read the article in the bmj

Samantha Batt-Rawden, president of the grassroots campaigning organisation the Doctors’ Association UK (DAUK), told The BMJ that doctors continued to receive abuse despite “risking their lives since March 2020.” In a recent survey, DAUK’s members reported verbal and physical abuse including insults, racism, death threats, and violence. One respondent told the campaign, “Physical abuse is a regular part of being an emergency medicine doctor. I have been hit and bruised by many patients for a variety of reasons. All staff have a story to tell, and it’s rare that the patients ever have to face any consequences.”

“It is not enough simply to clap once a week for NHS staff,” as the public were doing in the first lockdown of 2020, says Batt-Rawden, DAUK president. “We have to create a protected workplace that doesn’t leave them at risk of abuse.”

Read the full article here: https://www.bmj.com/content/372/bmj.n739

DAUK’s Dr Ellen Welch and Dr Katie Sanderson write in the BMJ.

For months now, it has been the norm in primary care to speak with patients calling to discuss their new coughs and fevers, and to be greeted with surprise and often outrage when a covid test and household isolation are suggested. “I know it’s not covid” or “I always get a cough at this time of year” are the commonest protestations, alongside the belief that an intact sense of smell invalidates all the other symptoms. After the well-rehearsed debate is over, what follows is typically an unconvincing agreement to follow the government advice, which inspires zero confidence that this will actually happen.

Meanwhile, on the wards, a similar narrative occurs while checking that the relatives of covid-19 patients are isolating. The response is often simply: “I can’t isolate”, with financial hardship acknowledged as the main influence. While we are sympathetic to this situation, there remains a profound lack of understanding about this disease, despite its omnipresence in our lives. The many patients dying of covid-19 in hospital invariably all ask: “How did this happen to me?”

The general public cannot be criticised for these misperceptions, since the guidance from the government throughout this pandemic has been confusing, ambiguous, and inconsistent, often changing at the last minute. The lack of financial support for those needing to self isolate has left some people unable to follow the guidance for fear of financial hardship or ruin. Instead of following the lead of countries like Australia, who isolated and tested anyone presenting with any upper respiratory symptoms (including rhinorrhoea and pharyngitis ), here in the UK clinicians have been forced to have daily disputes with patients about the nature of their cough, while ignoring patients who present with snotty noses and sore throats as these symptoms somehow aren’t included as covid-19 in the UK.

Read the full article here: https://blogs.bmj.com/bmj/2021/02/05/we-urgently-need-to-double-down-on-the-basics-if-we-are-to-find-a-way-out-of-lockdown/

DAUK (working in partnership with Messly) logged >1500 reports nationally highlighting inadequate access to PPE; 220 reports frontline doctors being warned, threatened, disciplined, or made to feel bullied or unsupported for raising issues about PPE

COVID-related HCW death: 
Katie Sanderson (DAUK), “We know that the appalling death toll of 882 frontline health and social care workers will continue to rise if no action is taken. “The investigation of these deaths has been piecemeal and inconsistent.”

PHE guidelines on PPE: 
Jenny Vaughan, “We do not feel that the PPE currently mandated by Public Health England offers healthcare workers an acceptable level of protection, and we are calling for the guidance to be urgently revised to ensure that all staff exposed to covid-19 have access to high level respiratory protection.

“There is also a clear lottery among hospital trusts: some are defying Public Health England rules to give their staff the protection they deserve due to concerns about hospital spread of the virus.”

Read the full article here: https://www.bmj.com/content/372/bmj.n442?utm_source=twitter&utm_medium=social&utm_term=hootsuite&utm_content=sme&utm_campaign=usage

Medical leaders have urged Public Health England to strengthen its guidance on personal protective equipment (PPE) to reflect the more transmissible forms of SARS-CoV-2 that healthcare staff are being exposed to.

Current guidance says that higher grade FFP3 masks should be provided to staff who are involved in aerosol generating procedures, but other staff looking after patients with covid-19 are only required to wear fluid resistant surgical masks.

In a letter to Public Health England sent on 13 January, BMA council chair Chaand Nagpaul said that, in light of the identification of the new variant of SARS-CoV-2, increased spread of the virus, and growing evidence of aerosol transmission, Public Health England should review its recommendations on PPE usage “so that a more precautionary approach is adopted to the provision of respiratory protective equipment (RPE) to ensure staff are protected from aerosol transmission.”

He wrote: “There are significant and growing concerns about the role of aerosol transmission of covid-19 in healthcare settings, and the need for wider use of RPE (for example, FFP3 respirators) outside of those procedures designated as aerosol generating. We are therefore calling on [Public Health England] to support the wider use of RPE in other high risk settings across primary and secondary care.”

Nagpaul mentioned evidence indicating lower infection rates among staff in areas where higher grade RPE is currently recommended.1 He also pointed out that the World Health Organization modified its guidance in December to advise that where respirators were available, they should be considered for wider use.2

The Doctors’ Association UK also called on Public Health England to review its guidelines on PPE for healthcare workers. The organisation said that there were 44 000 NHS staff currently absent because of covid-19, with many becoming unwell because of the new, more transmissible variant.

Katie Sanderson, spokesperson for the association, said, “Healthcare workers in the UK continue to become infected with covid-19 at work at rates that could be mitigated by access to better personal protective equipment.”

Jenny Vaughan, vice chair of the Doctors’ Association UK, said that the organisation was “calling for a full review of the PPE guidelines including wider access to FFP3 masks. So many NHS staff are getting sick because of the new, more transmissible variant. The covid-19 virus has changed, and yet the same guidelines we introduced in March have not been updated.”

Ensuring greater protection was especially vital for staff who were more at risk from covid-19, such as doctors from an ethnic minority background, the medical bodies said.

The interventions follow a similar call from Fresh Air NHS, a group of frontline healthcare workers who recently wrote an open letter to UK politicians urging them to recognise the importance of airborne transmission of SARS CoV-2 and to ensure that measures were in place to protect staff and patients.3

Yvonne Doyle, medical director at Public Health England, “NHS staff are under immense pressures and their safety has always been our highest priority. The NHS Infection Prevention Control group has reviewed the latest evidence and has advised that PPE should continue to be worn as laid out in the current [infection prevention and control] guidance, with FFP3 masks required for staff undertaking clinical aerosol generating procedures. This is supported by [the World Health Organization]. Emerging evidence and data on variant strains and transmission will be continually monitored and reviewed.”

Read the full article here: https://www.bmj.com/content/372/bmj.n146

References

1. ↵Shields  A, Faustini  SE, Perez-Toledo  M, et al. SARS-CoV-2 seroprevalence and asymptomatic viral carriage in healthcare workers: a cross-sectional study. Thorax2020;75:1089-94. doi:10.1136/thoraxjnl-2020-215414. pmid:32917840Abstract/FREE Full TextGoogle Scholar
2. ↵WHO. Advice on the use of masks in the community, during home care and in healthcare settings in the context of the novel coronavirus outbreak. 1 Dec. 2020, https://www.who.int/publications-detail-redirect/advice-on-the-use-of-masks-in-the-community-during-home-care-and-in-healthcare-settings-in-the-context-of-the-novel-coronavirus-(2019-ncov)-outbreak.
3. ↵Wise  J. Covid-19: Doctors and nurses demand better PPE for wider range of procedures. BMJ2021;372:n30.doi:10.1136/bmj.n30 pmid:33408072FREE Full Text