commencommentt conversations and cajoling to clearer data collection, open access to data based on...

Ihad to read through the email a few times to digest what a consultant had written to me. “Confl ating covid with institutional racism among your friends and colleagues is utterly shameful,” it said. “Nobody knows the

genetics of covid, but you see fi t to suggest that its predilection for BAME [black and minority ethnic people] is down to racism. Your views nauseate me—there is no room for them in today’s NHS.”

This was a response to my May BMJ column, in which I discussed whether racism was a factor in the increased mortality from covid-19 among ethnic minorities. Subsequently, further investigations and a report from Public Health England have established that racism and discrimination may have contributed to the increased risk. Yet, for this consultant, it was hurtful to even suggest racism in the NHS.

It made me refl ect on a wider problem—and an analogy with sexism. Many men responded indignantly to the MeToo movement. They missed the point that it wasn’t about them. It was about listening and refl ecting that there may be many colleagues whose views you’d not picked up on, not acted on, or ignored. It was about being vocal against the issue when observed and trying to bring an end to such a culture.

Racism in the NHS isn’t much diff erent. You may not be racist, but to be indignant at the notion of the NHS having a race bias may simply refl ect your ignorance or the bubble you inhabit. However, this sort of ignorance propagates the problem. When people see something that jars, they may remain silent or try to explain it away with “scientifi c” reasoning: cue the debate about vitamin D as the sole reason for greater mortality in the BAME population. If you can’t even accept that racism could be a problem in the amazing NHS, why try to solve it?

At an individual level, it’s time to be antiracist, to speak up and be allies. At a policy level, it’s time for the NHS to start affi rmative action—something like the Rooney rule, a US National Football League policy requiring teams to interview ethnic minority candidates for senior roles. So far in the NHS, cajoling

or nudging has achieved little. The 2019 Workforce Race Equality Standard showed that white applicants were still “1.46 times more likely to be appointed from shortlisting compared to BME applicants.”

Another big step would be to ditch terms such as BAME, which turn discrimination into a simplistic discussion about white and non-white communities. The issues infl uencing attainment and socioeconomic deprivation are fundamentally diff erent for someone who is black than for someone from India, Bangladesh, or China.

There’s no better moment to shift the dial from conversations and cajoling to clearer data collection, open access to data based on area and authority, and a commitment to a concept similar to the Rooney rule. The “Seacole statute” has a ring to it, and it would be a way to pay homage to a titan and pioneer in the fi ght for equality in healthcare. It’s worth thinking about .Partha Kar, consultant in diabetes and endocrinology,

Portsmouth Hospitals NHS Trust

[email protected] Twitter @parthaskar

Cite this as: BMJ 2020;369:m2583

commentcomment

At an individual level, it’s time to be antiracist, to speak up and be allies

the bmj | 4 July 2020 21

“Language frames the way we see people. Getting it wrong can cause hurt” DAVID OLIVER “Medical unity is beginning to fracture, and resentment is growing” HELEN SALISBURYPLUS Consent during a pandemic; safely easing shielding

THE BOTTOM LINE Partha Kar

The NHS needs a Seacole statute

22 4 July 2020 | the bmj

The 70 year old patient has been waiting months for his elective surgery. A few days before the operation, he has a swab test to detect any active covid-19

infection. It’s negative. Before the operation, the surgeon reminds him about the risks and benefi ts of the procedure, as well as the reasonable alternatives. The patient agrees and signs the consent form.

The operation, performed under general anaesthetic, is uneventful but postoperatively the patient develops severe respiratory complications that require admission to the intensive care unit. Retesting reveals covid-19. The patient, who has sustained serious harm from the complications, sues the trust for failure to obtain valid consent. He claims the surgeon should have discussed risks related to covid-19 and that, had he known, he would have waited until the pandemic had passed.

Many surgeons are now resuming elective work, yet we are aware some make no mention of the additional risks related to covid-19. Although the British Association of Spine Surgeons and some private hospitals have produced information sheets for patients undergoing surgery during the

pandemic, to our knowledge no formal guidance has been published by the GMC or the Royal College of Surgeons on obtaining consent in such circumstances.

Following the case of Montgomery v Lanarkshire Health Board (2015) UKSC 11, doctors must take reasonable care to ensure patients are aware of any material risks involved in the recommended treatment and any reasonable alternatives. A material risk is one to which a reasonable person in the patient’s position would be likely to attach signifi cance, or a risk that a doctor knows—or should reasonably know—this particular patient would probably consider signifi cant.

Pulmonary complications

An international cohort study in the Lancet analysed the outcomes of 1128 patients who had surgery between 1 January and 31 March. Some 74% had emergency surgery and about 25% elective. Covid-19 infection was confi rmed preoperatively in about 26% of patients. The study showed a 30 day mortality of nearly 24%, with pulmonary complications occurring in 51% of all patients. The mortality was associated with various factors, including sex (higher for males), age (higher for 70 and

older), and type of surgery (higher for major surgery and emergency operations).

Although limited to a single study at an earlier point in the pandemic, these are worrying fi gures. We believe a reasonable person about to undergo elective surgery would attach signifi cance to the risk of complications and serious harm from covid-19.

Given that a minuscule risk of death by anaesthetic is commonly shared with patients, we argue that patients who undergo elective surgery should be told that, despite measures to limit the risk of infection, there remains a risk of contracting covid-19 in hospital, whether before, during, or after the operation. The surgeon should explain that, if the risk eventuates, the impact on the patient’s health is currently unknown but could at worst lead to complications that require intensive care admission and, in a minority of cases, death.

Along with a verbal explanation, we recommend “covid-19 related complications” is expressly stated as a risk to any surgery on the consent form. This practice should aff ord

The threat to those most clinically vulnerable was communicated from the beginning of the covid-19 pandemic. On 16 March, the government advised those deemed to be at increased risk to follow stringent social distancing measures. A subset, believed to have the highest risk of mortality and severe morbidity, were identified and sent a letter asking them to “shield” for at least 12 weeks.

The government has now relaxed this guidance, but those who have been shielding fear support will vanish, leaving them at heightened risk in a second peak.

Guidance recommends those who were shielding maintain social distancing, but those people may be less familiar with the new etiquette, such as one way systems, that has become embedded into normality. Their anxiety is not just around leaving their

homes, but also how to maintain the 2 m distancing that decreases risk. If shielding no longer applies, support may diminish, just as the general public relax infection control measures, further heightening their concerns of contracting covid-19 in the community.

Those returning to frontline healthcare have particular worries; data from the Office for National Statistics show the risk of acquiring covid-19 in hospital is between four and six times that in the community. Without herd immunity or a vaccine there is no easy answer. Clinicians urgently need enough high protection PPE, preferably recyclable, to allow vulnerable staff to lower their shields while helping them to feel safe.

Failure of surgeons to raise the risks

of covid-19 during the consent process

is ethically and legally troubling

People generally want to be

considerate, but they need promptsHow can shielding be safely lowered as lockdown is eased?

PERSONAL VIEW Daniel Sokol , Rupen Dattani

How should surgeons get consent in the pandemic?Now hospitals are resuming elective surgery, what should patients be told about about the perioperative risks of covid-19?

BMJ OPINION Helen Iliff, Ilora Finlay


the surgeon a degree of legal protection. This should continue until the pandemic recedes and the risk becomes so negligible that no reasonable person in the patient’s position would deem it worthy of mention. A leafl et on the risks, though desirable, should be no substitute for a conversation—some patients do not read, or do not understand, leafl ets.

As part of the discussion on alternatives to imminent surgery, surgeons should explore the option of waiting until the pandemic subsides. For many patients, there will be risks associated with delay, so a balancing exercise will be necessary.

Finally, the consent discussion should take place days or weeks before and not, as is still too often the case, on the day of surgery.

T he failure of surgeons to raise the perioperative risks of covid-19 during the consent process is ethically and legally troubling. It would be helpful for the Royal College of Surgeons to give specifi c guidance, with updates as evidence becomes available. Daniel Sokol , medical ethicist and barrister , 12 King’s

Bench Walk, London [email protected] Rupen Dattani , consultant orthopaedic surgeon ,

Chelsea and Westminster Hospital, London


Those at higher risk need people to be kind, understanding, and allow them extra space, in public and in their workplaces. Many have invisible vulnerabilities. So how can we help those we can’t easily identify?

People generally want to be considerate of others, but they need prompts. Employers can support working from home. Colleagues can recognise the psychological impact of prolonged isolation. Some have welcomed the suggestion of an easily recognised lapel badge in the shape of a shield that says “Safer at 2m” or a facemask with the same easily identified symbol on it. These suggestions may help society to function at negligible cost.Helen Iliff, anaesthetics core trainee, Prince Charles

Hospital, and Bevan exemplar, Wales

Baroness Finlay of Llandaff, Bevan Commissioner

Wales

Language evolves, and some phrases are no longer used when it’s clear they’re offensive

In February, the Daily Telegraph ’s Celia Walden used her column to mock the Royal College of Nursing’s (RCN) style guide on the correct terminology and formats to use in

nursing communications. The piece was ostensibly light hearted, its

tone gently ribbing what Walden saw as the RCN’s po-faced attitude. But it wasn’t hard to construe the meaning behind the joke—namely, that we’ve become far too obsessed with “woke” language and identity politics, that it’s distracting and detracting from the vital work of clinical care, and that staff have better things to worry about than putting their foot in it or getting into trouble by accidentally using the “wrong” phrase—perhaps one that was standard a few years ago but has been superseded and might trigger hurtful emotions.

What was the substance behind Walden’s thesis? First, the RCN style guide is the kind of document you’ll see routinely in checklists for subeditors to ensure consistency: editorial manuals for scientifi c journals, professional membership organisations, unions, or charities. The guide’s target audience is not so much frontline nurses but people involved in communications and publications.

Walden’s column focused on a few key items. These included the instruction to refer to “staffi ng” instead of “manpower”; “older people” rather than “old age pensioners” or “the elderly”; “women” instead of “ladies”; “people with disabilities” instead of “disabled people”; and “alcohol misuse” as opposed to

“alcoholism.” The guide also urged us not to say “bed blocker” or “bed blocking” to describe patients stranded in hospital through no fault of their own.

I think that the RCN is right on this. Most NHS staff are women, especially in nursing. “Older people” have said that they prefer that term. People with disabilities or other long term conditions and charities that advocate for them don’t want to see people defi ned or stigmatised by their condition. Language evolves, and some phrases are no longer used when it’s clear they’re off ensive.

Walden went on to claim that this focus on language would detract and distract from good care, that the emphasis on language and terminology was “frivolity.” And, apparently, that terms such as “living with anxiety” or “misusing alcohol” instead of “suff ering from anxiety” or “alcoholic” would somehow mean that individuals took no responsibility for their own health or faced up to the need for help with their mental health.

I don’t want to see people disciplined at work for accidentally or even persistently using retro terms and phrases. But I don’t think that it does any harm to remind people to show some consideration. Language frames the way we see and treat people. Getting it wrong can cause hurt and resentment. So, why not make the

eff ort to get it right? It doesn’t make you a worse nurse or doctor to do so .

David Oliver, consultant in geriatrics and

acute general medicine , Berkshire

[email protected] @mancunianmedic


ACUTE PERSPECTIVE David Oliver

Caring about language is not frivolous


The health service is slowly returning to normal, after adapting rapidly and radically to meet the demands of the fi rst wave of coronavirus

infections. Operating theatres and anaesthetic rooms that were repurposed as high dependency units are resuming their original functions as the number of patients needing ventilation continues to fall. The space dedicated to assessing possible covid patients in hospital emergency departments and at “hot hubs” in the community is steadily shrinking.

In our practice, it seems that most patients have decided the pandemic is over. While a few are still cautious about coming to the surgery, most consider that the problems they’ve put off for the past three months now need urgent attention. Our telephone lines are buzzing, our appointments are all booked, and although we’re still triaging all our appointments by phone we’re gradually doing more assessments face to face.

However, while patients are now coming to us with symptoms that require investigations or specialist input, most departments at our local hospital are still not accepting referrals (except emergencies). Patients would like to know when they’ll be seen, or at least that they’re in a queue, but the computer (in this instance, the obligatory electronic referral system) says “no.” So I have a lengthening list of referrals pending, to revisit who knows when.

In normal times there’s a sense of relief when, as a GP, you’ve done all you can and hand on an unsolved problem or a diagnostic challenge to a specialist. The case is off your mind and desk, in somebody else’s inbox. Now, however, I continue to hold all responsibility, and it’s starting to feel uncomfortable.

Many hospital clinics, even if not accepting new referrals, are up and running, doing follow-ups by phone or video link. Unfortunately, this also results in extra work for the practice, as tasks that were previously done in clinic now arrive as instructions: “GP kindly perform XYZ blood tests, check blood pressure and, if normal, prescribe W.” While it’s clearly the most practical and convenient solution for the patient, this transfer of work to general practices—which are running at reduced capacity because of social distancing and personal protective equipment—has been neither negotiated nor agreed.

At the beginning of the pandemic there was a brief and happy moment when the medical profession pulled together, putting aside its usual turf wars and interdisciplinary wrangles in the face of a collective and urgent threat. That unity is now beginning to fracture, and resentment is growing. If the problem isn’t tackled soon it poses a

growing risk to the standard of care that we can off er our patients .

Helen Salisbury , GP, Oxford

[email protected]

Twitter @HelenRSalisbury


Listen and subscribe to The BMJ podcast on Apple Podcasts, Spotify, and other major podcast apps

Edited by Kelly Brendel, deputy digital content editor, The BMJ

This transfer of work to general practices has been neither negotiated nor agreed

Deep Breath In: Resetting general practiceHow will the post-covid world of general practice look? Will we drift back to business as usual or seize the opportunity to redefine the role of primary care? The latest episode of Deep Breath In tackles these questions. Here Martin Marshall, chair of the Royal College of General Practitioners, shares his thoughts on an area he’s keen to see supported once more:

“One of the concerns I have about where we are right now is that shared decision making largely seems, to me, to have stopped. We’ve become a very provider orientated, slightly dictatorial, population focused health system because we’ve had to. I’m not complaining about that during the crisis. We now need to rediscover some of the superb work that’s been done around shared decision making, like Choosing Wisely, for example, so that we can work more effectively with patients to give them a stronger voice. And we know that when you give patients a stronger voice, by and large, they choose less interventional approaches than doctors will choose.”

Talk Evidence: rehabilitation after covid-19As patients recover from covid-19, what challenges may lie ahead for them and what support will they need? This episode of Talk Evidence hears from Lynne Turner-Stokes, a professor of rehabilitation medicine at King’s College London, about what we know about potential rehabilitation needs. Here she talks about people who were not admitted to hospital and dealt with their symptoms at home:

“The first thing that I would say about those patients would be we really need to be having coordinated medical programmes that people can slot into, where they can be assessed and have the necessary investigations to make sure that it’s suitable for them to exercise safely.”

PRIMARY COLOUR Helen Salisbury

Normality will return—eventuallyLATEST PODCASTS


SARS-CoV-2 was declared a serious and imminent threat to public health on 10 February, 1 but covid-19 was added to the list of notifi able diseases only on 5 March. From the outset, the notifi cation system was inadequate. NHS 111 covid-19 call centres were hastily set up. Symptomatic patients were advised to stay at home and not contact their GPs or NHS 111 initially, and thereafter to contact NHS 111 online. This will have prevented rapid reporting of suspected cases.

A covid-19 clinical assessment service was also set up to receive and possibly reclassify referrals after NHS 111 triaging, using retired and locum or sessional GPs instead of general practices. It is not known whether registered medical practitioners working in NHS 111 or the assessment service notifi ed any suspected cases.

NHS guidance 4 did not alert GPs to the need to inform local authorities of suspected cases. It advised GPs to inform Public Health England (PHE) of symptomatic cases and then only in specifi ed settings or unusual scenarios. The guidance also wrongly implied that the requirements relating to notifi able diseases apply only to confi rmed cases. These failings were only partially rectifi ed in new

guidance dated 29 May. 5 PHE’s guidance wrongly implies that local authorities do not need to be notifi ed of suspected cases. 6

Historically, England’s system of communicable disease control has relied on close cooperation between

local health services and authorities. General practitioners, NHS and public health laboratories, and local public health offi cers play key roles, backed by legal notifi cation requirements.

That local system has gradually been eroded over several decades (box 1, overleaf). But instead of prioritising and rebuilding this system at the start of this epidemic, the government has created a separate system which steers patients away from GPs, avoids local authorities, and relies on commercial companies and laboratories to track, test, and contact trace. The ad hoc parallel system in England has three components: • Covid-19 primary care programme

which, until 29 May, did not include information on need to notify suspected cases to local authorities

• Centralised testing programme that relies heavily on private companies

• Centrally led contact tracing system that uses commercial call centres and may in future use a mobile phone app. We question why the government

has created this ad hoc parallel system when a straightforward, if weakened, system already existed. In addition, we are concerned by apparent failings in this parallel system. The notifi cation system (table, page 27) seems to have been mishandled from the beginning, and many suspected cases will have been missed as a result. Outsourced private testing services have been given the bulk of government business, with no clear public health standards. There is also a lack of clarity on where the results are being sent.

MAL

COLM

WIL

LETT

KEY MESSAGES

• England’s established system of local communicable disease control has been eroded over several decades

• In response to covid-19 the government created a parallel system which steers patients away from GPs and relies on commercial companies for testing and contact tracing

• Many suspected cases will have been missed because of mishandling of the notifi cation system

• NHS 111 covid-19 call centres and the covid-19 clinical assessment service should be reintegrated immediately into primary care and practices resourced to resume care

• Contact tracing and testing should be led by local authorities and coordinated nationally

• England must rebuild and reintegrate its local communicable disease control system

ANALYSIS

Getting back on track: controlling covid-19 outbreaks in the community Peter Roderick , Alison Macfarlane, and Allyson M Pollock argue there’s still time to change tack on the UK’s ad hoc system for tracking, testing, and contact tracing

Notification of suspected cases

Centralised and commercially run tests

A public health approach to testing requires a clear purpose, systematic delivery and data fl ows, informed participation, quality assurance, equity, and ethical oversight to build trust. Decisions should be safeguarded from political and commercial interference. 7 The testing programme announced by the government on 4 April 2020 8 with its “fi ve pillars” falls well short of what is required.

Instead of focusing on increasing capacity in PHE and NHS laboratories, which report results to PHE through its second generation surveillance system, the government designated these laboratories as “pillar 1” for people with a clinical need and health and care workers, and set up a separate, centralised, and commercially based “pillar 2” for the wider population.

Daily numbers of pillar 1 tests have levelled off , and numbers of pillar 2 tests now tend to exceed those for pillar 1. 9 They include in-person tests, which are counted when samples are taken at testing stations at about 50 regional sites and mobile testing units run by the army. Testing kits posted out to people at home and elsewhere are counted on dispatch, 10 and it is not known how many are actually used. Numbers have increased dramatically on some occasions when the government has been trying to reach preset targets for testing. 11

The president of the Institute of Biomedical Science has described creating this new additional structure as “perverse,” competing with NHS laboratories and freezing them out. 12

Pillar 2 is based on contracts with commercial companies. Very few appear on the government’s contracts fi nder website.

It seems from the list of data processors, 13 which has changed frequently, that

testers at regional sites are provided by Sodexo and Boots; some sites

are operated by Deloitte. Serco, G4S, and Levy provide facilities

management. Randox provides home testing kits,

the logistics for which are provided by

Amazon. Pillar 2

samples are analysed by the four new “lighthouse labs,” which involve AstraZeneca and GlaxoSmithKline (box 2), even though both state that “diagnostic testing is not part of either company’s core business.” 15 16 Randox analyses the samples from its home test kits, with a contract for £133m (€150m; $165m). 17 This compares with the £86.9m provided to PHE for infectious disease, surveillance, and outbreak management in 2018-19. 18 In all, 67 000 Randox tests are reported to have been sent to the US for analysis because of lack of capacity, but 29 500 results were found to be invalid and needed to be redone. 19

According to the government, 13 results of non-Randox tests are sent to the National Pathology Exchange (NPEx) hosted by Calderdale and Huddersfi eld NHS Foundation Trust. NPEx links them to test registration and passes results to NHS Digital and to the NHS Business Services Authority, which sends results to those who have been tested. The government also states that Palantir analyses anonymised data. 13

The strategy has three further pillars. Pillar 3 is mass antibody testing. Pillar 4 is a programme of serology and swab testing for national surveillance supported by PHE, the Offi ce for National Statistics, UK Biobank, universities, and other partners. The aim of Pillar 5 is to build a British diagnostics industry, with the short term aim of supplying the other pillars.

Feedback of results

It is unclear what happens to many test results, in particular whether they are fed back to individual patients’ GPs. Several hundred thousand tests are reported not to have been linked to NHS records, missing confi rmed cases. 20 There is also no indication whether results are made available to staff doing local contract tracing. The chief medical offi cer for England is reported to have apologised to local authorities for not having detailed data from tests conducted by Deloitte. 21 It is unclear whether PHE has timely access to test outcomes.

Further problems have arisen in relation to reporting numbers of tests and results in national statistics, prompting two letters to the secretary of state for health and social care from David Norgrove, chair of the UK Statistics Authority. 22 23 The second suggested that the statistics should enable an understanding of the epidemic and help manage the testing programme but pointed out that “the statistics and analysis serve neither purpose well” and that the main aim seemed to be to claim the largest possible numbers of tests.

Box 1 | Erosion of local communicable disease control in England

At its height, local communicable disease control was supported by more than 60 national, regional, and local public health laboratories. The service was strengthened from 1977-2002 by the creation of the Communicable Disease Surveillance Centre in Colindale.

Erosion began after NHS reorganisation in 1974 and continued when the Public Health Laboratory Service Board was abolished in 2003 and its local laboratories transferred to NHS trusts, at the same time as communicable disease control was centralised in the Health Protection Agency.

In 2012, the Health and Social Care Act abolished locally based bodies in England and carved public health functions out of the NHS. Public Health England was set up as an executive agency to fulfil the government’s duty to protect the public from disease, with only nine laboratories and eight regional centres. Local authorities were charged with improving public health. Each local authority was required, acting jointly with the secretary of state, to appoint a director of public health, with responsibility for exercising the authority’s public health functions.

NHS guidance did not alert GPs to the

need to inform local authorities of

suspected cases



Summary of legal requirements for notifying notifiable diseases in England, Scotland, Wales, and Northern Ireland

Data type Notifier Notified Timescale

England

Suspected cases and deaths Registered medical practitioner Proper office of local authority, who then

informs Public Health England

3 days (written) or, if urgent, orally as soon as reasonably practicable (for each

body)

Confirmed cases and deaths Operator of a diagnostic laboratory Public Health England 7 days (written) or, if urgent, orally as soon as reasonably practicable

Scotland

Suspected cases and deaths Registered medical practitioner Health board, which then informs the

Common Services Agency and Public

Health Scotland

Health board: 3 days (written) for health board or, if urgent, orally as soon as

reasonably practicable

PHS: no later than the end of the week in which the information is received or as

soon as practicable afterwards

Confirmed cases and deaths Director of a diagnostic laboratory Health board in whose area the laboratory

is situated, Common Services Agency, and

Public Health Scotland

10 days (written), or, if urgent, orally as soon as reasonably practicable

Wales

Suspected cases and deaths Registered medical practitioner Proper officer of local authority, who then

informs Public Health Wales

3 days (written), of, if urgent, orally as soon as reasonably practicable (for each

body)

Confirmed cases and deaths Operator of a diagnostic laboratory Proper officer of local authority, who then

informs Public Health Wales

Local authority: 3 days (written) or, if urgent, orally as soon as reasonably

practicable

PHW: 3 days (written), or, if urgent, orally as soon as reasonably practicable

Northern Ireland

Suspected and confirmed

cases and deaths

Medical practitioner Director of public health for Northern

Ireland

As soon as suspected or confirmed

Sources: England: The Health Protection (Notification) Regulations 2010, Regulations 2, 3, 4, and 6; Scotland: Public Health etc (Scotland) Act 2008, sections 13, 15, and 16, as amended; Wales: The Health

Protection (Notification) (Wales) Regulations 2010, Regulations 2, 3, 4, and 6; Northern Ireland: Public Health Act (Northern Ireland) 1967, section 2, as amended.

Box 2 | Lighthouse laboratories 14

Milton Keynes —managed by UK Biocentre, the largest facility in the UK for storing and processing biological samples. It is the trading subsidiary of the charity UK Biobank Alderley Park —a life science campus with a dedicated lab for covid-19 analysis led by Medicines Discovery Catapult, which was set up as a limited company with a grant from Innovate UK to support drug companies, contract research organisations, and diagnostic businesses operating in the health sector Glasgow— the lab is led by the University of Glasgow at the city’s Queen Elizabeth University Hospital. It is supported by the Scottish Government, BioAscent Discovery (a provider of integrated drug discovery services), and the University of Dundee Cambridge— a collaboration between AstraZeneca, GSK, and the University of Cambridge’s Anne McLaren laboratory

Making it work

Immediate steps should be taken to ensure that registered medical practitioners within NHS 111, the covid-19 assessment service, and general practice notify local authorities of suspected cases. Outbreak management plans should put local directors of public health in control of contact tracing, coordinated rather than led by PHE. The capacity of the NHS 111 covid-19 call centres and the assessment service should be immediately reintegrated into primary care and practices resourced to resume care. Offi cial advice to those with covid-19 symptoms should be amended to direct them to contact a GP or NHS 111.

These steps, however, are remedial. They do not amount to a coherent and adequate public health response to the epidemic in England. Such a response requires local authorities, NHS, and PHE laboratories to be suffi ciently resourced to take the lead on contact tracing and testing, and general practices being resourced to support patients, under central coordination. Parliament has given the secretary of state the powers to enable this to happen, and we urge him to exercise them.

In the longer term, the abysmal response of the government to the epidemic has served to underline the need for legislation to rebuild and reintegrate a strong local communicable disease control system. Peter Roderick, researcher , Newcastle University

[email protected] Alison Macfarlane, professor , University of London

Allyson M Pollock, professor , Newcastle University


Contact tracing is a local activity. Local authorities know their community, and tracing requires feet on the ground. But the tracing programme announced by the secretary of state on 23 April 2020 24 is centralised, using call centres operated by Serco and other companies with thousands of newly recruited call handlers. The programme may not be fully operational until September. 25 The NHS covid-19 app, which had been touted as key to contact tracing, has now been abandoned.

It is unclear how the contact tracing programme will operate, as outbreak management plans are yet to be produced. The government’s guidance does not mention GPs or local directors of public health. 26 It is not known whether, how, or to whom suspected cases will be notifi ed. Ineffi ciency, data quality issues, local data access diffi culties, and unnecessary expense are inevitable.

Details such as full postcodes, and age and sex of suspected and confi rmed cases are essential for monitoring outbreaks in a local authority area and identifying clusters. However, local authorities do not have live access to this information and are instead sent aggregated data. This approach, combined with the failures to require notifi cation of suspected cases and to undertake community testing, has further hampered outbreak control. Instead of restoring local data fl ows, the government is attempting to create a population surveillance system through the new Joint Biosecurity Centre. 27 The centre will receive data from numerous sources, including NHS data through the portal of NHSX’s covid-19 data store reference library. Over 50 datasets are being integrated and harmonised by private data companies Palantir and Faculty to create a “single source of truth.” 28

Centralised and commercially run contact tracing


LETTERS Selected from rapid responses on bmj.com

LETTER OF THE WEEK

Covid-19 recovery certificates: call for a citizens' jury In my rapid responses about covid-19 creating extraordinary times demanding imaginative responses (Editor’s Choice, 21 March), I wrote that people who had recovered from proven infection and were not shedding virus were a potentially invaluable asset. They must have at least partial, temporary immunity. I recommended that we give them a certificate indicating that they would be largely, if not wholly, immune to a second infection this year.

I anticipated reliable antibody testing would become available, which is becoming true, although it is controversial. Even a test with 99% sensitivity and specificity only has 83.8% predictive power of a positive test when the prevalence of infection is 5%.

Recovered patients could serve on the front line, not just in healthcare and nursing homes but also in retailers and factories. They could be offered registration for employment and volunteering purposes. I identified clinical, public health, legal, ethical, and social issues requiring research and scholarship as well as public debate. The Royal College of Physicians of Edinburgh hosted a video on this proposal.

There has been much debate, especially about “immunity passports.” This phrase implies a guarantee that cannot be achieved. WHO cautioned against this on 24 April. I have, however, not changed my mind and think the emphasis on antibody testing is misplaced and unnecessary, especially as much immunity to respiratory viruses is not humoral. It is a matter of probabilities, as there can never be certainties.

Chile, to my knowledge, is the first country to formally adopt this proposal. It is time to go beyond opinion, but research is just getting under way. The public, scholars, and policy makers need to debate this idea. I think the public, especially those who have been ill, might find the idea more attractive than scholars and researchers. Is it time for a citizens’ jury? Raj Bhopal, emeritus professor of public health , Edinburgh


COVID-19 AND ALCOHOL

Next generation alcohol problems Finlay and Gilmore rightly draw attention to two vulnerable groups of drinkers in the covid-19 lockdown (Editorial, 30 May). Regardless of whether parents drink more alcohol in lockdown, their children are far more likely to see them drink. And substantial evidence indicates the intergenerational transmission of alcohol habits and alcohol misuse through parental role modelling.

Parental alcohol use or misuse is associated with subsequent alcohol consumption and misuse in adolescence through adulthood. Yet, many studies and discussions

of adolescent drinking have failed to include parental drinking even as a confounding variable in the analyses, let alone as a major explanatory factor. To avert next generation problems, the UK must stand back from the bottle and see the elephant in the room—parental drinking. Covid-19 and alcohol might prove to be a dangerous cocktail in more ways than we realise. Aric Sigman, child health education lecturer ,

Brighton


SCIENTIFIC ADVISERS’ DUTY

Playground Machiavellian tactics Abbasi discusses transparency and political interference in scientific advice (Editor’s Choice, 30 May). Healthcare and politics are inexorably intertwined, because every healthcare decision involves resources. The term “independent adviser” has lost all meaning. Everyone either has an agenda or could easily have one manufactured for them.

The politicians of today are career professionals savvy in their art of political science. Healthcare professionals are understandably comparatively naive regarding the machinations of political life.

What is perhaps most disheartening about the covid-19 situation is that the politics being used is that of a playground Machiavelli. The current political mantra of “following the science” is obviously doublespeak, laying the foundations of the blame yet to come. Having the chief medical officer and colleagues up on the podium in front of the nation simply allows the public to put a face to the name when the inevitable inquiry begins. Sati Heer-Stavert, GP , Birmingham


Being a bystander is a choice Abbasi raises the issue of conscience and duty for scientific advisers in the covid-19 pandemic. Senior roles in government, rightly or wrongly, “train” such professionals to learn the art of compromise, but there should be limits to this. When lives are at stake and integrity is threatened, advisers should not be protecting politicians or government but should come out in the open and highlight the “truths,” however difficult or uncomfortable these might be.

Scientific advisers should not hide behind the notion that they only “advise” and the final decision is not theirs. If the final decision is wrong and threatens life, they are obliged to do more than just voice their concerns behind closed doors. We expect our senior scientific and medical leaders to have the integrity and courage to stand up for what is right.

Being a bystander is a choice, the choice to be complicit. Minesh Khashu, consultant neonatologist , Corfe Mullen



Helping healthcare workers heal Kisely and colleagues’ meta-analysis reinforces the expectation that healthcare workers might experience distress after working with covid-19 (Research, 23 May).

Any intervention should ensure disclosure is controlled by the individual and at a time they choose. One simple vehicle for venting and exploring emotions might be talking aloud or writing about events, uncensored, to a confidential recipient. This recipient need not be a “live” person.

We are piloting a process called Covid Confidential, which permits users to confidentially record their stories about the care of patients with covid-19 in spoken or written form to a website. This might provide the immediate emotional benefit of offloading negative experiences and a repository of frontline stories, enabling identification of the immediate and most important concerns. This could be a cost effective intervention, and the time users spend engaged with it. Paul Bennett, professor of clinical health psychology ;

Rachael Hunter , senior lecturer ; Steve Johnston, head ,

Swansea; David Jones, consultant in intensive care ,

Merthyr Tydfi l; Simon Noble, Marie Curie professor of

supportive and palliative medicine , Cardiff


Digital mental health solutions Gold’s editorial on psychological first aid interventions recognises the major psychological consequences of the covid-19 pandemic (Commentary, 23 May).

Digital mental health programmes offer the ability to respond quickly and efficiently and to reach people over great distances with minimal mobility requirements. There are more than 10 000 smartphone apps related to mental health, with diverse approaches ranging from remote cognitive behavioural

therapy to the use of automated “chat bots.” But little evidence based guidance exists.

Pragmatic clinical trials could allow us to rapidly assess the association between digital interventions and outcomes in a real world context. This could dramatically enhance our abilities to monitor, assess, and treat mental health, not just during covid-19 but potentially for underserved people in rural populations or low income regions.

Guided by a rigorous evidence based approach, digital health solutions might combat the behavioural and psychosocial fallout from this global pandemic. Bernard P Chang , associate professor of emergency

medicine ; Harold A Pincus, professor , New York;

Ronald C Kessler , McNeil family professor of health

care policy ; Matthew K Nock, Edgar Pierce professor of

psychology , Boston


Supporting healthcare students Gold’s editorial overlooks a subgroup in the clinical environment: healthcare students.

Student income is often dependent on maintenance loans, and many report resulting financial hardship. Strategies proved to boost staff morale, such as hazard pay, are not available for students, and part time jobs are now scarce.

Student societies have closed, removing protective peer support networks. When

campuses reopen, finding support will be hard for new students constrained by social distancing or lack of physical lectures. For international students, this will be an even bigger problem, especially if they face a period of quarantine. Expecting young people to move on without closure could lead to mental health crises.

As students prepare to restart clinical placements, it is key that students remain supported on placement and that mental health services are cognisant of the unique challenges in the wake of covid-19. Christopher A Smith, fi nal year medical student ,

Southampton


Preventing a crisis in primary care Kisely and colleagues and Gold point out the urgent need for strategies to minimise the psychological distress of healthcare workers. Evidence indicates that after the pandemic begins to recede, the subsequent economic crisis will have a knock-on effect on the mental health of the general population.

Spain has one of the highest numbers of cases of covid-19 in Europe and was also one of the countries most affected by the economic crisis of 2008. We compared mood, anxiety, and somatoform and alcohol related disorders among primary care attendees in Spain between 2006 and 2010. We found a substantial rise in several mental health disorders significantly associated with unemployment and mortgage difficulties. In the next stages of the pandemic, we must prevent primary care from being overwhelmed. Miquel Roca, professor of psychiatry ; Caterina

Vicens, primary care unit coordinator ; Margarita Gili,

professor of social psychology , Palma de Mallorca


Caring for patients with non-memory led dementia Carter raises concerns about the vulnerability of people in care homes, including those with dementia (Feature, 16 May). Non-memory led dementias account for around 15% of all dementia cases. They are relatively more common in people under 65 who do not fit perceptions of dementia, making their needs less noticeable.

Patients with behavioural variant frontotemporal dementia can lack insight and have behavioural disinhibition and compulsive behaviours, which make managing in lockdown difficult. People with posterior cortical atrophy have progressive visual impairments that lead to greater reliance on touch, which might increase the risk of covid-19 infection. People with primary progressive aphasia might have limited understanding of concepts like “virus,” “mask,” or “soap.”

Calls to the UCL Rare Dementia Support service have doubled. The service has launched a covid-19 emergency kit, increased phone and email support, established online discussions, and facilitated member-to-member virtual buddying by videoconference. Aida Suárez-González, senior research associate ;

Nicola Zimmermann, direct support services lead at

Rare Dementia Support; Claire Waddington, research

assistant ; Olivia Wood, research assistant; Emma

Harding , research associate ; Emilie Brotherhood,

research associate; Nick C Fox, professor of neurology;

Sebastian J Crutch, professor in neuropsychology , UCL

Queen Square Institute of Neurology


PSYCHOLOGICAL EFFECTS

NON-MEMORY LED DEMENTIAS


OBITUARIES

Bruno Cheong Consultant physician

(b 1957; q Cardiff, 1980;

FRCP), died from covid-19

on 27 April 2020

Bruno Cheong left his native Mauritius in 1975 to study medicine at the Welsh National School of Medicine in Cardiff, but he vowed to return and serve his island after his training. He completed most of his clinical training in Wales and specialised in internal medicine. He had a particular interest in respiratory medicine, specifically in the acute management of asthma. Shortly after being appointed as consultant physician in the UK, Bruno took the opportunity to work at the Khamis Mushayt Military Hospital in Saudi Arabia for a year. In 1989 he returned to Mauritius. Throughout his career, he contributed to improving the country’s healthcare system. He was the first frontline doctor in Mauritius to die from covid-19 after three weeks in intensive care. Bruno leaves his wife, Sandra, and two children. Julia Cheong, Satwant Gill


Longer versions are on bmj.com. Submit obituaries with a contact telephone number to [email protected]

William Anthony Warburton General practitioner

Magdalen Medical

Practice, Norwich

(b 1936; q Liverpool

1960), died from cancer

on 15 April 2020

William Anthony Warburton (“Tony”) interviewed me in 1978 for a place in the practice in Norwich, where he was junior partner. In the 1980s we bought Eyre’s garage, knocked it down, built our own premises, and Tony and the rest of us moved in. Another practice from the health centre joined, and we became Magdalen Medical Practice. Tony continued to work there until he retired in 1996. A couple of years ago he was diagnosed with cancer of the ampulla of Vater, underwent Whipple’s procedure, and made a good recovery initially. In the end, however, he was admitted to the Norfolk and Norwich University Hospital, where covid-19 precautions meant no visitors. In his final hours, however, his wife, Benita, was permitted to be with him. Tony leaves Benita, three sons, and five grandchildren. John Bennett


Harshadrai Patel Consultant anaesthetist

(b 1938; q Gujarat

University 1962;

FFARCS), died from renal

failure on 26 March 2019

Harshadrai Patel (“HP”) was educated in Mombasa, Kenya, but returned to his native India for his higher and university education. He came to England in 1965 and was appointed consultant anaesthetist at the Queen Victoria Hospital, East Grinstead, in 1976, where he continued his research, particularly into cerebral function during the use of controlled hypotension for plastic surgery. His artistry and skill in anaesthesia made him an excellent and inspirational teacher. His hospitality to friends, family, and colleagues was legendary; he often entertained on his narrow boat on the Oxford Union Canal. He was also a keen pilot; having started by flying gliders in India, he obtained his private pilot’s licence in the UK. He retired to Paphos in Cyprus in 1994, with his wife, Kathryn, who predeceased him in 2010. Chris Barham


Lynn M Price Associate specialist

Countess of Chester NHS

Trust (b 1957; q Otago,

Dunedin, New Zealand

1981; MRCGP), died

from adenocarcinoma

of the gall bladder on 23

August 2019

Lynn M Price did a genitourinary medicine post in Auckland, as part of her GP training. She came to the UK in 1987, to consider a career in GUM and did her diploma in GUM in 1989. She joined the Countess of Chester Hospital in 1991, at the height of HIV. Although she loved her job, she took early retirement in 2016 to spend time with her family, exploring her beloved Welsh mountains. She lived high above Llangollen and, despite snow on many occasions, never missed a day’s work, thanks to her ancient Land Rover. Lynn was serenity personified and an inspiration to colleagues and patients. She died within three months of diagnosis. She leaves her husband, Roger, and two children. Colm O’Mahony


John Mitchell Morgan Pathologist (b 1945; q St Andrews

1969; FRCPath), died from pneumonia

on 9 May 2020

John Mitchell Morgan (“Iain”) had a long and distinguished career working in the UK, Canada, Africa, and, most recently, the Cayman Islands. He moved back to Scotland in 2010 for his retirement and to concentrate on his love of outdoor pursuits. Born in Lanark in 1945, the son of the local chemist, Iain qualified in medicine with a distinction. His career started in Scotland and was followed by a role with the Royal Flying Doctor Service in Zambia, where he worked alongside his wife, Anne. After Zambia, Iain and Anne travelled to New Brunswick, Canada, where he was the local GP. On returning to the UK in 1974, he worked at Ninewells Hospital in Dundee and became a consultant at Leighton Hospital in Cheshire in 1980. Iain will be sadly missed by his family. Sacha Higgins


Kenneth Peter Goldman Consultant physician,

general and chest

disease, Dartford and

Gravesham (b 1928;

q Cambridge/St Mary’s

Hospital Medical School

1957; MD, FRCP),

died from covid-19

pneumonia on 14 April 202

Kenneth Peter Goldman (“Ken”) worked at Sully Hospital in south Wales between 1960 and 1963, which at the time was the Welsh Regional Centre for Thoracic and Cardiac Surgery. Ken became an expert in chest diseases of coal miners, an interest that continued until well after his retirement from the NHS. He was also the editor of the journal Tubercle from 1980 to 1991. He retired from the NHS in 1992, and in retirement he worked part time for the Ministry of Work and Pensions, examining and assessing coal miners with medical problems. When Ken, his wife, Lorna, and one of their sons developed covid-19 symptoms, he was admitted to hospital. He leaves Lorna, three children, and two grandchildren. Eric D Silove



On 25 March Adil El-Tayar, a renowned organ transplantation specialist, became the fi rst working NHS surgeon to die from covid-19 in hospital in the UK. A healthy and active 64 year old, he is thought to have contracted the virus at a hospital in the Midlands, where he worked during the week. He cared deeply about the NHS, an institution he had spent most his career serving.

Born in Atbara, Sudan, a railway city on the Nile, El-Tayar was the eldest son of a government clerk and a housewife. He had 11 siblings. A close knit community, Atbara had been built by the British to serve the railway line between Port Sudan on the Red Sea coast and the Wadi Halfa in the north. It was here that the fi rst Sudanese labour movement started in 1948. El-Tayar attended the local school and was a diligent student. During his childhood, one of his brothers, Osman, became ill and died without suitable medical treatment. Although El-Tayar rarely spoke about his brother’s death, he named his fi rst born son after him. It is likely that the experience of witnessing his brother’s suff ering and his loss led him to medicine.

Surgical career El-Tayar read medicine at the University of Khartoum. He moved to the UK in 1996, where he studied at the University of West London and worked at the West London Transplant Unit until 2005. He then moved to St George’s Hospital, Tooting, where he worked as

a consultant transplantation surgeon before moving to Saudi Arabia in 2007, where he spent three years working at the King Fahd General Hospital in Jeddah. He completed a masters degree in vascular medicine and technology in 1997 and a masters in health service and management, from the University of London, in 2002.

In 2011 he moved back to his native Sudan, helping to establish a transplantation programme while working at Ibn Sina Hospital, Khartoum. The worsening political situation in Sudan, however, and recent birth of a son persuaded El-Tayar to move back to the UK to work for the NHS. He had established a good transplantation unit in his home country. He returned to St George’s Hospital as a locum consultant surgeon, specialising in kidney transplantations, from 2017 to 2019.

On the frontline El-Tayar had volunteered to be on the frontline of the health service in order to fi ght the coronavirus pandemic. He lived in west London at weekends with his wife, Ekhlas, but worked at the Hereford County Hospital during the week, examining patients coming to the emergency department. It was there that, according to his family, El-Tayar believed he picked up the virus.

On 13 March the fi rst UK death from covid-19 was reported in Scotland. The next day, El-Tayar started feeling unwell. He returned to his London family home and self-isolated. During the following days, cases of covid-19 began to surge in the Midlands. After a week in bed, El-Tayar’s health deteriorated and he became

breathless and feverish. He knew what that meant and agreed for his family to call an ambulance. He managed to walk by himself to get into it, but after he was admitted to West Middlesex University Hospital in Isleworth on 20 March, his condition quickly worsened and he was placed on a ventilator. He later tested positive for covid-19 and died after fi ve days in intensive care on a ventilator.

Irfan Siddiq, the British ambassador to Sudan, paid tribute to El-Tayar on Twitter, “Saddened to hear of Sudanese doctor Adil El-Tayar’s death in the UK from covid-19. Health workers around the world have shown extraordinary courage. We cannot thank them enough. In this fi ght we must listen to their advice.”

In a tribute on BBC Radio 4’s From Our Own Correspondent , El-Tayar’s cousin, journalist Zeinab Badawi, said, “He was a dedicated doctor and devoted

family man. He wanted to be deployed where he would be most useful in the crisis—but in the end he paid for it with his life.”

David Mowbray, Wye Valley NHS Trust medical director, said, “We are saddened to learn of the death of Adil El Tayar, and our thoughts are with his family at this time. We were fortunate to have someone of his skill and stature working for the trust and many patients will have benefi ted from his talent and expertise.”

In his little spare time, El-Tayar enjoyed pottering around his garden, tending to his apple and pear trees, and planting fl owers. He made friends easily and invited them around for barbecues in the summer. He liked to reminisce about growing up in Sudan and was very proud to be Sudanese.

Adil El-Tayar was buried beside his father and grandfather in Sudan, as he wished. He leaves his wife and four children. Rebecca Wallersteiner , London [email protected] Cite this as: BMJ 2020;369:m1803

OBITUARIES

El-Tayar volunteered to work on the frontline in a Midlands hospital during the coronavirus pandemic

Adil El-Tayar (b 1956; University

of Khartoum, Sudan, 1982;

FRCS Ireland), died from

covid-19 on 25 March 2020

Adil El-Tayar NHS transplant surgeon who died from covid-19

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