commentcomment “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 SALISBURY PLUS Consent during a pandemic; safely easing shielding

THE BOTTOM LINE Partha Kar The NHS needs a Seacole statute

had to read through the email a few times to or nudging has achieved little. The 2019 Workforce digest what a consultant had written to me. Race Equality Standard showed that white applicants “Confl ating covid with institutional racism were still “1.46 times more likely to be appointed among your friends and colleagues is utterly from shortlisting compared to BME applicants.” Ishameful,” it said. “Nobody knows the Another big step would be to ditch terms genetics of covid, but you see fi t to suggest that its such as BAME, which turn discrimination into a predilection for BAME [black and minority ethnic simplistic discussion about white and non-white people] is down to racism. Your views nauseate me— communities. The issues infl uencing attainment there is no room for them in today’s NHS.” and socioeconomic deprivation are fundamentally This was a response to my May BMJ column, in diff erent for someone who is black than for someone which I discussed whether racism was a factor in from India, Bangladesh, or China. the increased mortality from covid-19 among ethnic There’s no better moment to shift the dial from minorities. Subsequently, further investigations and conversations and cajoling to clearer data collection, a report from Public Health England have established open access to data based on area and authority, and that racism and discrimination may have contributed a commitment to a concept similar to the Rooney rule. to the increased risk. Yet, for this consultant, it was The “Seacole statute” has a ring to it, and it would be hurtful to even suggest racism in the NHS. a way to pay homage to a titan and pioneer in the fi ght It made me refl ect on a wider problem—and an for equality in healthcare. It’s worth thinking about. analogy with sexism. Many men responded indignantly Partha Kar, consultant in diabetes and endocrinology, to the MeToo movement. They missed the point Portsmouth Hospitals NHS Trust that it wasn’t about them. It was about listening and [email protected] refl ecting that there may be many colleagues whose Twitter @parthaskar views you’d not picked up on, not acted on, or ignored. Cite this as: BMJ 2020;369:m2583 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 At an individual be racist, but to be indignant at the notion of the NHS level, it’s time having a race bias may simply refl ect your ignorance to be antiracist, or the bubble you inhabit. However, this sort of to speak up ignorance propagates the problem. When people see and be allies 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 the bmj | 4 July 2020 21 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? he 70 year old patient has been pandemic, to our knowledge no formal Failure of surgeons to raise the risks waiting months for his elective guidance has been published by the GMC or of covid-19 during the consent process surgery. A few days before the the Royal College of Surgeons on obtaining is ethically and legally troubling operation, he has a swab test consent in such circumstances. T to detect any active covid-19 Following the case of Montgomery v older), and type of surgery (higher for major infection. It’s negative. Before the operation, Lanarkshire Health Board (2015) UKSC 11, surgery and emergency operations). the surgeon reminds him about the risks doctors must take reasonable care to ensure Although limited to a single study at an and benefi ts of the procedure, as well as the patients are aware of any material risks earlier point in the pandemic, these are reasonable alternatives. The patient agrees involved in the recommended treatment and worrying fi gures. We believe a reasonable and signs the consent form. any reasonable alternatives. A material risk person about to undergo elective surgery would The operation, performed under general is one to which a reasonable person in the attach signifi cance to the risk of complications anaesthetic, is uneventful but postoperatively patient’s position would be likely to attach and serious harm from covid-19. the patient develops severe respiratory signifi cance, or a risk that a doctor knows—or Given that a minuscule risk of death by complications that require admission to the should reasonably know—this particular anaesthetic is commonly shared with patients, intensive care unit. Retesting reveals covid-19. patient would probably consider signifi cant. we argue that patients who undergo elective The patient, who has sustained serious harm surgery should be told that, despite measures from the complications, sues the trust for Pulmonary complications to limit the risk of infection, there remains failure to obtain valid consent. He claims the An international cohort study in the Lancet a risk of contracting covid-19 in hospital, surgeon should have discussed risks related analysed the outcomes of 1128 patients whether before, during, or after the operation. to covid-19 and that, had he known, he would who had surgery between 1 January and 31 The surgeon should explain that, if the risk have waited until the pandemic had passed. March. Some 74% had emergency surgery eventuates, the impact on the patient’s health Many surgeons are now resuming elective and about 25% elective. Covid-19 infection is currently unknown but could at worst lead work, yet we are aware some make no was confi rmed preoperatively in about 26% of to complications that require intensive care mention of the additional risks related to patients. The study showed a 30 day mortality admission and, in a minority of cases, death. covid-19. Although the British Association of of nearly 24%, with pulmonary complications Along with a verbal explanation, we Spine Surgeons and some private hospitals occurring in 51% of all patients. The mortality recommend “covid-19 related complications” have produced information sheets for was associated with various factors, including is expressly stated as a risk to any surgery on patients undergoing surgery during the sex (higher for males), age (higher for 70 and the consent form. This practice should aff ord

BMJ OPINION Helen Iliff, Ilora Finlay The threat to those most clinically vulnerable People generally want to be How can shielding was communicated from the beginning of considerate, but they need prompts be safely lowered as the covid-19 pandemic. On 16 March, the government advised those deemed to be homes, but also how to maintain the 2 m lockdown is eased? at increased risk to follow stringent social distancing that decreases risk. If shielding no distancing measures. A subset, believed to longer applies, support may diminish, just have the highest risk of mortality and severe as the general public relax infection control morbidity, were identified and sent a letter measures, further heightening their concerns asking them to “shield” for at least 12 weeks. of contracting covid-19 in the community. The government has now relaxed this Those returning to frontline healthcare guidance, but those who have been shielding have particular worries; data from the Office fear support will vanish, leaving them at for National Statistics show the risk of heightened risk in a second peak. acquiring covid-19 in hospital is between four Guidance recommends those who were and six times that in the community. Without shielding maintain social distancing, but herd immunity or a vaccine there is no easy those people may be less familiar with the answer. Clinicians urgently need enough high new etiquette, such as one way systems, protection PPE, preferably recyclable, to allow that has become embedded into normality. vulnerable staff to lower their shields while Their anxiety is not just around leaving their helping them to feel safe.

22 4 July 2020 | the bmj ACUTE PERSPECTIVE David Oliver Caring about language is not frivolous

n February, the Daily Telegraph ’s “alcoholism.” The guide also urged us not Celia Walden used her column to to say “bed blocker” or “bed blocking” mock the Royal College of Nursing’s to describe patients stranded in hospital (RCN) style guide on the correct through no fault of their own. terminology and formats to use in I think that the RCN is right on this. Most I the surgeon a degree of legal protection. This nursing communications. NHS staff are women, especially in nursing. should continue until the pandemic recedes The piece was ostensibly light hearted, its “Older people” have said that they prefer and the risk becomes so negligible that no tone gently ribbing what Walden saw as the that term. People with disabilities or other reasonable person in the patient’s position RCN’s po-faced attitude. But it wasn’t hard long term conditions and charities that would deem it worthy of mention. A leafl et to construe the meaning behind the joke— advocate for them don’t want to see people on the risks, though desirable, should be no namely, that we’ve become far too obsessed defi ned or stigmatised by their condition. substitute for a conversation—some patients with “woke” language and identity politics, Language evolves, and some phrases are no do not read, or do not understand, leafl ets. that it’s distracting and detracting from longer used when it’s clear they’re off ensive. As part of the discussion on alternatives to the vital work of clinical care, and that Walden went on to claim that this focus imminent surgery, surgeons should explore staff have better things to worry about on language would detract and distract the option of waiting until the pandemic than putting their foot in it or getting into from good care, that the emphasis on subsides. For many patients, there will be trouble by accidentally using the “wrong” language and terminology was “frivolity.” risks associated with delay, so a balancing phrase—perhaps one that was standard And, apparently, that terms such as “living exercise will be necessary. a few years ago but has been superseded with anxiety” or “misusing alcohol” Finally, the consent discussion should and might trigger hurtful emotions. instead of “suff ering from anxiety” or take place days or weeks before and not, as is What was the substance behind “alcoholic” would somehow mean that still too often the case, on the day of surgery. Walden’s thesis? First, the RCN style guide individuals took no responsibility for their The failure of surgeons to raise the is the kind of document you’ll see routinely own health or faced up to the need for perioperative risks of covid-19 during the in checklists for subeditors to ensure help with their mental health. consent process is ethically and legally consistency: editorial manuals for scientifi c I don’t want to see people disciplined at troubling. It would be helpful for the Royal journals, professional membership work for accidentally or even persistently College of Surgeons to give specifi c guidance, organisations, unions, or charities. The using retro terms and phrases. But I don’t with updates as evidence becomes available. guide’s target audience is not so much think that it does any harm to remind Daniel Sokol , medical ethicist and barrister, 12 King’s frontline nurses but people involved in people to show some consideration. Bench Walk, London [email protected] communications and publications. Language frames the way we see and treat Rupen Dattani , consultant orthopaedic surgeon , Walden’s column focused on a few key people. Getting it wrong can cause hurt Chelsea and Westminster Hospital, London items. These included the instruction to and resentment. So, why not make the Cite this as: BMJ 2020;369:m2539 refer to “staffi ng” instead of “manpower”; eff ort to get it right? It doesn’t make you “older people” rather than “old age a worse nurse or doctor to do so. pensioners” or “the elderly”; David Oliver, consultant in geriatrics and “women” instead of “ladies”; acute general medicine , Berkshire Those at higher risk need people to be kind, “people with disabilities” [email protected] understanding, and allow them extra space, instead of “disabled people”; and Twitter @mancunianmedic in public and in their workplaces. Many have “alcohol misuse” as opposed to Cite this as: BMJ 2020;370:m2524 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 Language can support working from home. Colleagues evolves, and can recognise the psychological impact of some phrases prolonged isolation. Some have welcomed the suggestion of an easily recognised lapel are no longer badge in the shape of a shield that says “Safer used when it’s at 2m” or a facemask with the same easily clear they’re identified symbol on it. These suggestions offensive 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 the bmj | 4 July 2020 23 PRIMARY COLOUR Helen Salisbury LATEST PODCASTS Normality will return—eventually

he health service is slowly In normal times there’s a sense of returning to normal, after relief when, as a GP, you’ve done all you adapting rapidly and radically can and hand on an unsolved problem to meet the demands of the or a diagnostic challenge to a specialist. Tfi rst wave of coronavirus The case is off your mind and desk, in infections. Operating theatres and somebody else’s inbox. Now, however, I anaesthetic rooms that were repurposed continue to hold all responsibility, and as high dependency units are resuming it’s starting to feel uncomfortable. Deep Breath In: Resetting their original functions as the number of Many hospital clinics, even if not general practice patients needing ventilation continues accepting new referrals, are up and How will the post-covid world of general practice to fall. The space dedicated to assessing running, doing follow-ups by phone or look? Will we drift back to business as usual possible covid patients in hospital video link. Unfortunately, this also results or seize the opportunity to redefine the role emergency departments and at “hot hubs” in extra work for the practice, as tasks that of primary care? The latest episode of Deep in the community is steadily shrinking. were previously done in clinic now arrive Breath In tackles these questions. Here Martin In our practice, it seems that most as instructions: “GP kindly perform XYZ Marshall, chair of the Royal College of General patients have decided the pandemic is blood tests, check blood pressure and, if Practitioners, shares his thoughts on an area over. While a few are still cautious about normal, prescribe W.” While it’s clearly the he’s keen to see supported once more: coming to the surgery, most consider most practical and convenient solution for “One of the concerns I have about where we that the problems they’ve put off for the patient, this transfer of work to general are right now is that shared decision making the past three months now need urgent practices—which are running at reduced largely seems, to me, to have stopped. We’ve attention. Our telephone lines are buzzing, capacity because of social distancing become a very provider orientated, slightly our appointments are all booked, and and personal protective equipment—has dictatorial, population focused health system although we’re still triaging all our been neither negotiated nor agreed. because we’ve had to. I’m not complaining appointments by phone we’re gradually At the beginning of the pandemic about that during the crisis. We now need doing more assessments face to face. there was a brief and happy moment to rediscover some of the superb work that’s However, while patients are now when the medical profession pulled been done around shared decision making, like coming to us with symptoms that require together, putting aside its usual turf Choosing Wisely, for example, so that we can investigations or specialist input, most wars and interdisciplinary wrangles work more effectively with patients to give them departments at our local hospital are in the face of a collective and urgent a stronger voice. And we know that when you still not accepting referrals (except threat. That unity is now beginning to give patients a stronger voice, by and large, they emergencies). Patients would like to fracture, and resentment is growing. If choose less interventional approaches than know when they’ll be seen, or at least that the problem isn’t tackled soon it poses a doctors will choose.” they’re in a queue, but the computer growing risk to the standard of care (in this instance, the obligatory that we can off er our patients. Talk Evidence: rehabilitation electronic referral system) says Helen Salisbury , GP, Oxford after covid-19 “no.” So I have a lengthening list [email protected] As patients recover from covid-19, what of referrals pending, to revisit Twitter @HelenRSalisbury challenges may lie ahead for them and what who knows when. Cite this as: BMJ 2020;369:m2617 support will they need? This episode of Talk Evidence hears from Lynne Turner-Stokes, a This transfer of professor of rehabilitation medicine at King’s College London, about what we know about work to general potential rehabilitation needs. Here she talks practices has about people who were not admitted to hospital been neither and dealt with their symptoms at home: negotiated “The first thing that I would say about those patients would be we really need to be having nor agreed 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.” 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

24 4 July 2020 | the bmj 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

istorically, England’s system of communicable disease control has relied on close H 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, WILLETT MALCOLM test, and contact trace. The ad hoc Notification of suspected cases parallel system in England has three components: SARS-CoV-2 was declared a serious and guidance dated 29 May. 5 PHE’s guidance • Covid-19 primary care programme imminent threat to public health on 10 wrongly implies that local authorities do not which, until 29 May, did not February,1 but covid-19 was added to the need to be notifi ed of suspected cases.6 include information on need to list of notifi able diseases only on 5 March. notify suspected cases to local From the outset, the notifi cation system was KEY MESSAGES authorities inadequate. NHS 111 covid-19 call centres England’s established system of local • Centralised testing programme that were hastily set up. Symptomatic patients • communicable disease control has relies heavily on private companies were advised to stay at home and not contact been eroded over several decades • Centrally led contact tracing system their GPs or NHS 111 initially, and thereafter In response to covid-19 the that uses commercial call centres to contact NHS 111 online. This will have • government created a parallel system and may in future use a mobile prevented rapid reporting of suspected cases. which steers patients away from GPs phone app. A covid-19 clinical assessment service was and relies on commercial companies We question why the government also set up to receive and possibly reclassify for testing and contact tracing has created this ad hoc parallel system referrals after NHS 111 triaging, using retired Many suspected cases will have been when a straightforward, if weakened, and locum or sessional GPs instead of general • missed because of mishandling of the system already existed. In addition, we practices. It is not known whether registered notifi cation system are concerned by apparent failings in medical practitioners working in NHS 111 or NHS 111 covid-19 call centres and the this parallel system. The notifi cation the assessment service notifi ed any suspected • covid-19 clinical assessment service system (table, page 27) seems to have cases. 4 should be reintegrated immediately been mishandled from the beginning, NHS guidance did not alert GPs to the into primary care and practices and many suspected cases will have need to inform local authorities of suspected resourced to resume care been missed as a result. Outsourced cases. It advised GPs to inform Public Health • Contact tracing and testing should private testing services have been England (PHE) of symptomatic cases and be led by local authorities and given the bulk of government then only in specifi ed settings or unusual coordinated nationally business, with no clear public health scenarios. The guidance also wrongly implied • England must rebuild and reintegrate standards. There is also a lack of that the requirements relating to notifi able its local communicable disease control clarity on where the results are being diseases apply only to confi rmed cases. These system sent. failings were only partially rectifi ed in new the bmj | 4 July 2020 25 Centralised and commercially Box 1 | Erosion of local communicable disease control in England run tests 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 A public health approach to testing requires of the Communicable Disease Surveillance Centre in Colindale. a clear purpose, systematic delivery and Erosion began after NHS reorganisation in 1974 and continued when the Public Health Laboratory data fl ows, informed participation, quality Service Board was abolished in 2003 and its local laboratories transferred to NHS trusts, at the same assurance, equity, and ethical oversight to time as communicable disease control was centralised in the Health Protection Agency. build trust. Decisions should be safeguarded In 2012, the Health and Social Care Act abolished locally based bodies in England and carved from political and commercial interference.7 public health functions out of the NHS. Public Health England was set up as an executive agency to The testing programme announced by the fulfil the government’s duty to protect the public from disease, with only nine laboratories and eight government on 4 April 20208 with its “fi ve 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 pillars” falls well short of what is required. responsibility for exercising the authority’s public health functions. Instead of focusing on increasing capacity in PHE and NHS laboratories, which report results to PHE through its second generation NHS guidance did not alert GPs to the Feedback of results surveillance system, the government need to inform local authorities of designated these laboratories as “pillar 1” suspected cases It is unclear what happens to many test for people with a clinical need and health results, in particular whether they are and care workers, and set up a separate, samples are analysed by the four new fed back to individual patients’ GPs. centralised, and commercially based “pillar 2” “lighthouse labs,” which involve AstraZeneca Several hundred thousand tests are for the wider population. and GlaxoSmithKline (box 2), even though reported not to have been linked to NHS Daily numbers of pillar 1 tests have levelled both state that “diagnostic testing is not part of records, missing confi rmed cases. 20 off , and numbers of pillar 2 tests now tend either company’s core business.” 15 16 Randox There is also no indication whether to exceed those for pillar 1. 9 They include analyses the samples from its home test kits, results are made available to staff in-person tests, which are counted when with a contract for £133m (€150m; $165m).17 doing local contract tracing. The chief samples are taken at testing stations at about This compares with the £86.9m provided to medical offi cer for England is reported 50 regional sites and mobile testing units PHE for infectious disease, surveillance, and to have apologised to local authorities run by the army. Testing kits posted out to outbreak management in 2018-19.18 In all, for not having detailed data from tests people at home and elsewhere are counted 67 000 Randox tests are reported to have been conducted by Deloitte.21 It is unclear on dispatch,10 and it is not known how many sent to the US for analysis because of lack of whether PHE has timely access to test are actually used. Numbers have increased capacity, but 29 500 results were found to be outcomes. dramatically on some occasions when the invalid and needed to be redone.19 Further problems have arisen in government has been trying to reach preset According to the government,13 results of relation to reporting numbers of tests targets for testing.11 non-Randox tests are sent to the National and results in national statistics, The president of the Institute of Biomedical Pathology Exchange (NPEx) hosted by prompting two letters to the secretary Science has described creating this new Calderdale and Huddersfi eld NHS Foundation of state for health and social care additional structure as “perverse,” competing Trust. NPEx links them to test registration and from David Norgrove, chair of the UK with NHS laboratories and freezing them out.12 passes results to NHS Digital and to the NHS Statistics Authority.22 23 The second Pillar 2 is based on contracts with Business Services Authority, which sends suggested that the statistics should commercial companies. Very few appear on results to those who have been tested. The enable an understanding of the the government’s contracts fi nder website. government also states that Palantir analyses epidemic and help manage the testing It seems from the list of data processors, 13 anonymised data.13 programme but pointed out that “the which has changed frequently, that The strategy has three further pillars. statistics and analysis serve neither testers at regional sites are provided Pillar 3 is mass antibody testing. Pillar 4 is a purpose well” and that the main aim by Sodexo and Boots; some sites programme of serology and swab testing for seemed to be to claim the largest are operated by Deloitte. Serco, national surveillance supported by PHE, the possible numbers of tests. G4S, and Levy provide facilities Offi ce for National Statistics, UK Biobank, management. Randox universities, and other partners. The aim of provides home testing kits, Pillar 5 is to build a British diagnostics the logistics for which industry, with the short term aim are provided by of supplying the other Amazon. pillars. Pillar 2

26 4 July 2020 | the bmj 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 3 days (written) or, if urgent, orally as soon as reasonably practicable (for each informs Public Health England 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 Health board: 3 days (written) for health board or, if urgent, orally as soon as Common Services Agency and Public reasonably practicable Health Scotland 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 10 days (written), or, if urgent, orally as soon as reasonably practicable is situated, Common Services Agency, and Public Health Scotland Wales Suspected cases and deaths Registered medical practitioner Proper officer of local authority, who then 3 days (written), of, if urgent, orally as soon as reasonably practicable (for each informs Public Health Wales body) Confirmed cases and deaths Operator of a diagnostic laboratory Proper officer of local authority, who then Local authority: 3 days (written) or, if urgent, orally as soon as reasonably informs Public Health Wales practicable PHW: 3 days (written), or, if urgent, orally as soon as reasonably practicable Northern Ireland Suspected and confirmed Medical practitioner Director of public health for Northern As soon as suspected or confirmed cases and deaths Ireland 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.

Centralised and commercially run contact tracing Making it work

Contact tracing is a local activity. Local Details such as full postcodes, and age Immediate steps should be taken to ensure authorities know their community, and and sex of suspected and confi rmed cases that registered medical practitioners within tracing requires feet on the ground. But are essential for monitoring outbreaks NHS 111, the covid-19 assessment service, the tracing programme announced by in a local authority area and identifying and general practice notify local authorities of the secretary of state on 23 April 202024 is clusters. However, local authorities do not suspected cases. Outbreak management plans centralised, using call centres operated by have live access to this information and should put local directors of public health in Serco and other companies with thousands are instead sent aggregated data. This control of contact tracing, coordinated rather of newly recruited call handlers. The approach, combined with the failures to than led by PHE. The capacity of the NHS programme may not be fully operational require notifi cation of suspected cases and 111 covid-19 call centres and the assessment until September. 25 The NHS covid-19 app, to undertake community testing, has further service should be immediately reintegrated which had been touted as key to contact hampered outbreak control. Instead of into primary care and practices resourced tracing, has now been abandoned. restoring local data fl ows, the government to resume care. Offi cial advice to those with It is unclear how the contact tracing is attempting to create a population covid-19 symptoms should be amended to programme will operate, as outbreak surveillance system through the new Joint direct them to contact a GP or NHS 111. management plans are yet to be produced. Biosecurity Centre.27 The centre will receive These steps, however, are remedial. They do The government’s guidance does not data from numerous sources, including not amount to a coherent and adequate public mention GPs or local directors of public NHS data through the portal of NHSX’s health response to the epidemic in England. health.26 It is not known whether, how, or covid-19 data store reference library. Such a response requires local authorities, to whom suspected cases will be notifi ed. Over 50 datasets are being integrated and NHS, and PHE laboratories to be suffi ciently Ineffi ciency, data quality issues, local harmonised by private data companies resourced to take the lead on contact tracing data access diffi culties, and unnecessary Palantir and Faculty to create a “single and testing, and general practices being expense are inevitable. source of truth.”28 resourced to support patients, under central coordination. Parliament has given the 14 Box 2 | Lighthouse laboratories secretary of state the powers to enable this to Milton Keynes—managed by UK Biocentre, the largest facility in the UK for storing and happen, and we urge him to exercise them. processing biological samples. It is the trading subsidiary of the charity UK Biobank In the longer term, the abysmal response of Alderley Park —a life science campus with a dedicated lab for covid-19 analysis led by the government to the epidemic has served to Medicines Discovery Catapult, which was set up as a limited company with a grant from underline the need for legislation to rebuild Innovate UK to support drug companies, contract research organisations, and diagnostic and reintegrate a strong local communicable businesses operating in the health sector disease control system. Glasgow—the lab is led by the University of Glasgow at the city’s Queen Elizabeth University Peter Roderick, researcher , Newcastle University Hospital. It is supported by the Scottish Government, BioAscent Discovery (a provider of [email protected] integrated drug discovery services), and the University of Dundee Alison Macfarlane, professor , University of London Cambridge—a collaboration between AstraZeneca, GSK, and the University of Cambridge’s Allyson M Pollock, professor , Newcastle University Anne McLaren laboratory Cite this as: BMJ 2020;369:m2484 the bmj | 4 July 2020 27 LETTERS Selected from rapid responses on bmj.com

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 LETTER OF THE WEEK politics being used is that of a playground Machiavelli. The current political mantra of “following the science” is obviously doublespeak, laying the Covid-19 recovery certificates: foundations of the blame yet to come. Having the chief medical officer and call for a citizens' jury colleagues up on the podium in front of the nation simply allows the public to In my rapid responses about covid-19 creating put a face to the name when the inevitable inquiry begins. extraordinary times demanding imaginative responses Sati Heer-Stavert, GP , Birmingham (Editor’s Choice, 21 March), I wrote that people who Cite this as: BMJ 2020;369:m2532 had recovered from proven infection and were not shedding virus were a potentially invaluable asset. They must have at least partial, temporary immunity. I Being a bystander is a choice recommended that we give them a certificate indicating Abbasi raises the issue of conscience and duty for scientific advisers in the that they would be largely, if not wholly, immune to a covid-19 pandemic. Senior roles in government, rightly or wrongly, “train” second infection this year. such professionals to learn the art of compromise, but there should be limits I anticipated reliable antibody testing would to this. When lives are at stake and integrity is threatened, advisers should not become available, which is becoming true, although be protecting politicians or government but should come out in the open and it is controversial. Even a test with 99% sensitivity highlight the “truths,” however difficult or uncomfortable these might be. and specificity only has 83.8% predictive power of a Scientific advisers should not hide behind the notion that they only positive test when the prevalence of infection is 5%. “advise” and the final decision is not theirs. If the final decision is wrong Recovered patients could serve on the front line, and threatens life, they are obliged to do more than just voice their concerns not just in healthcare and nursing homes but also behind closed doors. We expect our senior scientific and medical leaders to in retailers and factories. They could be offered have the integrity and courage to stand up for what is right. registration for employment and volunteering Being a bystander is a choice, the choice to be complicit. purposes. I identified clinical, public health, legal, Minesh Khashu, consultant neonatologist, Corfe Mullen ethical, and social issues requiring research and Cite this as: BMJ 2020;369:m2534 scholarship as well as public debate. The Royal College of Physicians of Edinburgh hosted a video on COVID-19 AND ALCOHOL this proposal. There has been much debate, especially about Next generation “immunity passports.” This phrase implies a guarantee alcohol problems that cannot be achieved. WHO cautioned against this Finlay and Gilmore rightly draw on 24 April. I have, however, not changed my mind and attention to two vulnerable groups think the emphasis on antibody testing is misplaced of drinkers in the covid-19 lockdown and unnecessary, especially as much immunity to (Editorial, 30 May). Regardless of of adolescent drinking have failed to respiratory viruses is not humoral. It is a matter of whether parents drink more alcohol include parental drinking even as a probabilities, as there can never be certainties. in lockdown, their children are far confounding variable in the analyses, Chile, to my knowledge, is the first country to formally more likely to see them drink. And let alone as a major explanatory factor. adopt this proposal. It is time to go beyond opinion, but substantial evidence indicates the To avert next generation problems, research is just getting under way. The public, scholars, intergenerational transmission of the UK must stand back from the and policy makers need to debate this idea. I think the alcohol habits and alcohol misuse bottle and see the elephant in the public, especially those who have been ill, might find through parental role modelling. room—parental drinking. Covid-19 and the idea more attractive than scholars and researchers. Parental alcohol use or misuse alcohol might prove to be a dangerous Is it time for a citizens’ jury? is associated with subsequent cocktail in more ways than we realise. Raj Bhopal, emeritus professor of public health, Edinburgh alcohol consumption and misuse Aric Sigman, child health education lecturer, Brighton Cite this as: BMJ 2020;369:m2590 in adolescence through adulthood. Yet, many studies and discussions Cite this as: BMJ 2020;369:m2525

28 4 July 2020 | the bmj PSYCHOLOGICAL EFFECTS

Helping healthcare workers heal campuses reopen, finding support will be Kisely and colleagues’ meta-analysis hard for new students constrained by social reinforces the expectation that healthcare distancing or lack of physical lectures. For workers might experience distress after international students, this will be an even working with covid-19 (Research, 23 May). bigger problem, especially if they face a Any intervention should ensure disclosure period of quarantine. Expecting young is controlled by the individual and at a time people to move on without closure could lead they choose. One simple vehicle for venting to mental health crises. and exploring emotions might be talking As students prepare to restart clinical aloud or writing about events, uncensored, to placements, it is key that students remain a confidential recipient. This recipient need therapy to the use of automated “chat bots.” supported on placement and that mental not be a “live” person. But little evidence based guidance exists. health services are cognisant of the unique We are piloting a process called Covid Pragmatic clinical trials could allow us challenges in the wake of covid-19. Confidential, which permits users to to rapidly assess the association between Christopher A Smith, fi nal year medical student, Southampton confidentially record their stories about the digital interventions and outcomes in a Cite this as: BMJ 2020;369:m2491 care of patients with covid-19 in spoken real world context. This could dramatically or written form to a website. This might enhance our abilities to monitor, assess, and provide the immediate emotional benefit treat mental health, not just during covid-19 Preventing a crisis in primary care of offloading negative experiences and a but potentially for underserved people in Kisely and colleagues and Gold point out repository of frontline stories, enabling rural populations or low income regions. the urgent need for strategies to minimise identification of the immediate and most Guided by a rigorous evidence based the psychological distress of healthcare important concerns. This could be a cost approach, digital health solutions might workers. Evidence indicates that after the effective intervention, and the time users combat the behavioural and psychosocial pandemic begins to recede, the subsequent spend engaged with it. fallout from this global pandemic. economic crisis will have a knock-on effect on the mental health of the general Paul Bennett, professor of clinical health psychology; Bernard P Chang , associate professor of emergency Rachael Hunter , senior lecturer; Steve Johnston, head , medicine; Harold A Pincus, professor , New York; population. Swansea; David Jones, consul tant in intensive care , Ronald C Kessler , McNeil family professor of health Spain has one of the highest numbers of Merthyr Tydfi l; Simon Noble, Marie Curie professor of care policy; Matthew K Nock, Edgar Pierce professor of supportive and palliative medicine , Cardiff psychology, Boston cases of covid-19 in Europe and was also Cite this as: BMJ 2020;369:m2536 Cite this as: BMJ 2020;369:m2541 one of the countries most affected by the economic crisis of 2008. We compared mood, anxiety, and somatoform and Digital mental health solutions Supporting healthcare students alcohol related disorders among primary Gold’s editorial on psychological first Gold’s editorial overlooks a subgroup in care attendees in Spain between 2006 aid interventions recognises the major the clinical environment: healthcare and 2010. We found a substantial rise in psychological consequences of the covid-19 students. several mental health disorders significantly pandemic (Commentary, 23 May). Student income is often dependent associated with unemployment and Digital mental health programmes offer on maintenance loans, and many report mortgage difficulties. In the next stages of the ability to respond quickly and efficiently resulting financial hardship. Strategies the pandemic, we must prevent primary care and to reach people over great distances with proved to boost staff morale, such as hazard from being overwhelmed. minimal mobility requirements. There are pay, are not available for students, and part Miquel Roca, professor of psychiatry ; Caterina more than 10 000 smartphone apps related time jobs are now scarce. Vicens, primary care unit coordinator ; Margarita Gili, to mental health, with diverse approaches Student societies have closed, removing professor of social psychology , Palma de Mallorca ranging from remote cognitive behavioural protective peer support networks. When Cite this as: BMJ 2020;369:m2520

NON-MEMORY LED DEMENTIAS Patients with behavioural variant Calls to the UCL Rare Dementia Support frontotemporal dementia can lack insight service have doubled. The service has Caring for patients with non- and have behavioural disinhibition and launched a covid-19 emergency kit, increased memory led dementia compulsive behaviours, which make phone and email support, established online Carter raises concerns about the managing in lockdown difficult. People discussions, and facilitated member-to- vulnerability of people in care homes, with posterior cortical atrophy have member virtual buddying by videoconference. including those with dementia (Feature, progressive visual impairments that Aida Suár ez-González, senior research associate; 16 May). Non-memory led dementias lead to greater reliance on touch, Nicola Zimmermann, direct support services lead at Rare Dementia Support; Claire Waddington, research account for around 15% of all dementia which might increase the risk of covid-19 assistant; Olivia Wood, research assistant; Emma cases. They are relatively more common in infection. People with primary progressive Harding , research associate ; Emilie Brotherhood, people under 65 who do not fit perceptions aphasia might have limited understanding research associate; Nick C Fox, professor of neurology; Sebastian J Crutch, professor in neuropsychology, UCL of dementia, making their needs less of concepts like “virus,” “mask,” or Queen Square Institute of Neurology noticeable. “soap.” Cite this as: BMJ 2020;369:m2489

the bmj | 4 July 2020 29 Longer versions are on bmj.com. Submit obituaries with a contact telephone number to [email protected]

OBITUARIES Bruno Cheong John Mitchell Morgan Lynn M Price Consultant physician Pathologist (b 1945; q St Andrews Associate specialist (b 1957; q Cardiff, 1980; 1969; FRCPath), died from pneumonia Countess of Chester NHS FRCP), died from covid-19 on 9 May 2020 Trust (b 1957; q Otago, on 27 April 2020 John Mitchell Morgan (“Iain”) had a Dunedin, New Zealand Bruno Cheong left his long and distinguished career working 1981; MRCGP), died native Mauritius in in the UK, Canada, Africa, and, most from adenocarcinoma 1975 to study medicine recently, the Cayman Islands. He of the gall bladder on 23 at the Welsh National moved back to Scotland in 2010 for August 2019 School of Medicine in Cardiff, but he vowed his retirement and to concentrate on Lynn M Price did a genitourinary medicine to return and serve his island after his his love of outdoor pursuits. Born in post in Auckland, as part of her GP training. training. He completed most of his clinical Lanark in 1945, the son of the local She came to the UK in 1987, to consider training in Wales and specialised in internal chemist, Iain qualified in medicine a career in GUM and did her diploma in medicine. He had a particular interest in with a distinction. His career started GUM in 1989. She joined the Countess of respiratory medicine, specifically in the in Scotland and was followed by Chester Hospital in 1991, at the height of acute management of asthma. Shortly after a role with the Royal Flying Doctor HIV. Although she loved her job, she took being appointed as consultant physician in Service in Zambia, where he worked early retirement in 2016 to spend time with the UK, Bruno took the opportunity to work alongside his wife, Anne. After her family, exploring her beloved Welsh at the Khamis Mushayt Military Hospital in Zambia, Iain and Anne travelled to mountains. She lived high above Llangollen Saudi Arabia for a year. In 1989 he returned New Brunswick, Canada, where he and, despite snow on many occasions, never to Mauritius. Throughout his career, he was the local GP. On returning to the missed a day’s work, thanks to her ancient contributed to improving the country’s UK in 1974, he worked at Ninewells Land Rover. Lynn was serenity personified healthcare system. He was the first frontline Hospital in Dundee and became a and an inspiration to colleagues and doctor in Mauritius to die from covid-19 after consultant at Leighton Hospital in patients. She died within three months of three weeks in intensive care. Bruno leaves Cheshire in 1980. Iain will be sadly diagnosis. She leaves her husband, Roger, his wife, Sandra, and two children. missed by his family. and two children. Julia Cheong, Satwant Gill Sacha Higgins Colm O’Mahony Cite this as: BMJ 2020;369:m2051 Cite this as: BMJ 2020;369:m2050 Cite this as: BMJ 2020;369:m2047 Harshadrai Patel Kenneth Peter Goldman William Anthony Warburton Consultant anaesthetist Consultant physician, General practitioner (b 1938; q Gujarat general and chest Magdalen Medical University 1962; disease, Dartford and Practice, Norwich FFARCS), died from renal Gravesham (b 1928; (b 1936; q Liverpool failure on 26 March 2019 q Cambridge/St Mary’s 1960), died from cancer Harshadrai Patel Hospital Medical School on 15 April 2020 (“HP”) was educated 1957; MD, FRCP), William Anthony in Mombasa, Kenya, died from covid-19 Warburton (“Tony”) but returned to his native India for his pneumonia on 14 April 202 interviewed me in 1978 for a place in the higher and university education. He came Kenneth Peter Goldman (“Ken”) worked at practice in Norwich, where he was junior to England in 1965 and was appointed Sully Hospital in south Wales between 1960 partner. In the 1980s we bought Eyre’s consultant anaesthetist at the Queen Victoria and 1963, which at the time was the Welsh garage, knocked it down, built our own Hospital, East Grinstead, in 1976, where Regional Centre for Thoracic and Cardiac premises, and Tony and the rest of us moved he continued his research, particularly Surgery. Ken became an expert in chest in. Another practice from the health centre into cerebral function during the use of diseases of coal miners, an interest that joined, and we became Magdalen Medical controlled hypotension for plastic surgery. continued until well after his retirement from Practice. Tony continued to work there until His artistry and skill in anaesthesia made him the NHS. He was also the editor of the journal he retired in 1996. A couple of years ago he an excellent and inspirational teacher. His Tubercle from 1980 to 1991. He retired was diagnosed with cancer of the ampulla of hospitality to friends, family, and colleagues from the NHS in 1992, and in retirement he Vater, underwent Whipple’s procedure, and was legendary; he often entertained on his worked part time for the Ministry of Work and made a good recovery initially. In the end, narrow boat on the Oxford Union Canal. Pensions, examining and assessing coal however, he was admitted to the Norfolk and He was also a keen pilot; having started by miners with medical problems. When Ken, his Norwich University Hospital, where covid- flying gliders in India, he obtained his private wife, Lorna, and one of their sons developed 19 precautions meant no visitors. In his pilot’s licence in the UK. He retired to Paphos covid-19 symptoms, he was admitted to final hours, however, his wife, Benita, was in Cyprus in 1994, with his wife, Kathryn, who hospital. He leaves Lorna, three children, and permitted to be with him. Tony leaves Benita, predeceased him in 2010. two grandchildren. three sons, and five grandchildren. Chris Barham Eric D Silove John Bennett Cite this as: BMJ 2020;369:m2048 Cite this as: BMJ 2020;369:m2049 Cite this as: BMJ 2020;369:m2046 the bmj | 4 July 2020 41 OBITUARIES Adil El-Tayar NHS transplant surgeon who died from covid-19

Adil El-Tayar (b 1956; University a consultant transplantation of Khartoum, Sudan, 1982; surgeon before moving to Saudi FRCS Ireland), died from Arabia in 2007, where he spent covid-19 on 25 March 2020 three years working at the King Fahd General Hospital in On 25 March Adil El-Tayar, a Jeddah. He completed a masters renowned organ transplantation degree in vascular medicine specialist, became the fi rst and technology in 1997 and working NHS surgeon to die a masters in health service from covid-19 in hospital in and management, from the the UK. A healthy and active University of London, in 2002. 64 year old, he is thought to In 2011 he moved back to have contracted the virus at a his native Sudan, helping to hospital in the Midlands, where establish a transplantation he worked during the week. He programme while working at cared deeply about the NHS, an Ibn Sina Hospital, Khartoum. institution he had spent most The worsening political his career serving. situation in Sudan, however, Born in Atbara, Sudan, and recent birth of a son a railway city on the Nile, persuaded El-Tayar to move GHAZANFAR ABBAS El-Tayar was the eldest son back to the UK to work for the El-Tayar volunteered to family man. He wanted to be of a government clerk and a NHS. He had established a work on the frontline in a deployed where he would be housewife. He had 11 siblings. good transplantation unit in his Midlands hospital during most useful in the crisis—but A close knit community, Atbara home country. He returned to the coronavirus pandemic in the end he paid for it with had been built by the British to St George’s Hospital as a locum his life.” serve the railway line between consultant surgeon, specialising breathless and feverish. He David Mowbray, Wye Valley Port Sudan on the Red Sea in kidney transplantations, from knew what that meant and NHS Trust medical director, coast and the Wadi Halfa in the 2017 to 2019. agreed for his family to call an said, “We are saddened to learn north. It was here that the fi rst ambulance. He managed to of the death of Adil El Tayar, Sudanese labour movement On the frontline walk by himself to get into it, but and our thoughts are with his started in 1948. El-Tayar El-Tayar had volunteered to be after he was admitted to West family at this time. We were attended the local school and on the frontline of the health Middlesex University Hospital fortunate to have someone of was a diligent student. During service in order to fi ght the in Isleworth on 20 March, his his skill and stature working for his childhood, one of his coronavirus pandemic. He lived condition quickly worsened and the trust and many patients will brothers, Osman, became ill and in west London at weekends he was placed on a ventilator. have benefi ted from his talent died without suitable medical with his wife, Ekhlas, but He later tested positive for covid- and expertise.” treatment. Although El-Tayar worked at the Hereford County 19 and died after fi ve days in In his little spare time, rarely spoke about his brother’s Hospital during the week, intensive care on a ventilator. El-Tayar enjoyed pottering death, he named his fi rst born examining patients coming to Irfan Siddiq, the British around his garden, tending to son after him. It is likely that the the emergency department. It ambassador to Sudan, paid his apple and pear trees, and experience of witnessing his was there that, according to tribute to El-Tayar on Twitter, planting fl owers. He made brother’s suff ering and his loss his family, El-Tayar believed he “Saddened to hear of Sudanese friends easily and invited them led him to medicine. picked up the virus. doctor Adil El-Tayar’s death in around for barbecues in the On 13 March the fi rst UK the UK from covid-19. Health summer. He liked to reminisce Surgical career death from covid-19 was workers around the world have about growing up in Sudan and El-Tayar read medicine at the reported in Scotland. The next shown extraordinary courage. was very proud to be Sudanese. University of Khartoum. He day, El-Tayar started feeling We cannot thank them enough. Adil El-Tayar was buried moved to the UK in 1996, where unwell. He returned to his In this fi ght we must listen to beside his father and he studied at the University of London family home and self- their advice.” grandfather in Sudan, as he West London and worked at isolated. During the following In a tribute on BBC Radio 4’s wished. He leaves his wife and the West London Transplant days, cases of covid-19 began From Our Own Correspondent , four children. Unit until 2005. He then to surge in the Midlands. After El-Tayar’s cousin, journalist Rebecca Wallersteiner , London moved to St George’s Hospital, a week in bed, El-Tayar’s health Zeinab Badawi, said, “He was a [email protected] Tooting, where he worked as deteriorated and he became dedicated doctor and devoted Cite this as: BMJ 2020;369:m1803

42 4 July 2020 | the bmj