this week CIRCUIT BREAK page 381 • EXPERTS DIVIDED page 382 • BMA CONFERENCE page 385 TOLGA AKMEN/GETTYIMAGES TOLGA New measures to curb UK infection rate

The prime minister has set out new national of COBRA, the government’s emergency All staff in restaurants, bars, measures designed to halt the current rise committee, Johnson said the new measures and pubs will now have to in covid-19 cases. were likely to be in place for six months. wear masks, as will customers told MPs that, in England, “We always knew that, while we might whenever they are not eating or drinking at a table hospitality venues, including pubs, bars, have driven the virus into retreat, the and restaurants, will have to shut by 10 pm prospect of a second wave was real. I’m from 24 September and will be legally sorry to say that, as in Spain and France permitted to provide table service only. and many other countries, we’ve reached a He added that masks will be compulsory perilous turning point,” he said. for staff in shops, drivers and people using Scotland and Northern Ireland—whose taxis, and staff and customers in indoor leaders attended the COBRA meeting—have hospitality venues, except when seated at both announced that households will be a table to eat or drink. Fines for breaking banned from mixing. Wales is expected these rules will increase. People are also to announce further restrictions, after advised to work from home if possible. imposing a series of local lockdowns. Guidelines for the retail, leisure, tourism, Johnson said the threat of covid had LATEST ONLINE and other sectors will become legal not disappeared since the fi rst national GP is restored to obligations, and the maximum number of lockdown. “If we fail to act together medical register at people at weddings will be reduced from 30 now, we not only put others at risk but second attempt to 15 from 28 September. jeopardise our own futures with the more “Mass The fresh restrictions came after the drastic action that we will inevitably be hysterectomies” four UK chief medical offi cers announced forced to take.” are carried out on on 21 September that the UK’s alert level Saff ron Cordery, deputy chief executive migrants in US was being raised from level 3 to 4, as the of NHS Providers, which represents NHS detention centre incidence of the infection was “high or trusts, said, “No one doubts the impact of Patient groups rising exponentially.” That day 4368 daily these restrictions on people’s lives. But the failed to cases were reported in the UK, and cases consequences of failing to act and failing to disclose are doubling every seven to eight days. protect the NHS would be even worse.” £14m from Announcing the changes in the House of Gareth Iacobucci, The BMJ drug companies Commons on 22 September after a meeting Cite this as: BMJ 2020;370:m3712 the bmj | 26 September 2020 379 SEVEN DAYS IN New indicators will track doctors’ careers to expose racism NHS England has launched a set of indicators to expose ethnic disparities in the medical workforce, with data set to be presented to trusts later this year. The Medical Workforce Race Equality Standard (MWRES) will capture “several issues” particular to doctors that are not picked up by the general NHS staff WRES introduced in 2015. Around two fi ft hs (41%) of NHS doctors are from ethnic minority groups, and evidence shows they are less likely to be treated favourably than their white colleagues and have poorer experience and progression opportunities. The new indicators include the percentage of ethnic minority people in each medical and dental subgroup in NHS trusts and clinical commissioning groups; consultant recruitment; and complaints received. Diff erential attainment in medical schools and diff erential pass rates in postgraduate examinations will also be looked at, as well as experiences of harassment, bullying, or abuse from patients, relatives, or other staff . Mala Rao, chair of the working group that created the indicators, said, “The MWRES is a world fi rst in creating an evidence base to expose racism in the medical workforce at a national level. It will enable the NHS to translate that evidence into meaningful action.”

MARK THOMAS/SPL Elisabeth Mahase, The BMJ Cite this as: BMJ 2020;370:m3659

Covid-19 people who are infected, public winter peak of the pandemic, Lithium product “must Moonshot pr oject faces health measures such as face said MPs and peers on the Joint stay on market” legal challenge coverings, physical distancing, Committee on Human Rights. Pharmacists, GPs, psychiatrists, The government’s Moonshot and quarantine for those who They also urged the government and patients urged the project, which could spend as may have contact with an infected to ensure that care homes were government to ensure that much as £100bn to increase person continue to be very not implementing blanket bans Priadel, a brand of lithium costing covid-19 testing capacity to important.” on visiting, saying that any £4.02 for a pack of 400 mg 10 million people a day, is facing restrictions “must take into tablets, remains available to a legal challenge. The move is Point-of-care test reports account the risks to the person’s patients. Essential Pharma, which the latest in a series of High Court 94% sensitivity emotional wellbeing and mental owns the rights to Priadel, has challenges from the Good Law The CovidNudge test—which health of not having visits.” announced it will withdraw the Project, a not-for-profit group, the government plans to roll brand next April and has raised over the government’s handling out nationwide—can provide Prescribing the price of the other main brand of the pandemic. The group results in 90 minutes, with 94% “Allow minor substitutions” of the drug, Camcolit, to £48.18 sent a letter before action to the sensitivity and 100% specificity in drug shortages per pack of 400 mg tablets. government’s lawyers, claiming when compared with standard Leaders from the BMA, the Royal In direct drug costs alone it is that the project was unlawful polymerase chain reaction College of General Practitioners, estimated that the change will because it ignored scientific testing, found a study by the pharmacy organisations, and cost the NHS around £15m a year. evidence and committed a vast manufacturers published in the patients’ group National sum of public money with no Lancet Microbe . But the study’s Voices wrote to England’s health Public health transparency about how the lead author, Graham Cooke, and social care secretary, Matt Paying GP clinics to provide decisions were made. emphasised the test was not Hancock, calling for pharmacists LARCs cuts abortions likely to be used at crowded to be allowed to make minor A 2009 Universal screening is events because the machine can substitutions for a GP’s scheme likely to miss cases process only one test at a time, prescription in a drug shortage, paying GPs to One time screening for SARS- with a daily maximum of 15 tests particularly after Brexit. Currently, offer patients CoV-2 in apparently healthy per machine. pharmacists are legally obliged to information people is likely to miss those refer back to the prescriber before on long who are infected, concluded a MPs and peers say lessons making even a minor adjustment, acting reversible contraceptives rapid review of 22 studies by the from deaths must be learnt which “can cause delays resulted in an extra 4.53 Cochrane Library. Lead author The government should in access to medicines prescriptions per 1000 women Meera Viswanathan, from RTI immediately organise a quick and takes up health above what would be expected International in North Carolina, interim review into deaths from professionals’ time, without the scheme by 2013-14, said, “We are unsure whether covid-19—making deaths in care which could be used a study in PLOS Medicine found. combined screenings, repeated homes a priority—to ensure elsewhere to Abortions fell by 38% beyond symptom assessment, or rapid that lessons are support patient what was expected in the same laboratory tests are useful. learnt before a care,” they period—equivalent to 95 170 Because screening can miss new autumn or wrote. fewer abortions in the UK.

380 26 September 2020 | the bmj SIXTY SECONDS MEDICINE ON . . . CIRCUIT BREAK Surgery Exercise can help Perioperative care can cut reduce complications complications by 80% after surgery by up to IS THIS A PHYSICS LESSON? An evidence review by the 80%, said the study of No, it’s just the government’s latest Centre for Perioperative Care—a perioperative care covid-19 buzz phrase. It refers to a proposal, partnership between the Royal apparently under consideration by ministers, to tighten restrictions for a short period to try College of Anaesthetists, other to halt the current surge in England. medical and nursing royal colleges, and NHS England— HOW WOULD IT WORK? found that good perioperative The BBC reports that the government’s care could reduce the length Scientifi c Advisory Group for Emergencies of stays in hospital by an has suggested rewiring the current set-up so average of two days across A&E that parts of the hospitality industry could be different types of surgery. It Pilot scheme tests NHS 111 COVID-19 closed or asked to close early for a couple of weeks, while schools and workplaces would also reduced the need for for booking urgent care Between 18 March intensive care and improved Twenty five trusts will receive remain open. and 21 September communication between a share of £150m to expand ARE WE HEADING FOR ANOTHER patients and clinicians. their A&E departments to make the NHS in NATIONAL LOCKDOWN? Different interventions, such more physical space for treating England dealt The government is desperate to avoid this, as “prehabilitation,” exercise, patients and managing patient with but with covid-19 cases now doubling every and smoking cessation, could flow while improving infection seven to eight days, rising to 4368 new cases reduce complications after control, said England’s health 913 542 reported on 21 September, it says “targeted surgery by 30-80%. and social care secretary, Matt telephone interventions” are needed to keep infection rates down as much as possible, while Hancock. He also announced a inquiries for Medicinal cannabis pilot scheme for NHS 111 to be protecting education and the economy. coronavirus and Lack of prescribing harms the “first point of contact” for BUT WHAT ABOUT THE RULE OF SIX? patients, say experts patients seeking urgent care. 3 211 167 That’s still in place, and the government is Under the plans, intended to closely monitoring its impact to see if it has be rolled out nationally from online helped slow the spread of covid-19. Ministers December, patients will call the assessments have emphasised that people caught helpline before being booked into [NHS Digital] meeting in groups of more than six will face A&E or an urgent treatment centre police action—particularly if they live next or to see a GP. door to the home secretary, Priti Patel, who has said she would report them. Overseas news DOES WANT US ALL Most youth covid deaths in TO SNOOP ON OUR NEIGHBOURS? “The failure of the medical US are in ethnic minorities Yes. The health secretary has also said he and pharmacy professions to A US review of covid-19 deaths in would be prepared to twitch the curtains embrace CBPMs [cannabis people aged under 21 found that, if necessary and has said it’s critical that based products for medicinal of 121 such fatalities reported to people follow the guidelines and any local use] despite their being made the Centers for Disease Control lockdown rules that are in place. ‘legal’ over 18 months ago is and Prevention before 31 July, 94 a great worry to patients” and (78%) involved ethnic minority BUT WILL A CIRCUIT may have led to preventable groups. A quarter of the reported BREAK WORK? The jury is out. Rowland deaths from conditions such as deaths involved previously Kao, professor of veterinary epilepsy, researchers wrote in healthy people, said the review epidemiology and data BMJ Open . Barriers to doctors published in the Morbidity and science at the University of prescribing included misplaced Mortality Weekly Report, while Edinburgh, said, “While a two concerns about a perceived 75% had underlying conditions, week lockdown will undoubtedly reduce lack of scientific evidence of which the most common were the infection rate, it is uncertain whether for CBPMs and government chronic lung disease, including something less than the total lockdown insistence that they be asthma (28%); obesity (27%); of March will have enough of an impact considered a “special” product, neurological and developmental if schools and universities are allowed to said the authors. They called for conditions (22%); and continue to operate with in-person contact.” a change in attitudes to promote cardiovascular conditions (18%). the appropriate use of CBPMs Gareth Iacobucci, The BMJ for pain relief. Cite this as: BMJ 2020;370:m3696 Cite this as: BMJ 2020;370:m3686

the bmj | 26 September 2020 381 COVID-19

Independent R esults of tracing app pilots SAGE’s plan to must be published, experts say avoid lockdown The Independent Scientifi c Advisory The absence ealth experts have won’t exacerbate existing health Group for Emergencies has published of data urged the government inequalities by leaving some people a 10 point plan to avoid a national leaves major to publish the results at greater risk of covid-19 than lockdown, while criticising the questions of pilots of its covid-19 others, the foundation said. It said government for abdicating its over the app’s H contact tracing app to that piloting the app in Newham, one responsibility to provide such a plan. demonstrate that it is eff ective and of England’s most ethnically diverse Stephen Reicher, professor of social effectiveness won’t exacerbate health inequalities. and deprived boroughs, provided an psychology at the University of St unanswered The app was due to be launched in opportunity to understand how it Andrews, said, “If we dither and waste Josh Keith, England and Wales on 24 September, worked among diff erent groups but a week, as we did in March, then we Health Foundation but the government has not yet said the fi ndings should be made will slither into a national lockdown.” released the results of pilots that took public to understand the app’s eff ect. The plan calls for urgent measures place in August on the Isle of Wight that will be reviewed when a working and Newham in east London. “Digital divide” test system is in place and infections The Health Foundation said that The foundation also pointed to are under control. It calls for pubs and greater transparency was needed to previously unreleased polling cafes to be limited to outdoor service, show that the app was eff ective and by Ipsos MORI on its behalf that for people to work at home, and for ready for mass rollout. This will be reinforced concerns of a potential aff ected workers to get fi nancial help. crucial to building public confi dence “digital divide” along the lines of It also says schools should be funded and encouraging people to download ethnicity, occupation, educational to allow smaller, socially distanced and use it, it argued. level, and age. classes and for universities not to As well as publishing data The polling, conducted between have any face-to-face teaching. to confi rm the app’s overall 17 and 29 July among British adults, Jacqui Wise, London eff ectiveness, ministers must found that respondents from an Cite this as: BMJ 2020;370:m3695 demonstrate that the technology ethnic minority background, women, Experts divide into two camps: shielding v blanket policies

Two open letters sent to the UK’s four chief medical conditions interventions should medical offi cers signal the polarisation of be targeted at these groups. Given the high opinion among medical professionals over proportion of covid deaths in care homes, how the government should tackle the these should be a priority, they add. emerging “second wave” of covid-19. “This large variation in risk by age One group of doctors and academics and health status suggests that the harm is calling for segmentation and shielding caused by uniform policies (that apply to of the most vulnerable groups of people all persons) will outweigh the benefi ts,” The harm caused by uniform rather than local or national lockdowns. the group’s letter says. It adds that blanket policies will outweigh the benefits However, another group says eff orts should policy interventions can have adverse Sunetra Gupta and Karol Sikora continue to suppress the virus across the eff ects on physical and mental health as entire population. well as social and economic impacts. The eff ect on cancer treatment is especially Targeted approach acute, it says, with people delaying or Sunetra Gupta, professor of theoretical missing screenings, tests, or treatments. epidemiology at Oxford University, Carl Meanwhile Trisha Greenhalgh, chair Heneghan, director of Oxford’s Centre for of primary care health sciences at Oxford Evidence Based Medicine, Karol Sikora, and 21 others argue against pursuing a consultant oncologist at the University a “herd immunity” approach (p 400). of Buckingham, and 30 others are calling They say that although the incidence To divide a group of vulnerable on the government to take a more targeted and outcomes of covid-19 vary across people from those less vulnerable is approach rather than blanket policy diff erent groups, deaths have occurred in practically impossible interventions (bit.ly/3mJtq5a). all age, sex, and ethnic groups and among Trisha Greenhalgh and Harry Burns They argue that because 89% of covid people with no pre-existing medical deaths are in the over 65s and are also conditions. They also point out that “long concentrated in people with pre-existing covid,” in which symptoms extend for

382 26 September 2020 | the bmj Testing service wasn’t prepared for surge, chief admits

England’s NHS Test and Trace service wasn’t prepared for the increased demand that has seen thousands of people unable to access tests, the head of the service has admitted. But insisted that the service had followed modelling from the government’s PAUL ELLIS/GETTY IMAGES PAUL Scientific Advisory Group for Emergencies when the youngest and oldest age groups, took place in August have been notably planning for schools to be reopened this month. routine and skilled manual workers, absent, leaving major questions over The past week has seen a growing number of and unemployed people had a lower the app’s eff ectiveness unanswered.” reports of people across England being unable to awareness of the government’s plan to A spokesperson for the Department access covid-19 tests at local sites. Harding told use a smartphone contact tracing app. of Health and Social Care for England MPs that current estimates showed that demand Josh Keith, senior fellow at the said that trials had shown the app to was up to four times higher than capacity. foundation, said, “With a virus that is be accurate and responsive. transmitted as quickly as covid-19, the The spokesperson added, “We have “Absolutely on track” automated contact tracing that the app spoken with groups with protected “We built our [autumn] testing capacity plans promises could prove invaluable in characteristics, such as age, ethnicity, based on SAGE modelling. We published our reducing its spread. and disability, those experiencing business plan at the end of July, and are absolutely “However, for any major nationwide health inequalities, and those groups on track to deliver that,” she told the Science and public health intervention it is particularly impacted by coronavirus, Technology Committee on 17 September. important the government publishes and the app and supporting material “I don’t think anybody was expecting the really evidence that it is eff ective and ready will be available in multiple languages.” sizeable increase in demand that we’ve seen over for mass rollout in advance of its Gareth Iacobucci, The BMJ the last few weeks.” launch. Any data on the pilots that Cite this as: BMJ 2020;370:m3708 But she added, “I strongly refute that the system is failing. We planned for a sizeable increase in testing capacity. As the prime minister said [last multi-generational households. week], plainly we don’t have enough today, and we ONE LETTER The signatories say a goal of herd are doing everything in our power to increase the immunity rests on the unproved testing capacity.” argues that because 89% assumption that reinfection will Harding said that surveys carried out at testing of covid deaths are in the over not occur and that no examples of a sites had found that up to a quarter of people 65s and are also concentrated segmentation and shielding policy asking for a test didn’t have symptoms. “It is clear in people with pre-existing having worked exist in any country. that demand is significantly outstripping the medical conditions, They say the UK may have to move capacity. We need to make sure that we protect interventions should be fl exibly between levels of restriction capacity for the people that most need it. targeted at these groups rather than either full lockdown or “The constraint in the testing system is in the release, depending on how well the processing and the laboratories. We have to restrict virus is controlled. They also say that the number of people who are taking tests so that weeks or months after infection, is a measures that would help control there is no risk of those tests going out of date debilitating disease aff ecting tens of the virus while also promoting when they are processed,” she said. thousands of people in the UK and can economic recovery include making Around half of the testing capacity was occur in previously young and healthy face coverings mandatory in crowded being reserved for NHS patients, NHS individuals. indoor spaces, improving ventilation staff, and care homes, she said. The next This letter, whose signatories in schools and workplaces, continuing priorities were people in hotspot areas, include Harry Burns, former chief to require social distancing, and then key workers. medical offi cer for Scotland, and discouraging large indoor gatherings. Harding also confirmed the UK was Martin McKee, professor of European They add it is important to restore using overseas labs to process tens Public Health at the London School of routine medical appointments of thousands of samples. Hygiene and Tropical Medicine, also through a combination of remote Gareth Iacobucci, The BMJ argues that to divide a particular group appointments together with face-to- Cite this as: BMJ 2020;370:m3676 of vulnerable people from those less face appointments with appropriate vulnerable is practically impossible, personal protective equipment. I strongly refute that particularly in disadvantaged groups, Jacqui Wise, London the system is failing who may live in cramped housing and Cite this as: BMJ 2020;370:m3702 Dido Harding the bmj | 26 September 2020 383 GPs challenge royal college’s “irrational” interpretation of assisted dying vote

says the solicitor’s letter sent on behalf of We have been stonewalled at every RCGP members Aneez Esmail and Sam turn by the RCGP Council Everington, the non-profi t company the Good Aneez Esmail Law Project, and the pressure group Dignity in Dying. They accuse the college of a “fl awed The letter accuses the RCGP Council of and unlawful decision making process” that failing in duties required by the Charities Act was “irrational, failed to take into account 2011 and of lacking transparency, including relevant factors, and took into account by not publishing details about members of irrelevant factors.” a steering group it set up to analyse the 2019 The letter says, “With such a polarised survey results. he Royal College of General result on an important ethical issue there was Esmail said, “The [2019] survey was Practitioners has been threatened a fundamental error in treating ‘neutrality’ intended to fi nd out if RCGP members had with legal action unless it as a stand-alone third option as opposed to changed their views since 2013, and there reconsiders its “irrational” representing the middle ground between two is undeniable evidence that they had.” The T decision to continue to oppose competing, but polar opposite, views with college’s 2013 consultation included a survey any change in law to permit assisted dying. similar levels of support.” of 234 members. It found that 77% wanted The college said on 21 February that its The letter continues, “ The results clearly the college to maintain opposition, 18% 2019 membership survey did not present supported change in the college’s position and wanted it to assume a neutral stance, and 5% a mandate to change its stance opposing so neutrality is arguably the only logical way of wanted it to support a change in the law. assisted dying. Critics argue that most refl ecting that change.” Esmail added that he and Everington had respondents voted for the college to change Legalisation of assisted dying would, in been “stonewalled at every turn” when trying its position from opposition and that a neutral specifi c circumstances, permit doctors to to raise their concerns with the RCGP Council. position would best refl ect the results. prescribe lethal drugs to some terminally ill The RCGP chair, Martin Marshall, said, “We “The college is failing in its obligations to people for them to take themselves. Some are very disappointed to hear of this action, properly represent the views of its members,” people call it assisted suicide. especially as we were transparent about our methodology and decision making processes The survey, run by Savanta ComRes from 29 October to 15 December 2019, had 6674 respondents, a 13% from the outset of the consultation.” response rate. Of these, 47% (3144) said the RCGP should oppose a change in the law, 40% (2684) Richard Hurley , The BMJ said it should support a change in the law, and 11% (701) favoured a neutral position for the college Cite this as: BMJ 2020;370:m3679 Ig Nobel wins for Donald Trump and Boris Johnson

Politicians are better than of French kissing won the OTHER AWARDS distinctive looking eyebrows doctors or scientists at medical economics prize for Christopher were typical in people “who • Acoustics: for education. Leaders such as Watkins, a psychologist at express higher levels of grandiose getting an alligator Donald Trump and Boris Johnson Abertay University in Dundee, to bellow in a chamber of narcissism,” he said. and their counterparts in Russia, and colleagues from 13 helium enriched air A woman who became Belarus, Brazil, India, Mexico, countries. “Kissing plays a role aggressive when she heard • Physics: for showing Turkey, and Turkmenistan have in keeping human pair bonds what happens to an a sneeze led to the discovery used covid-19 to teach their together,” he said. In countries earthworm vibrated of a disorder, misophonia, by citizens about life and death. with greater income inequality, at high frequency psychiatrists at the University For their eff orts they jointly his research showed that people • Management: to of Amsterdam Medical Centre. won the 2020 Ig Nobel prize for kiss more, as commitment to a Chinese hitmen Damiaan Denys said some people medical education, although partner is more important in a who mismanaged an became so irritated by sounds none of them showed up to make harsh environment. assassination plot and went made by others while eating or an acceptance speech. Eyebrows as indicators of to jail. The victim survived breathing they could become The Ig Nobels are awarded for narcissism won the psychology • Entomology: the discovery violent. “The consequences are achievements that make people prize for Nicholas Rule and that many entomologists are huge. They socially isolate,” he laugh and then make them think. Miranda Giacomin of the afraid of spiders, which are said. He has found about 5000 The 30th awards were virtually University of Toronto. “We started not insects people with the problem that can handed out on 17 September. with whether people could • Materials science: proof that be treated with coping strategies. frozen faeces do not make Research on how income detect narcissism from the face,” Janice Hopkins Tanne, New York good knives inequality predicts frequency Rule told The BMJ. They found Cite this as: BMJ 2020;370:m3675

384 26 September 2020 | the bmj Roundup The BMA annual representative meeting Gareth Iacobucci, Abi Rimmer , and Elisabeth Mahase report the virtual conference’s highlights

Call to fund extra NHS the pandemic. Aftab health should be employed gastroenterology registrar capacity to tackle backlog said, “This block booking on contracts equivalent to who proposed the motion, The government must is costing the NHS an those of NHS consultants said, “Although the UK fund extra NHS capacity estimated £400m a to ensure that they have government has said the to deal with the backlog month. Is this the best use “adequate guarantees NHS is not on the table, we of planned care caused by of public money?” of freedom to make are greatly concerned that the covid-19 pandemic, professional advice public.” any negotiations carried doctors said. Handling of pandemic must out without any proper We are Given the likely effect be subject to public inquiry Reward healthcare staff for scrutiny and appropriate concerned any on NHS waiting lists, Representatives voted pandemic work protections could lead UK-US trade a motion passed by overwhelmingly to pass An overwhelming majority to concessions which talks could lead representatives called a motion that said a of representatives voted prioritise economic gains to concessions on the BMA to work with public inquiry into the in favour of a motion over health.” which prioritise governments to develop government’s handling commending the work of a public information of the pandemic should healthcare staff during Government must act economic gains campaign on the likely cover, as a minimum, the covid-19 pandemic, on racism and diversity over health timescale for the NHS to the mismanagement who they said should be The government has a Gio Sheiybani return to normal services. of care homes; the adequately remunerated “moral imperative” to take Sakkaf Ahmed Aftab purchase, delivery, quality for extra work done. firm action against racism of the BMA’s Yorkshire control, and guidelines The motion said staff and health inequalities Regional Council, for personal protective have worked outside that have been laid bare who proposed the equipment; the UK testing their specialties, worked by the covid-19 pandemic motion, outlined the strategy; the wellbeing of additional hours, and and the Black Lives seriousness of the health and care staff; the worked at increased risk Matter movement, the backlog, highlighting timing of interventions; to their health, and it BMA urged. The meeting estimates from the NHS and the timing of the asked the BMA to pursue called for all NHS boards Confederation that waiting easing of restrictions. policies to “ensure that to reflect the ethnic lists may increase to Proposing the motion, an additional reward is 10 million people by the GP Steven Miller said, made to all healthcare end of this year. “We owe it to the nation staff to reflect the personal He said, “Gradually, to ensure that lessons are sacrifices and increase in because of this backlog, learnt. Not to do so would risk to health made during anger is growing among be a betrayal.” this pandemic.” the waiting patients. It is The motion also called important that the BMA New public health agency for reassurances that works with the government must be independent temporary changes to to have a public information Public Health England’s working patterns would not campaign to explain the replacement must be become permanent and constraint under which fully independent of the that no long term changes doctors are working, in government and must be to job plans or contracts order to maintain public able to hold it to account would be imposed without trust in the NHS. on matters of public negotiation with doctors. “We must ask the health, doctors agreed. government for adequate They passed a motion UK trade deal with US must SZYMANOWICZ/SHUTTERSTOCK’ WIKTOR funding to increase NHS calling for the new agency not lead to drug price rises make-up of the workforce capacity to address the to include a national public The BMA must work to of the organisation backlog and the growing health infection service ensure that any future they manage, for more waiting lists.” that is “professionally led trade deal between the transparent recruitment Representatives also and in charge of strategy, UK and the US does not and promotion systems in backed a motion calling operations, education lead to a rise in the price all NHS organisations, and for the return of NHS and training, with an of drugs or weaken the for every person involved in funds that were paid appropriate budget and UK’s ability to negotiate NHS recruitment to receive to the private sector to regional offices.” prices with US companies, training on diversity and retain capacity but have The motion also said that representatives said. unconscious bias. been underused during all consultants in public Gio Sheiybani, a For full reports see bmj.com/news the bmj | 26 September 2020 385 THE BIG PICTURE Photographs that captured lockdown

In May the National Portrait Gallery launched Hold Still to create a unique collective portrait of the UK during lockdown. The public was invited to submit photographs taken in a six week period that focused on three core themes: Helpers and Heroes, Your New Normal, and Acts of Kindness. The gallery received more than 31 000 submissions, 100 of which now form an exhibition in the London gallery and online (bit.ly/2Hcf24W). Alison Shepherd, The BMJ Cite this as: BMJ 2020;370:m3688

Long-awaited Cuddle (main image) by Lesley Garven, Auchinleck, East Ayrshire The photographer made her mother a “cuddle blanket” so she could hug her grandchildren

Akuac (right) by Anastasia Orlando, London Taken at a Black Lives Matter protest

We Always Wear a Smile (below) by Jill Bowler and Trevor Edwards, Preston Care workers Beth and Sade reassure their residents that they are still smiling beneath their masks

386 26 September 2020 | the bmj the bmj | 26 September 2020 387 EDITORIAL The NHS people plan A missed opportunity to tackle the workforce crisis

HS England and NHS Improvement published the long overdue people plan for 2020-21 on 30 NJuly 2020.1 The NHS is the UK’s largest employer and one of the biggest employers globally. It has been described as “the most complex, risky, and expensive single industry in Europe with the most educated (and intrinsically motivated) staff .”3 Staffi ng has overtaken funding to become the top risk facing the health and care sector,4 yet the NHS has a poor track record of workforce hospitals, mental health services, and Staffing has of the healthcare system. How likely planning. Responsibility for community providers were already overtaken is this change in culture? The interim workforce issues at a national level reporting roughly 100 000 full time funding to people plan openly stated that a has been fragmented since reforms vacancies, and shortages of general become the previous policy attempt “has not led introduced by the Health and Social practitioners and other staff working top risk facing to the widespread culture change . . . Care Act 2012, and worryingly high in primary care and community In part, this is because the national the health and numbers of doctors and nurses are services are concerning. bodies have not visibly demonstrated leaving their jobs early. This inevitably care sector the importance of the framework.”2 aff ects the ability to deliver good local Essential changes So, can we feel assured that the services and the best outcomes for Nevertheless, the plan contains national bodies will act diff erently patients. some important and valuable this time around? Why has a workforce plan taken commitments. These include The people plan provides a so long to publish? To be fair to its essential changes such as a welcome vision to better support authors, the exit from the European commitment to greater job fl exibility, the healthcare workforce,1 and Union, general election, and global helping to make the NHS a better although many of the outlined actions pandemic meant that the national employer and support the health and can be delivered by local leaders workforce plan was not as high as wellbeing of the 1.3 million people and will help to make positive and it might have been on the political who work in the service. But it is necessary changes, the huge scale to-do list. Covid-19 has proved a deep diffi cult to see how the other core of the staffi ng crisis means they will shock to the health and care sector. elements of the published plan— not be enough. In November 2018, But whatever the next few years hold, “New ways of working and delivering the King’s Fund set out fi ve key tests the NHS relies on its staff to deliver care” and “Growing for the future”— that the NHS long term plan and a and must have suffi cient numbers can be anything other than ambitions supporting workforce strategy would of people with the right skills and without meaningful new funding. need to pass,10 including addressing support. There is strong evidence that a workforce shortages now and in the Unfortunately, the people plan is motivated and engaged workforce medium term and reducing race and not the funded, strategic workforce delivers better care for patients. 4 Yet gender inequalities in both pay and plan that was hoped for.1 Published staff stress is at a fi ve year high, and progression. before the government’s 2020 the reported levels of bullying and A seven month people plan comprehensive spending review, harassment are unacceptable.5 Even could never pass these tests. It is it lacks the necessary government before covid-19, the NHS experienced Suzie Bailey, disheartening that what could have funding to tackle the scale of the burnout and diffi culty in retaining director of been the most important workforce leadership and workforce challenges facing the staff , and excessive workloads and strategy in the history of the NHS organisational service. The plan is for the remainder stress have been normalised.5 - 7 doesn’t directly tackle how to reduce development, of the 2020-21 fi nancial year, so These problems are endemic in King’s Fund, the huge workforce gap. 5 in eff ect is for only the next seven the NHS, and therefore the actions London, UK Cite this as: BMJ 2020;370:m3398 months, in what are already uncertain outlined in the people plan will need s.bailey@ Find the full version with references at times. Before covid-19, NHS to be consistently driven at every level kingsfund.org.uk http://dx.doi.org/10.1136/bmj.m3398

388 26 September 2020 | the bmj EDITORIAL is scientifically unsound Proposals could do more harm than good to people, populations, and the economy

he polymerase chain suboptimal products, 12 possibly reaction (PCR) swab encouraged by the magnitude of test is useful (but not government contracts, low levels of perfect) for detecting government scrutiny, and the lack SARS-CoV-2 virus RNA of an eff ective regulatory process for T 1 13 in symptomatic patients. However, diagnostic tests. problems arise using the test for Frequent repeat testing is purposes that disregard symptoms necessary as the proposed test or time of infection—namely, will only identify people with new case fi nding, mass screening, and infections when their viral load disease surveillance. becomes high. Since Moonshot This is because PCR is not a proposes the use of point-of-care test of infectiousness. Rather, the tests, delays in receiving results test detects trace amounts of viral would be eliminated and isolation genome sequence, which may be can be immediate. But no point-of- either live transmissible virus or care tests approved for home use are irrelevant RNA fragments from currently available. previous infection.2 One fundamental challenge The PCR “cycle threshold” (Ct) is that proper evaluation of any provides an estimate of the quantity point-of-care test destined for of target RNA in the swab sample. WILLETT MALCOLM mass screening requires a robust It correlates with symptoms,4 and There are no screening—even with a lower and reliable way to identify true people with low Ct values (indicating point-of- care maximum Ct value cut off —is not infectiousness: we need a reference more viral material) are those most epidemiologically sound. standard against which the new 5 tests approved likely to be infectious. Using a for home use test’s performance can be compared. low maximum Ct value has been currently Unworkable Viral culture is one option, but suggested to reduce problematic Now, Operation Moonshot has culture based tests are hard to run detection of dead virus,6 but it available proposed that mass screening with and have high failure rates.5 will also miss early infection “less accurate” point-of-care tests will The Moonshot proposals and rising infectiousness in both help “reduce the ‘R’ rate, keep the have been condemned for not presymptomatic and symptomatic economy open and enable a return to considering the potential harms from people. It is impossible to defi ne normal life.”10 Could this work? repeated frequent testing of whole a universally optimal Ct value for The Moonshot proposals are based populations.12 All tests generate reliable identifi cation of those who exclusively on computer modelling 11 some false positives and false are infectious. not empirical evidence. Critically, negatives. The consequences of high If PCR is used to identify cases the model considers repeated use of false negative rates are most serious through mass testing of healthy tests that are positive only in infected in symptomatic people who can people, it will deliver positive results people with high viral loads of SARS- transmit disease. in individuals with previous resolved CoV-2. The crux of the assumptions False positives become a problem infections, new infections, and Jonathan J Deeks, in the Moonshot modelling is that when individuals and their contacts potential re-infections, as well as professor of the test must have a high chance have to self-isolate unnecessarily. false positives in people genuinely biostatistics, of being positive when a person is Even with a specifi city of 99%, not harbouring the virus (around University of infectious and a low chance when proposals to do 10 million tests a 0.8% of all tests performed8 ). Birmingham they are not.11 Thus, although the day will generate many thousands J.Deeks@ Real concern exists that many proposed test has lower sensitivity of false positive results, causing bham.ac.uk people who are not infectious (and than PCR for detecting any infection unnecessary but legally enforced Anthony J Brookes, not likely to become infectious) will with SARS-CoV-2, it must have equal isolation of both cases and professor of receive positive test results and, genetics , University sensitivity for detecting infections contacts with potentially damaging together with their contacts, will be of Leicester that could be passed on to others. consequences for the UK economy forced to isolate unnecessarily. In Allyson M Pollock, It is inappropriate to describe a and for civil liberties. the context of mass surveillance, this professor of public test with these properties as “less Cite this as: BMJ 2020;370:m3699 could be a majority of those who test health , Newcastle accurate”— a description that has Find the full version with references at positive. Using PCR for population University allowed some companies to launch http://dx.doi.org/10.1136/bmj.m3699 the bmj | 26 September 2020 389 BRIEFING What has gone wrong with covid testing?

Increase in demand, “ineligible” applicants, and laboratory capacity have all been blamed. Jacqui Wise examines the key questions around the lack of People queue for a walk-in covid-19 testing centre in London last week access to tests in the community

How big is the problem? Are people having needless tests? “heartfelt apologies to anyone who cannot get a covid test at present.” She added, “All of our The UK’s community testing system for Speaking in the House of Commons on testing sites have capacity, which is why they covid-19 seems to be under immense 8 September, the health secretary for England, don’t look overcrowded, it’s our laboratory strain. This is the “pillar 2” testing: the Matt Hancock, said that “about 25%” of processing that is the critical pinch point. We commercial, centralised system set up by tests were being used by asymptomatic and are doing all we can to expand quickly.” Deloitte consisting of local drive-in and uninfected people. When questioned by The Allan Wilson, president of the Institute walk-in test sites, with swabs being sent to BMJ the Department for Health and Social of Biomedical Sciences, agreed it was a fi ve Lighthouse laboratories for analysis. Care said that “the fi gure came from internal laboratory capacity issue, although he In recent weeks the media have been full track and trace research.” They added, “There believes this may have been overstated in of stories of people fi nding that no tests has been a spike in demand in recent weeks the fi rst place. “I would dearly love to know are available or that they must travel and the message is clear: only people with how capacity was defi ned. The trouble is it is hundreds of kilometres to get one. This symptoms should be requesting a test.” shrouded in secrecy,” he told The BMJ . has led to people turning up at emergency departments demanding tests and to long Is laboratory capacity the What is the laboratory capacity? queues at testing sites. bottleneck? Speaking at the Commons Science and The government says that testing capacity Technology Committee on 17 September, There seems to be no shortage of staff or is higher than ever. Its dashboard shows that Dido Harding, the head of NHS Test and swabs at the testing sites. Sarah Jane Marsh, the UK laboratory daily testing capacity was Trace in England, admitted the demand director of testing for NHS Test and Trace, said more than 370 000 last week. However, this is for tests was three or four times higher it was the laboratories that were “the critical the total capacity and includes pillar 1 (tests than capacity. pinch point.” On 8 September she tweeted done in healthcare settings), pillar 3 (antibody

Has demand increased?

Demand for tests across the UK has soared in recent weeks with children going back to school, people returning from summer holiday, and more people going back to workplaces. In addition, there are rhinoviruses circulating producing symptoms that could be mistaken for those of covid-19, something that is only likely to worsen through the fl u season. Harding said there had been a marked rise in the number of parents getting children tested and that this hadn’t been predicted by the Scientifi c Advisory Group The private Lighthouse labs—including this one in Glasgow—have asked for ‘urgent’ help from NHS labs to process community covid-19 tests for Emergencies (SAGE).

390 26 September 2020 | the bmj seven day averages up to 14 September the UK had carried out 2.8 tests per 1000 people, higher than most other European countries, including France (2.1 per 1000) and Spain and Germany (both 1.8). However, this was below Denmark, at 5.7, and how tests are counted is not necessarily the same in each country. Maggie Rae, president of the Faculty of Public Health, told The BMJ, “Other countries are managing a more eff ective system on less tests than we are doing, so we need to build a much more intelligent and agile testing strategy.” She said that the £10bn being spent on NHS Test and Trace would be better We need to act now and redesign spent on a more localised system, like that in the test and trace system, as we Germany. She fears that the current situation cannot afford to wait will become even worse in the coming Maggie Rae, Faculty of Public Health weeks, particularly once the new NHS covid-

LEON NEAL/GETTYLEON IMAGES 19 app is launched, which will encourage more people to get tested. “We need to act tests), and pillar 4 (surveillance testing run Why is capacity limited at now and redesign the system, as we cannot by the Offi ce for National Statistics). On Lighthouse labs? aff ord to wait,” she warns. 17 September 236 219 pillar 1 and 2 tests were processed, and the combined capacity listed It seems to be staffi ng problems rather than What is the government’s plan? for pillar 1 and 2 was 242 911. Of this, around a shortage of equipment or reagents that is 160 000 is pillar 2. However, on 12 September the issue. “We do know the Lighthouse labs Johnson, appearing before the Commons capacity for pillar 1 and 2 was breached, have lost a lot of staff with many postgrads and Liaison Committee on 16 September, admitted according to government data. senior scientists returning to academia,” says the testing system had “huge problems.” Duncan Robertson, a policy and strategy Wilson. “But all that was highly predictable.” The government has said it plans to analytics expert at Loughborough University He adds, “I think they will struggle to recruit increase capacity to 500 000 tests a day who has been analysing the government’s data, staff , as there is a limited pool of experienced by the end of October. It hopes this can be told The BMJ that pillar 2 capacity was also scientists, and every hospital trust and health achieved when new Lighthouse laboratories breached on 23 August, when 121 555 pillar board is fi shing from the same pool.” in Newport, Gwent, and Charnwood, 2 tests were carried out, against a capacity of The Mail on Sunday reported that Boris Leicestershire, are added to the network in the 120 000. He says, “Once there is a backlog Johnson has written to the 50 top universities coming weeks. Until these come on stream, then this can build up, and it can take a long and medical schools asking for urgent the plan is to ration tests by giving priority time to get rid of it. It may be they are cutting support to staff the Lighthouse laboratories. to NHS acute care patients, NHS and social down on capacity to help clear this backlog.” care staff , and teaching staff with symptoms, He says that pillar 4 surveillance tests also How is lab capacity affecting as well as for outbreak surveillance. This vastly exceeded stated capacity throughout availability of tests? priority list was announced by Hancock in August and September and that these may the Commons on September 21. However, have been processed under pillar 2. He is also Limited capacity in the laboratories has led Robertson warns, “We cannot wait for extra concerned that capacity in pillar 1 laboratories booking for tests and home testing kits being capacity to come along in October. There is (those run by the NHS and Public Health periodically taken off line to throttle demand. now a very real risk that the test, trace, and England) is more than 80% utilised, which Harding admitted this to the Science and isolate system will break down and we will may aff ect how easily NHS workers and Technology Committee, saying, “We have to see the virus becoming out of control.” inpatients get tests in the near future. restrict the number of people who are taking The Lighthouse laboratories were built Hancock told parliament on 15 September tests in the testing sites so there’s no risk of extremely quickly because the UK had very that the backlog was reducing and is less those tests going out of date when they are few diagnostic testing facilities of this type. than one day’s processing capacity. Health processed in the labs.” The government chose to centralise the department documents leaked to the Sunday The health department spokesperson also system, working with private companies Times state that there was a backlog of told The BMJ that it was targeting testing and universities, rather than existing NHS 185 000 tests on 11 September, which led to capacity at the areas that needed it most, laboratories. Wilson believes this was a some tests being sent to Italy and Germany including those with an outbreak. mistake. “The Lighthouse lab model isn’t for processing. The Guardian also revealed sustainable in the long term, and we need an an email sent on 24 August asking NHS How does the UK compare with exit strategy,” he says. laboratories to help analyse community swabs other countries? Jacqui Wise, journalist , London because the privately run Lighthouse labs were [email protected] overwhelmed. The Our World in Data website shows that Cite this as: BMJ 2020;370:m3678 the bmj | 26 September 2020 391 DOCTORS’ TRAINING Medical schools fear for quality of education as funding axe falls

As nearly a million students start term this month, universities face a perfect storm of fi nancial problems that could dramatically aff ect medical degree teaching, reports Stephen Armstrong

he sense of a Clinical funding crisis in academic higher education is consultants very signifi cant,” and senior “T warns Malcolm academic Reed, dean of Brighton and Sussex Medical School and co-chair of the GPs are paid Medical Schools Council. “Most at least 2.8% universities have started to feel a less than squeeze, and many will have run equivalent voluntary severance schemes—there’s NHS posts an unpredictable uptake, and they can’t control who goes. They’re not yet going to be compulsory, but it would not be a surprise if that happens.” Reed is one of many people in higher annual income. This means that 2.8% less than equivalent NHS posts, education battling the realities of a less prestigious and fi nancially attracting senior academic clinicians severe funding squeeze due to reduced weaker institutions face insolvency, away from teaching. research grants, a drastic drop in the institute says, with some 13 numbers of international students, unnamed universities needing a Too many and too few and lockdown related losses of government bailout to survive. Before this summer’s A level fi asco, revenue from student accommodation Medical schools should be in 9500 training places were on off er and conference operations. a strong position to weather this this autumn around the UK. After the The situation is so dire that letters storm because their funding comes recent confusion over grades, which seen by The BMJ show medical from three pillars: student fees, the saw many students initially refused schools asking staff to consider government/NHS, and research but then awarded their fi rst choice voluntary pay reductions, early grants. Recent fi gures from the place at universities and medical retirement, redundancy, or changes Medical Schools Council show that schools, the government lifted the to clinical academic contracts to cope clinical academic posts throughout cap on the number of medical school with budget constraints. These moves the UK are paid for by a combination places on off er and agreed to cover are causing signifi cant concern about of university funding (46%), NHS the cost of additional places. the eff ects on student education. (42%, including the National The Medical School Council In July, the Institute for Fiscal Institute for Health Research), and estimates that an extra 950-1000 Studies warned that the covid-19 research councils, charities, and domestic students will start training crisis posed a considerable fi nancial endowments (12%). this autumn, and visa applications threat to universities. Although And yet, fees and grants are severely from prospective international the size of the sector’s losses is threatened after covid-19, while recent students are running at 10-15% of uncertain, the institute expects the pay rises for NHS staff mean that previous years’ totals. For the fi rst two fi gure to be around £11bn, which clinical academic consultants and pre-clinical years of medical school is more than 25% of the sector’s senior academic GPs are paid at least training international students pay

392 26 September 2020 | the bmj For the fi nancial year 2020-21 20 AMRC members expect a 41% fall in funding, resulting in a projected 18 reduction in medical research 2.0 investment of £252m-£368m. As 87% of AMRC funds went through 16 universities to pay for 17 000 researchers’ salaries, including 1750 14 PhD students, that funding stream drying up will threaten jobs. 7.6 12 Cat Ball, AMRC head of policy, explains, “A huge chunk of charity funded research at universities has 10 1.3 been paused thanks to lab closures, £ bn social distancing, and working 8 2.0 from home—meaning that research 3.8 becomes more expensive. Lots of 6 clinical academics were seconded to 2.7 the front line and returned to full time 1.5 clinical care. But the biggest impact is 4 felt in future research.” 1.3 0.7 2 4.3 1.0 Staff cuts leave shortages 2.8 The BMJ has seen letters to staff 1.4 in medical schools at a number of 0 universities, including University Pessimistic Central Optimistic scenario scenario scenario College London, off ering a voluntary retirement scheme, voluntary International fees Pensions temporary unpaid leave, a career break, and part time working options. UK and EU fees Other financial Aberdeen has asked staff for a change Accommodation, to existing contracts to eff ectively conferences, and catering forgo one year of an agreed three year Potential income loss universities fear because of covid-19. pay rise.

ALAMY Source: Institute of Fiscal Studies Two senior academics at two city about £35 000 a year, depending on based medical schools, who wished The number so much uncertainty?” the university, and fees for the fi nal not to be named, have told The BMJ of readers In the resulting cuts, says one clinical years rise to over £45 000. By of their “signifi cant concerns” about and senior professor, “there has been no comparison, domestic students pay a the eff ects of fi nancial pressure on lecturers protection for the medical school maximum of £9250 a year. the quality of student education. One in medical whatsoever. There is no sense that the “There has been some help, of the schools has followed some school has to meet a national need to some funding for research brought London medical schools in cancelling schools keep the medic pipeline going—that forward, but no bailout,” says Reed. fi xed term contracts. One of the has fallen has no sway at all. They’re just battling “Universities have been set up as academics tells The BMJ, “All of the by 26.8% faculties off against each other.” independent bodies and encouraged fi xed term and short term contracts since 2014 to compete around the world for have been picked off , reducing in Senior academics needed international students. This year it particular the number of GP tutors at To date, the BMA believes that looks like international recruitment a time when high quality GP training staff redundancies have been may drop off a cliff .” has never been more important.” administrative rather than academic, Although there was NHS funding although the process is still under way. Charity shortfall for one post, the college would not “There will be some universities Alongside this is the hit to medical start the hiring process because using this as an excuse to get rid of research funds. In 2019, members of of a blanket recruitment ban, he the people they don’t want,” says the Association of Medical Research adds. “The NHS money is not the David Strain, senior clinical lecturer Charities (AMRC) invested £1.9bn university’s money,” he says, “but at the University of Exeter Medical in UK research and development— the university said it’s their policy School and co-chair of the BMA’s roughly the same as the total funding not to advertise posts. Universities Medical Academic Staff Committee. provided by the Medical Research have trustees—what are they doing to He adds that, after the A level issue Council and the National Institute for protect health professional training, and the subsequent huge increase Health Research added together. at this time of limited resources and in medical school places, making the bmj | 26 September 2020 393 Soldiering on despite covid-19 academics redundant recent years, and we now would seriously cannot aff ord to lose any Covid is changing the kind of teaching medical damage teaching. more: to do so would be students can expect. Many medical schools have “As it is, administrative disastrous for the extent suspended clinical placements and moved teaching redundancies mean an of medical research in online. Most schools have cohorts of volunteer patients or patient experts, simulation suites, and actors to academic like me would the UK and the quality of replace the experience of students being on ward or at have to spend more time learning in our medical a general practice. doing those duties which schools, to the detriment Despite the increased hours and additional tasks, the we are not as good at, of the NHS workforce pressure on jobs and salaries, and the confusion over and we are an expensive of tomorrow. It’s vital, student numbers, “clinical staff and NHS staff have resource to put on that We need the then, that universities soldiered on,” says Malcolm Reed, dean of Brighton type of job,” he says. clinical academics are able to off er this and Sussex Medical School. The University and in place to teach award in full.” “Staff were sent off campus, and it’s been a struggle College Union warns medical students Both academics to persuade them things have changed and that they that cuts could not have Jo Grady, UCU who spoke to The BMJ can come back to work safely—but they’ve returned,” come at a worse time, describe their universities says Reed. “Every medical school has contingency plans for producing a safe foundation year 1. There’s with clinical academics treating as having borrowed heavily to innovation, adaptation, and steps forward in the way patients during lockdown and expand campuses, now facing the we’re delivering education and learning . . . This year’s medical researchers leading the fi ght additional strain of debt repayments. cohort of students will have a very different experience, against the virus. The union’s general The sector’s debts have risen over but I am sure they will be good and safe doctors.” secretary, Jo Grady, says, “NHS key the past year to £10.8bn, three times Chris Smith, a final year medical student at workers have rightly been celebrated higher than before the fi nancial Southampton University and co-chair of the BMA’s throughout the pandemic, but we crash, show fi gures compiled by the student committee, says that students depend on the need the clinical academics in place Times . “goodwill” of academics to do extra teaching sessions. to teach medical students, or we risk Strain says, “Universities across “Social distancing means that teaching groups have leaving the NHS under-resourced. the country have over-expanded, had to get smaller,” Smith explains. “For simulations, for instance, the academics have had to run extra “It’s very worrying to see cuts to the which has made them particularly sessions, from two groups of six to four groups of medical schools that teach our doctors. vulnerable to these fi nancial three, which means everyone We urge universities to work with us to problems. At Exeter we were working into the evening. Certain make sure their medical schools have fortunate to be preparing for an facilities have strict limits on the capacity to research and develop expansion which we’ve put on hold, the number of people in a room: new medicines, and the staff in place helping us weather the storm. Other medical students might not be to train the doctors our NHS needs.” universities are not as lucky.” allowed in, so we’re missing out Clinical academics have received Bethan Clayton, a fi nal year on seeing patients. There’s also support from the University and medical student at Manchester uncertainty about the format of Colleges Employers Association, University, says that staff have exams—you can’t move from the trade body for UK higher worked hard to minimise the pressure station to station, for instance.” Bethan Clayton, a final year education institutions, which wrote on students. “The academics are medical student at Manchester to universities at the end of August under a lot of pressure, but they don’t University, is trying to make recommending that they increase pay pass it on to us,” she says. “You can the best of a difficult situation. for clinical academic consultants and tell they’ve been working hard and “Since we’ve gone back in mid- senior academic GPs by 2.8%, in line are stressed, but we’ve been very August I’ve been catching up on with that recently off ered to senior sheltered and protected by them.” psychiatry,” she says. “It’s not hospital doctors. Chris Smith, a fi nal year medical been the same—we’re allowed The BMA is concerned about the student at Southampton University one medical student on the decline in senior clinical academics: and co-chair of the BMA’s Medical ward at a time. I’m at Bolton, although the overall clinical Students Committee, describes a which is obviously a hotspot, so everything is very carefully academic staffi ng numbers have sense of solidarity with staff . “We’ve handled. Today I did a 24 mile remained roughly level from 2004 heard stories up down the country journey to hear a doctor speak to 2019, the number of readers and of medical school staff leaving and to a patient on the phone. I senior lecturers has fallen by 26.8%, not being replaced,” says Smith. understand why, but it’s not the while the number of junior lecturers “We stand shoulder to shoulder best learning experience.” has risen by 59%. Strain says that with the academics: we don’t want She adds, “I don’t blame the temptation to join the NHS is to see anyone forced into taking a anyone. Medical schools have strong—“where we would be paid for pay cut, and, if we lose academics, never faced this issue, and I have our hours, not for the job”—and that medical students will be the ones a lot of patience. If I was a third a pay diff erential will only increase that lose out.” year going into patient contact, the departure of senior academics. Stephen Armstrong, freelance journalist, on the other hand, I’d be worried. Malcolm Reed (top), London [email protected] That’s a formative time when you’re Chris Smith, and He adds, “We’ve lost too many Cite this as: BMJ 2020;370:m3656 getting to grips with medicine.” Bethan Clayton senior clinical academics over

394 26 September 2018 | the bmj