this week RONALDO AND COKE page 465 • RECOVERY TRIAL page 466 • EARLY RETIREMENT page 468 MARK THOMAS GMC “complacent about discrimination”

An employment tribunal has ruled for and discrimination at Heatherwood and The GMC (above) is accused the fi rst time that the GMC discriminated Wexham Park Trust, now Frimley Health of failing to take racial against a doctor on the grounds of race. Trust. The trust accused him of bullying and discrimination into account Omer Karim, a consultant urologist threatening behaviour towards a colleague. when dealing with the case against Omer Karim (inset) referred to the GMC by his employers, was The trust referred him to the GMC in treated diff erently from a white doctor who 2014. The next year interim conditions was also under investigation, the Reading were placed on his practice, pending a employment tribunal held, and there was full investigation. These were lifted later no credible explanation for the diff erence. that year, but it took three more years for a The way the GMC dealt with some of the hearing to clear him of any misconduct. allegations suggested that the regulator was The tribunal heard that although black “looking for material to support allegations and other ethnic minority doctors made up LATEST ONLINE . . . rather than fairly assessing matters 29% of UK doctors they were the subject of presented,” the tribunal noted. 42% of employers’ complaints. UK graduate GP is liable only The tribunal said it was “concerned doctors from ethnic minorities were 50% for costs of harm related to her there was a level of complacency about the more likely to get a sanction or warning than advice in case of operation of discrimination in the work of their white peers. “wrongful birth,” GMC or that there might be discrimination Karim accused the GMC of a “callous say Supreme infecting the referral process.” It noted disregard for the truth and honesty.” He Court judges “the failure of all the witnesses to express added, “Right from the outset, the GMC saw Trieste’s mental how, if at all, the awareness of the over- me as a guilty black doctor. We doctors need healthcare model representation of [black and ethnic to work to change the system.” is under threat, minority] doctors in complaints to the GMC A GMC spokesperson said, “We are giving claim supporters was considered in the investigation process full consideration to the fi ndings.” of the community or whether discrimination may have been a Frimley trust said in a statement, “We based approach factor consciously or unconsciously in the want to be the best possible employer and Hancock comes allegations faced by the claimant.” we will continue doing everything we can to under renewed The tribunal heard that Karim, a specialist listen to staff and eliminate inequalities.” pressure from PM’s in prostate cancer and robotic surgery, Clare Dyer , The BMJ former chief aide blew the whistle on poor practice, bullying, Cite this as: BMJ 2021;373:n1595 the bmj | 26 June 2021 463 SEVEN DAYS IN Eight in 10 doctors experienced moral distress during pandemic, BMA survey fi nds Four fi ft hs of nearly 2000 doctors who responded to a BMA survey said the term “moral distress” resonated with their experiences of working during the pandemic, and over half said the same for “moral injury.” The BMA defi ned moral distress as the “psychological unease generated where professionals identify an ethically correct action to take but are constrained in their ability to take that action.” Moral injury, the BMA said, can arise where sustained moral distress leads to impaired function or longer term psychological harm. “Moral injury can produce profound guilt and shame, and in some cases also a sense of betrayal, anger, and profound ‘moral disorientation,’” it explained. Helen Fidler, deputy chair of the BMA’s Consultants Committee, said what was important was “being able to now name the struggles that many doctors are having and pinpoint exactly what needs to be done to alleviate them.” The BMA has called for extra investment in the NHS, better staffi ng, and emotional and psychological support for healthcare workers.

Abi Rimmer , The BMJ Cite this as: BMJ 2021;373:n1543

Covid-19 Chaand Nagpaul, chair of BMA pharmacological interventions for a new members’ bill that Health secretary ordered council, said that compulsory such as ketamine as justification seeks to change the law on to disclose documents vaccination of healthcare staff for excessive police force, which assisted dying in Scotland, The UK information commissioner raised new ethical and legal is disproportionately cited in paving the way for the first ordered England’s Department implications and that efforts cases where black men die in law debate on prospective of Health and Social Care to should be focused on targeted enforcement custody. legislation in Holyrood for more disclose two briefing papers engagement. Any policy must than five years. Supported by forming part of Exercise Cygnus, avoid discrimination, he said, Assisted dying Dignity in Dying, the bill would which Moosa Qureshi, an NHS given that uptake of the vaccine Hancock wants “holistic” legalise assisted dying as a consultant haematologist, has was lower in some ethnic and informed debate choice for terminally ill, mentally been campaigning for since the minority groups. England’s health secretary, competent adults—a change pandemic started. The papers Matt Hancock, acknowledged supported by 87% of the public cover how the NHS and social care problems with the current law in Scotland. would cope if a major pandemic that prohibits assisted dying as overwhelmed resources. Qureshi well as the risks in changing it. He Prevention said in a blog, “By refusing to told the All Party Parliamentary NHS will offer “health provide a population triage Group for Dying Well, which MOTs” at vaccination sites protocol, both the Department opposes assisted suicide, that The NHS in England plans of Health and NHS England have assisted dying was a matter to offer “health MOTs” at arguably transferred blame—and for parliament to decide. “It is NHS vaccination services, legal liability—from politicians important that any debate that pharmacies, clinics, and other and corporate executives to Excited delirium we have [on assisted dying] is sites. Announcing the plan, NHS NHS healthcare workers who AMA opposes “excited nested in a wider debate about England’s chief operating officer, had already risked their lives on delirium” diagnosis how we support people better Amanda Pritchard, said that the the front line.” The government The American Medical towards the end of their lives,” aim was to make “every contact has 28 days to respond to the Association adopted a policy said Hancock. He pledged to help count” by rolling out tests such request. to oppose “excited delirium” improve the evidence base and as blood pressure, heart rhythm, as a medical diagnosis and accepted that palliative care and cholesterol checks when Mandatory vaccination to warn against using certain services needed further patients already have other could extend to NHS pharmacological interventions investment. appointments. Checks Staff in England’s care solely for a law enforcement will be offered when homes will be required to be purpose without a legitimate Bill is introduced in patients attend for top-up vaccinated against SARS-CoV-2 medical reason. It said that the Scottish parliament covid vaccinations or flu from October if legislation is new policy, adopted at the AMA’s Liam McArthur (right), vaccinations this autumn approved by parliament, and special meeting of its House of MSP for Orkney, lodged in locations such as village the government is set to consult Delegates, follows reports that proposals in the halls, churches, on whether to extend the showed a pattern of using the Scottish mosques, and local requirement to NHS workers. term “excited delirium” and parliament sports centres.

464 26 June 2021 | the bmj SIXTY SECONDS MEDICINE ON . . . RONALDO Antibiotics AND COKE Use on UK pig farms has more than doubled HAVE THEY TEAMED UP? Unpublished industry data show Quite the opposite. Cristiano Ronaldo—the that the use of aminoglycosides A steep rise in footballing superstar and global icon—has been widely praised by public health experts on UK pig farms rose from aminoglycoside aft er he shunned Coca-Cola during a press 2.607 mg/PCU (mg per kg of body use in piggeries conference at the UEFA Euro 2020 football weight) to 5.957 mg/PCU from raises fears of championships, where the soft drinks giant 2015 to 2019, raising concerns resistance is an offi cial sponsor. about the effect this could have on rise of antibiotic resistant AWKWARD. IS HE A PEPSI MAN? infections. Agricultural leaders management services, as well as Not as far as we’re aware (although he has have suggested a recent jump in a £30m enhanced service for GPs COVID advertised both brands in the past). But the use of aminoglycosides could to treat patients with long covid. aft er ostentatiously shift ing two bottles be because of the push to reduce DEATHS of Coke away from his vicinity during the other antibiotic use, as well as CPR press conference, the never shy nor retiring the upcoming EU ban on the use NHS offers training Peru ranks top Portugal captain held up a bottle of water before declaring, “Agua!”—encouraging of zinc oxide, which is commonly after footballer’s collapse in the world for people to choose the old H O instead. used to control scour (diarrhoea) The NHS and St John Ambulance deaths per million 2 in piglets. have joined forces to encourage population at TAP OR BOTTLED? people to learn cardiopulmonary He didn’t specify, so we can’t rule out Childbirth resuscitation and how to use 5864, with that he’s a secret agent for “Big Water.” Caesarean sections But given that he’s still in peak physical a defibrillator (below). NHS Hungary next at continue to rise worldwide England’s medical director, condition and breaking records at 36, when most footballers have hung up their boots, Research from WHO showed Stephen Powis, highlighted 3066. The that caesarean section rates how the life of the Danish pronouncements he makes relating to health worldwide have risen from footballer Christian Eriksen, who UK ranks 17th at tend to be listened to. around 7% in 1990 to 21% today required 13 minutes of CPR after deaths WILL HIS FANS STOP DRINKING COKE? and are projected to continue collapsing during a Euro 2020 1910 Who knows? But such is the power and increasing throughout this game, was saved by doctors. per million global reach of Ronaldo (he has almost 300 decade. Ian Askew, director of Powis said thousands more lives [State of Health] million Instagram followers) that aft er his WHO’s Department of Sexual could be saved if more people gesture Coca-Cola’s share price dropped and Reproductive Health and were equipped with lifesaving almost immediately, and its market value Research, said caesareans were skills. The charity will seek to went from $242bn (£173bn) to $238bn. “absolutely critical to save lives train 60 000 people as part DID THIS CAUSE THINGS TO KICK OFF? in situations where vaginal of the new programme. The organisers of the tournament attempted deliveries would pose risks,” but to diff use the situation, pointing out that he said that not all the procedures Suicide “players are off ered water, alongside were needed for medical reasons WHO issues Coca-Cola and Coca-Cola Zero Sugar, on and “can be harmful, both for a prevention guidance arrival at our press conferences,” before woman and her baby.” The World Health adding, “Everyone is entitled to their Organization launched drink preferences.” Primary care guidance called LIVE LIFE to GPs get extra funding support countries in preventing IS THAT THE FINAL SCORE ON THIS MATTER? for weight management suicide, as figures showed that Not quite. Following in Ronaldo’s footsteps, NHS England announced a £50m more than 700 000 people Italy’s Manuel Locatelli placed Coca-Cola package of changes to the general worldwide took their own bottles out of view, saying, “Acqua,” practice contract agreement for life in 2019—one in every while France’s Paul Pogba moved 2021-22, which it has identified 100 deaths. The guidance some Heineken non-alcoholic as a priority in recovery from the recommends limiting access beer (another major tournament pandemic. Practices will be able to the means of suicide, sponsor) away from his orbit. to voluntarily access £20m in responsible media reporting, Maybe Ronaldo’s biggest legacy extra funding for an enhanced fostering socioemotional life won’t be his goals but his impact on service for weight management, skills in adolescents, and early sponsorship in sport. to encourage GPs to engage identification of people at risk. with obese patients about their Gareth Iacobucci, The BMJ weight and refer people to weight Cite this as: BMJ 2021;373:n1604 Cite this as: BMJ 2021;373:n1567

the bmj | 26 June 2021 Labour calls for openness in appointment of new head of NHS England

NHS staff , as the holder of this role quality care and who will never fail will shape the future of the health to champion a public universal NHS, service at arguably the most critical stand up to Rishi Sunak, and secure time in its history,” the letter said. crucial extra investment.

MARK THOMAS “I urge you to take action to make “This is one of the biggest healthcare abour has called for the The process the recruitment and selection jobs in the world. Patients expect the appointment process of the must be free process public and subject to proper appointment to be made transparently new chief executive of NHS from the scrutiny to ensure that there is proper and on the basis of merit.” England to be transparent, cronyism of confi dence in the next holder of this The news comes after one L based on merit, and the past year important role.” prospective candidate for the role, without undue political infl uence. Jon Ashworth Commenting on the letter, Ashworth Dido Harding, faced criticism for In a letter sent to cabinet secretary said, “The NHS needs a chief executive comments she made about the NHS Simon Case on 19 June, Labour’s with a proven track record of delivering workforce. According to the Sunday shadow health minister, Jon Ashworth, also called for the process to be “free from the cronyism that has NAGPAUL said nearly 87 000 NHS doctors are from overseas. existed over the past year.” “This is a matter of the utmost The cost of replacing them with UK trained doctors will be £46bn importance for both patients and regardless of the fact that the NHS is so enriched by diversity

Regeneron’s antibody combination cuts deaths in seronegative covid patients, Recovery trial finds

Regeneron’s antibody combination admitted to hospital with covid were treatment cut deaths in patients who randomised to receive either usual had not mounted their own antibody care plus the antibody combination or response to SARS-CoV-2 by one fifth, usual care alone between September the Recovery trial has found. 2020 and May 2021. Of these, about The researchers found that for every a third were seronegative at baseline, 100 seronegative patients treated half were seropositive, and one sixth with the combination of casirivimab had unknown serostatus. and imdevimab there were six fewer Among patients who received usual deaths. They said patients admitted care alone, 28 day mortality was twice to hospital should now be tested for as high in those who were seronegative

antibodies to determine whether they (30%) than in seropositive patients KHAN/SHUTTERSTOCK IRFAN could benefit from the treatment. (15%) at study entry. Among those (median 13 days v 17 days with usual The two virus neutralising antibodies who were seronegative at baseline, care only.) work by binding non-competitively to however, the combination reduced The treatment did not have an effect the critical receptor binding domain of deaths by a fifth: from 30% in the on people who were seropositive at SARS-CoV-2’s spike protein, thereby usual care group to 24% (rate ratio baseline. stopping the virus from binding to and 0.80 (95% confidence interval 0.70 entering human cells. to 0.91)). The treatment also cut the Belt and braces approach As part of the trial, 9785 patients duration of hospital stay by four days In the study preprint the researchers said that, although they did not Among patients who received usual care alone, 28 day mortality was twice as high in those who were specifically look at variants, the major variants circulating in the UK seronegative than in seropositive patients at study entry (30%) (15%) throughout the trial, such as alpha, remained sensitive to the treatment. Among those who were seronegative at baseline, the antibody combination reduced deaths by a fifth: from They added that although spike 30% in the usual care group to 24% in the antibody combination group glycoprotein mutations in the beta and

466 26 June 2021 | the bmj Times, the former head of NHS Test UK regulator extends lateral flow test and Trace wants to challenge the “prevailing orthodoxy” in government authorisation despite US concerns that it is better to recruit medical staff from overseas rather than train them The UK medicines Products Regulatory Agency tests are authorised for use in the UK. regulator has extended the (MHRA) said its decision to in detecting positive cases Responding to her comments on authorisation for lateral fl ow extend the exceptional use of asymptomatic covid-19 Twitter, the BMA’s chair of council, tests used as part of the mass authorisation (EUA) followed and are used in schools and Chaand Nagpaul, said, “The NHS has covid testing programme, a “satisfactory outcome” of before larger events, such had a multicultural workforce since its despite concerns raised a review in response to US as Euro 2020 matches. The inception, without which it wouldn’t by the US regulator over concerns. But, despite the public can also order two exist today. Nearly 87 000 doctors in the main test—the Innova apparently positive fi ndings, tests a week for general use. the NHS are from overseas. The cost SARS-CoV-2 antigen rapid the MHRA has extended the Scientists have previously of replacing them with UK trained qualitative test. authorisation for only two warned the tests may miss doctors will be £46bn regardless of months—until 28 August. as many as half of cases, the fact that the NHS is so enriched Binned MHRA director of devices depending on who is using by diversity.” The US Food and Drug Graeme Tunbridge said, them, and provide false Infectious diseases consultant Agency last week warned “We have now concluded reassurance to people Sanjay Bhagani said on Twitter, the public to stop using the our review of the risk who receive a “I am a ‘foreigner,’ Dido Harding, Innova test and suggested assessment and negative result. and extremely proud of what I have that any unused tests should are satisfi ed that Sheila Bird, contributed to the NHS. It’s a shame be destroyed, binned, or no further action former programme that you don’t appreciate what makes returned. is necessary leader at the MRC the NHS tick and makes it the world The agency issued a or advisable. Biostatistics Unit, Cambridge class health service that it is.” class 1 recall after an This has allowed us University, said that the Abi Rimmer, The BMJ investigation uncovered to extend the EUA to allow MHRA’s transparency Cite this as: BMJ 2021;373:n1607 “signifi cant concerns that an ongoing supply over the failures, including that it had the performance of the test coming months. People can not provided details on how has not been adequately be assured of the MHRA’s the recent review was carried delta variants have been associated established, presenting a risk work to continuously out or its fi ndings, must be with a reduction of casirivimab’s to health.” monitor the tests in use; as is immediately redressed. neutralisation activity the combination However, the UK’s our standard process.” Elisabeth Mahase, The BMJ treatment remains potent because Medicines and Healthcare In the UK, the lateral fl ow Cite this as: BMJ 2021;373:n1582 of imdevimab’s inhibitory activity. The researchers described the treatment as having a “belt and braces Delta cases rise by 79%, but rate slows approach” so that if one fails the other should still work. Almost all new UK cases of The most recent data and the delta variant is now covid are the delta variant, show 99% of sequenced dominant. The increase is Convalescent plasma but new data indicate that, and genotyped cases primarily in younger age One question raised in light of the while case numbers are across the country are groups, a large proportion positive results was why this antibody increasing, the rate of growth the delta variant of whom were unvaccinated treatment works but convalescent is slower than a week ago. but are now being invited plasma—which contains antibodies Public Health England’s was higher among patients to receive the vaccine. It is to SARS-CoV-2 from people who’ve weekly data on variant with delta than those with encouraging to see hospital recovered from the virus—does not. cases show that numbers of alpha, but its analysis found admissions and deaths are Peter Hornby, Recovery trial chief delta in the UK have risen two doses of vaccine gave not rising at the same rate, investigator and professor of emerging by 33 630 since last week to more than 90% protection but we will continue to infectious diseases and global health 75 953, a 79% increase. The against admission. monitor it closely.” at Oxford University, said it came down most recent data show 99% Up to 14 June 806 people Paul Hunter, professor in to the dose and quality of antibodies. of sequenced and genotyped were admitted to hospital medicine at the University He said, “The monoclonal antibodies cases across the country are with delta, an increase of of East Anglia, said, “Cases are selected to be highly potent. And the delta variant. 423 from the previous week. are still rising but apparently we give a very high dose. Whereas The data also show that Of these, 527 people were not as rapidly as they were with convalescent plasma you’ve got 58 830 positive test results unvaccinated and 84 had a week ago. On balance, it a mix of high quality and low quality were recorded between 11 received two doses. does appear the epidemic antibodies and much lower quantities. and 17 June, an increase of Jenny Harries, the UK in the UK may no longer be It’s just a much less potent product.” 33.7% on the previous week. Health Security Agency’s increasing exponentially.” Elisabeth Mahase, The BMJ PHE said the data showed chief executive, said, Adrian O’Dowd, London Cite this as: BMJ 2021;373:n1570 the risk of hospital admission “Cases are rising rapidly, Cite this as: BMJ 2021;373:n1596 the bmj | 26 June 2021 467 T rust is fined BMJ INVESTIGATION £733 000 for Number of doctors retiring unsafe care of early has trebled since 2008 mother and son

A hospital trust that admitted he number of doctors taking over this period, from 141 000 to 176 000. failing to provide safe care and early retirement from the The fi gures were provided to The BMJ treatment for a newborn baby NHS has more than trebled by the NHS Business Services Authority and his mother has been fined over the past 13 years, offi cial in response to a freedom of information £733 000. T fi gures show. In England and request. They relate to doctors who claimed East Kent Wales 1358 GPs and hospital doctors took their NHS pension in a specifi c pension year, Hospitals voluntary early retirement or retired because some of whom may have returned to work University of ill health in 2020-21, up from 401 in in the NHS in other roles after claiming their Trust pleaded 2007-08. pensions. guilty last Overall, the total number of doctors As the number of doctors retiring early April to retiring rose by 21% over this period, from has risen, the number retiring on the providing 2431 in 2007-08 to 2952 in 2020-21. The basis of age has fallen: from 2030 in 2007- unsafe care total number of doctors employed by the 08 to 1594 in 2020-21. The average age at resulting in NHS in England and Wales rose by 25% which doctors are retiring has also fallen avoidable over this period, from 61 years in 2007-08 harm to Harry DOCTORS TAKING EARLY RETIREMENT to 59 in 2020-21. Richford and his mother, Sarah, in FROM NHS IN ENGLAND AND WALES Changes to pension tax regulations since the first such criminal prosecution 2500 2010 have left many senior doctors facing of an acute care NHS trust. At a large tax bills. The BMA said that changes to sentencing hearing on 18 June at 2000 tax regulation were one of the main reasons Folkestone magistrates court the prompting doctors to retire, a situation trust was also ordered to pay a 1500 confi rmed last week by the fi nancial

£170 victim surcharge and costs No of doctors retiring watchdog the National Audit Committee. of £28 000. 1000 The fl uctuations in the number of doctors Harry died a week after his taking early retirement also refl ect this, 500 emergency delivery in 2017 showing sharp increases in some years. For at Queen Elizabeth the Queen 0 instance, in 2013-14 2069 doctors took Mother Hospital in Margate. The early retirement ahead of the changes to the prosecution by the Care Quality 2007-082008-092009-102010-112011-122012-132013-142014-152015-162016-172017-182018-192019-202020-21 NHS pension scheme in 2015. Commission came after his Year The BMA has also warned that successive parents, Sarah and Tom Richford (above), spent years searching for answers as to why their baby died. “Artificial pancreas” tr ial for type 1 diabetes Initially the trust described his death as “expected,” and it This Up to 1000 patients with remove the need for “In a year that marks a was only in 2020 that a coroner’s technology type 1 diabetes will be fi nger prick tests. century since insulin inquest was held. The coroner has the fi tted with an “artifi cial Announcing the was discovered, this found his death was “wholly potential pancreas” in a landmark trial at the NHS innovation is a prime avoidable” and contributed to to make a NHS trial. Confederation’s virtual example of the NHS’s by neglect at the hospital. He remarkable T he “closed conference on 15 continued progress in found more than a dozen areas of loop” technology June, NHS England’s modern medicine and difference to concern, including the delivery by automatically balances chief executive, Simon technology.” an inexperienced locum doctor millions of blood sugar levels by Stevens, said the Up to 1000 hybrid and delays in resuscitation. people’s lives constantly measuring technology marked a closed loop systems will An independent inquiry, Simon Stevens glucose concentrations new phase of innovation be off ered to adults and commissioned by NHS England and delivering in diabetes care. “Living children at specialist and headed by Bill Kirkup, is insulin directly to the with diabetes is a daily centres in England, carrying out an urgent review of bloodstream, when challenge for millions of which will submit data maternity and neonatal services at needed, through a people across England, through the NHS’s the trust, which is due to report in pump. It is designed and this technology has National Diabetes Audit. late 2022. to off er better glucose the potential to make a Results will be fed into Clare Dyer, The BMJ control, reduce the risk remarkable diff erence the evidence assessment Cite this as: BMJ 2021;373:n1589 of hypoglycaemia, and to their lives,” he said. undertaken by NICE.

468 26 June 2021 | the bmj failures in government recruitment and FIVE MINUTES WITH . . . retention schemes have meant that the UK has been seriously short of doctors Alan Mitchell for many years. Commenting on the new fi gures, The president of the European Vishal Sharma, chair of the BMA’s Committee for the Prevention of pensions committee, said that repeated Torture on the eff ect of the pandemic surveys from the BMA had shown that more than half of doctors planned to retire before the age of 60, with most ovid has made the past 15 citing pension taxation as their primary WILLETT MALCOLM months diffi cult for all of us, reason. He said that the current pension retiring even earlier as a result of these but for those who have been taxation system was “punitive” and left changes,” he said. “The combination of deprived of their liberty the “senior doctors with little option but to an exhausted workforce coupled with “C privations associated with consider early retirement.” the freezing of the lifetime allowance their situation are even worse. Prisoners have The strain of working through being imposed at the same time will been locked in their cells for much longer. the pandemic has left many doctors potentially result in a mass exodus of There are restrictions on visits, the ability to exhausted and battling stress and highly experienced doctors, at a time take outdoor exercise, and access to showers burnout, Sharma added. “Many have when patients need them the most.” and to telephone calls. It is important that, as had their annual leave cancelled, and He said a “simple but eff ective” things open up, the roadmap that has been they have not had adequate time to rest change the government could developed for communities is accompanied by and recover from the tumultuous year make would be to implement a tax a roadmap for those deprived of their liberty. they have had, with no sign of let up as unregistered pension scheme in the “ Our mandate is the prevention of torture and they now face the biggest backlog and NHS. “The government has already inhuman or degrading treatment or punishment waiting lists since records began.” implemented such a scheme for the within the 47 member states. Although a lot Sharma said the situation had been judiciary to address similar recruitment of our work is focused on prisons, we also visit exacerbated by the government’s and retention issues,” he said. “A police stations, psychiatric hospitals in respect decision to freeze the lifetime allowance comparable solution within the NHS of involuntary patients, immigration detention for pensions taxation for the next fi ve will allow our most experienced doctors facilities, and social care homes where years, which will increase the amount to remain working in the NHS and avert guardianship orders are in place. of tax many doctors have to pay on their this workforce crisis.” “We undertake periodic visits to member pensions. “A BMA survey demonstrated Tom Moberly, The BMJ states typically every four to five years and that 72% of doctors would consider Cite this as: BMJ 2021;373:n1594 produce reports which we encourage states to publish. By and large, cooperation is good. If a member state pays scant regard to our A BMA SURVEY found that 72% of doctors recommendations, we can make a public would consider retiring earlier because of the tax changes statement of our concerns, and in recent years that has happened with Belgium, Bulgaria, Greece, Turkey, and the Patients who are eligibility criteria reading. NHS England Russian Federation. off ered the technology that are based on “a said over 40% of people “The pandemic has will ordinarily already be pragmatic consideration with type 1 diabetes been unprecedented in using pump therapy and of those most likely benefi t from fl ash terms of the challenges it fl ash glucose monitors to benefi t from the glucose monitoring. has presented. For the first or continuous glucose new technology from Partha Kar, NHS time in our history visits monitors and will not a clinical perspective specialty adviser for had to be suspended from be achieving an HbA1C based on current diabetes, said the trial March to July last year, and of less than 8.5%. The technology use and signalled a “quantum although we’ve been able to WHEN WE TALK Diabetes Technology glucose control,” NHS leap” for type 1 diabetes undertake all the planned ABOUT PUBLIC Network, a subgroup of England said. technology. He added, visits this year it hasn’t been HEALTH WE the Association of British The trial follows the “This technology is without difficulty. MUST CONSIDER PRISONS Clinical Diabetologists, increasing availability an extension of the “When we talk about has developed clinical on the NHS of non- fantastic work achieved public health we must consider prisons as part invasive glucose devices by the NHS, third sector, of that public health response. That is the added like the Freestyle Libre, and industry partners value that I, as a medical doctor, hope to bring to which is worn under the working together to the office of president over the next two years.” skin and continuously improve the lives of More information about the work of the committee can be monitors glucose levels, patients.” found at www.coe.int/en/web/cpt/home allowing patients to Gareth Iacobucci , The BMJ Bryan Christie , Edinburgh scan a sensor to get a Cite this as: BMJ 2021;373:n1538 Cite this as: BMJ 2021;373:n1584 the bmj | 26 June 2021 469 1 2

THE BIG PICTURE Caring in wards without water

As covid-19 continues to hit Malawi, more than half its health facilities lack handwashing facilities, almost two thirds have no decent toilets, and almost a fi fth do not have clean water on site. Ntchisi, a rural district of 300 000 people, has one hospital and three health centres. None have adequate water, sanitation, or hygiene facilities. As part of a campaign ahead of next year’s World Health Assembly, researchers from WaterAid, which is working with the Wimbledon Foundation to bring clean water and eff ective sanitation to the district, spoke to health workers, patients, and families about conditions before, during, and after childbirth. The researchers heard that an assistant at one centre has to collect water four times a day from community boreholes, 300 m away; that at another unit, which delivers up to 60 babies a month, the labour ward has one working toilet, which is often blocked; and that across all the sites water supply is intermittent, which means that doctors and nurses cannot always wash their hands. Helen Hamilton, a senior policy analyst at WaterAid, said, “Globally, 1.8 billion people are at greater risk of contracting covid-19 and other diseases simply because they use or work in a health facility that lacks basic water services. Two years ago, at the World Health Assembly, global leaders resolved to prioritise water, sanitation, and hygiene in all healthcare facilities. Now is the time for them to make good on those promises. “It would take just 30 US cents a year [per head of population] to make sure every health centre and hospital in the 47 poorest countries had a reliable water supply and working toilets, saving the lives of one million new mothers and babies every year.” Alison Shepherd, The BMJ Cite this as: BMJ 2021;373:n1602

470 26 June 2021 | the bmj the 3 bmj

| 26 June 2021 in Mkunzi health centre health in Mkunzi apatient daughter, her for food preparing 3. Loveness Saulosi, centre health Kangolwa at mother a new midwife with assistant, acommunity 2 .Steria, 1. Khuwi health centre 471

DENNIS LUPENGA/WATERAID/WIMBLEDON FOUNDATION EDITORIAL Persistent pulmonary disease after covid-19 Lingering pathology contributes to a wider picture of poor health after hospital discharge

t has been over a year since the if fi brosis is the underlying cause). fi rst patients were discharged Currently, the benefi t of such treatment from UK hospitals following remains unclear. A single study from treatment for covid-19. the UK reported improvement in I Hospital admission was dyspnoea scores, lung function, and largely dictated by the requirement imaging with a tapering course of for supplementary oxygen and corticosteroids starting six weeks after additional respiratory support. 1 discharge for patients with persistent Acute imaging commonly showed infl ammatory change on CT.11 multifocal airspace opacifi cation, However, this was an uncontrolled and venous thromboembolism was observational study of just 30 patients, recorded in around a quarter of and since outcome studies have shown adults admitted to critical care.2 This improvement in these measures over led to concern about the long term time without use of corticosteroids, 5 - 11 respiratory consequences of covid-19, it is diffi cult to draw conclusions. particularly interstitial lung disease Our a small prospective study from Pulmonary emboli are common in and pulmonary vascular disease.3 understanding Wuhan (n=83) looked at respiratory patients in hospital with covid-19.2 Fifteen months later, our of the outcomes over the course of a Analysis of healthcare claims in the 10 understanding of the complications complications year after hospital discharge. US also found an increased incidence after hospital treatment for covid-19 after hospital The percentage of patients with of venous thromboembolism 200 is improving. A UK study of 47 780 radiological abnormalities fell from days after the acute illness, 13 although treatment for discharged patients reported all cause 78% at 3 months to 27% (22/83) by little is known about the burden of mortality of 12% and readmissions in covid-19 is 9 months and remained unchanged chronic thromboembolic disease. one third after 140 days of follow-up.4 improving at 12 months. Only four patients Interestingly, a small pilot study from Interestingly, although respiratory reported dyspnoea one year after the UK (n=9) using hyperpolarised disease was diagnosed in 29.6% after discharge and functionally, patients xenon magnetic resonance imaging discharge, rates of extrapulmonary recovered well with normalisation of the lungs found regional diff usion complications, including diabetes, of six minute walk distance. These abnormalities persisting for three adverse cardiovascular events, and fi ndings are reassuring, but wide months after hospital discharge, even liver and kidney dysfunction were extrapolation should be avoided: in those with near normal appearances also increased compared with those participants had a median age of 60 on computed tomography.14 These in population matched controls, but had no pulmonary and cardiac fi ndings may indicate enduring indicating that the eff ect of covid-19 comorbidities, had never smoked, pulmonary vascular abnormalities extends far beyond the lungs. and 46% did not require respiratory after acute covid-19, but further Outcome data from single centre support during the acute infection. investigation is required. The clinical cohorts have shown that the lungs signifi cance of these abnormalities are often physiologically and Ground glass opacification remains unknown. radiologically impaired 3-4 months The follow-up studies use various M any studies4 - 15 highlight the after hospital discharge.7 8 radiological descriptions, but extent of non-respiratory physical and Concordance among these studies “ground glass opacifi cation” is often psychological symptoms after acute suggests the fi ndings are likely to reported. 5 - 11 In the absence of dilated covid-19, and follow-up studies report be applicable to hospital treated bronchi, this can indicate a potentially all-cause mortality exceeding 10% patients more generally. Indeed, lung reversible cellular (infl ammatory) in the six months after discharge. 4 15 abnormalities persisting a few months infi ltrate.12 However, in the year Thus, while persisting lung damage after other viral pneumonias are long Wuhan study,10 ground glass may be substantial for some, for recognised.9 Interestingly, however, opacifi cation noted at nine months many, morbidity and mortality after while most patients in these studies was still present at 12 months, covid-19 are infl uenced most by Emily Fraser , had persisting symptoms (particularly raising the possibility it may in part pre-existing conditions, infection consultant in fatigue, memory problems, and represent fi ne fi brosis. This distinction severity, and the extra-pulmonary respiratory psychological sequelae), only a medicine, Churchill is important as it could infl uence use complications of SARS-CoV-2. 5-8 minority reported dyspnoea. Hospital, Oxford, UK of immunomodulatory therapy in Cite this as: BMJ 2021;373:n1565 Data on longer term post-covid patients with persisting ground glass Emily.Fraser@ Find the full version with references at sequelae remain sparse, although ouh.nhs.uk opacifi cation (which will have no eff ect http://dx.doi.org/10.1136/bmj.n1565

472 26 June 2021 | the bmj EDITORIAL The NHS needs a comprehensive recovery plan This system-wide challenge demands a system-wide response

ven before covid-19, remain valid—we must now add the NHS was in need dealing with growing backlogs of of some emergency care, long covid, and an ongoing treatment. In the 2019 pandemic. Leaked estimates suggest E general election1 the that between £2bn and £10bn UK government promised 50 000 (€2bn-€12bn; $3bn-$14bn) a year more nurses, 6000 more general will be required to reduce elective practitioners, and another 6000 waiting lists back to acceptable other primary care professionals levels 10—the wide range underlines in addition to the 20 000 already uncertainties over future trends promised. The reason for these in demand, not least from all the commitments was easy to see: patients who should have been widespread staff shortages and a referred in 2020 but were not. slow but steady decline in many key Fourthly, a proper conversation markers of performance, whether in with the public is required. The NHS elective or accident and emergency The service the number of GPs and practice and the public will not be well served care (where data are good) or in desperately nurses is not rising (measured by by overly optimistic commitments general practice, mental health, and needs a whole time equivalents) even if on recovery that cannot be community services (where they workforce plan some progress is being made on the delivered. This will mean living aren’t). that provides recruitment of other professions through a period when patients’ Covid-19 then intervened, causing into primary care.7 Anecdotal overall expectations are not going some relief to a massive disruption to services. At reports of rising demand for mental to be met and making some tough their lowest point, GP referrals to staff health services are consistent with prioritisation decisions until capacity hospital fell by around 75% from the the eff ect of prolonged lockdowns and productivity recover. previous year,2 diagnostic tests by and interruptions in care.8 This is a Despite the tragedy of the 70%,3 emergency admissions by just system-wide challenge and needs a pandemic, the health and care under 40%,4 and GP appointments by system-wide response. system enters this new era having about a third.5 Elective activity is back learnt some valuable lessons from to around 90% of pre-covid levels,6 Long term planning the response to covid-19. The although in any normal year a 10% Secondly, we need long term digital experience has shown the fall in activity would still be shocking. planning. Some of the key NHS capable of large scale change The size of the hospital waiting resources—such as operating at pace. The stronger relationships list fi rst dropped sharply as referrals theatres and medical imaging forged with both local government dried up, before rising by 1.3 million scanners—don’t get built overnight. and parts of the voluntary sector also as activity picked up again. By June Most critically of all, workforce off er the chance to provide a more 2021, even as covid-19 admissions to shortages are so deep that they integrated service that should be hospital once again begin to rise, signs cannot be overcome quickly, and better at tackling the longstanding of returning demand are appearing the service desperately needs a inequalities that often need a system- across the NHS. Attendances at major workforce plan that provides some wide approach. emergency departments hit their relief to staff already exhausted by If it all sounds too daunting, second highest level ever in May,4 and the past year while also setting out remember this has been done before. the volume of appointments with GPs longer term staffi ng commitments After years of decline, the NHS has risen above pre-pandemic levels5 and how they will be met.9 Plan in 2000 kicked off a decade of even without fully accounting for Thirdly, the plans will need improving access and consistent and covid vaccinations. funding. The government had rapid increases in staff numbers— Confronting these challenges will set out spending totals for the backed of course by a proper need a long term solution made up of NHS through this parliament, but workforce plan and improving four key elements. Firstly, although these were all agreed before the outcomes. If the government the visibility of the waiting list Richard Murray , chief pandemic and excluded essential provides the resources, history draws attention to the acute sector, executive, King’s budgets such as training, public shows the NHS can deliver. solutions need to be about more Fund, London, UK health, and capital spending. To Cite this as: BMJ 2021;373:n1555 than acute care. In general practice, the pre-existing priorities from the R.Murray@ Find the full version with references at despite the increases in activity, kingsfund.org.uk NHS long term plan—many of which http://dx.doi.org/10.1136/bmj.n1555 the bmj | 26 June 2021 473 INVESTIGATION Chronic fatigue syndrome and long covid: moving beyond the controversy

Many patients with long covid are experiencing extreme fatigue, a situation that has re-polarised approaches to treatment and rehabilitation. Melanie Newman reports

submitted the fi rst and academics who have been positive trial of cognitive challenged over their views on behavioural therapy [CBT] treatment of long covid, or their as a treatment for chronic research intentions, where “exercise” “I fatigue in the ’90s,” has become a toxic term for some. recalls Michael Sharpe, a professor of Clinicians working with long covid psychological medicine who was then patients have also told The BMJ that, a lecturer at Oxford University. “Next despite the challenges, long covid thing, my head of department got provides an opportunity to progress an unsigned letter, sent to The BMJ , the understanding of postviral saying that the research study was syndromes and to acknowledge that made up.” they are a very real condition. It was the start of a lengthy campaign to prevent and undermine Challenged for speaking out Sharpe’s research by some advocates The pandemic has seen Sharpe of chronic fatigue syndrome/myalgic back in Oxford, helping to set up encephalomyelitis (CFS/ME) who a multidisciplinary long covid object to suggestions that their illness clinic involving specialists, has a psychological element. physiotherapists, occupational health After a period of “a lot of awfulness” practitioners, and psychologists. Sharpe moved to Edinburgh Clinics of this sort, with a similar University, where he initially decided range of expertise, have been set up to abandon the fi eld but was drawn around the UK. back by the Pace trial. Pace examined The insurance company Swiss Re— the eff ectiveness of CBT and graded inappropriate use of exercise and CBT, Finding the with which Sharpe makes clear he has exercise therapy (GET), in which stating that the evidence is mixed or right balance no fi nancial link—asked him to do a the patient does progressively more unclear. between presentation on early observations exercise over time, combined with Tensions have now resurfaced gentle activity at the clinic. The slides from his talk medical care. It was always going to be with the advent of the pandemic and to avoid showed that long covid encompasses controversial. long covid or post-covid symptoms. a range of conditions, with deconditioning “The Medical Research Council As many as 376 000 people in the symptoms infl uenced by biological, was being lobbied, people were UK report symptoms more than and not psychological, and social factors, trying to stop participants joining the 12 months after the fi rst onset of triggering including media coverage, and that it trial—we had so much fl ak,” he says. covid-19, often experiencing extreme post-exercise has some similarities with CFS/ME. Published in 2011 in the Lancet , the fatigue along with a wide range of malaise is “We need to balance ‘keeping an Pace trial found that both CBT and other symptoms. important in open mind’ with a pragmatic approach GET led to greater improvements in Clinicians report a complex each patient to management,” the slides advised. some participants than medical care picture. Patients with long covid “Patients need to feel listened to and alone. Since then the trial has been a are a diverse group, and it’s hard to believed—physicians must manage lightning rod for ME/CFS advocates’ know what treatment path to put uncertainty.” Referencing the Pace anger, drawing ceaseless attacks them on. Finding the right balance trial, they added, “At present the best on the conduct of the research, the between gentle activity to avoid treatment is psychologically informed researchers, and the results. deconditioning and not triggering rehabilitation.” However, while most A decade after publication it seems post-exercise malaise is important in patients will improve, “there is likely to unlikely that a consensus will ever be each patient. But the advice given, be some long term disability.” reached. NICE has since reviewed its the research conducted, and how it is Sharpe’s inclusion of the Pace guidance on ME/CFS, which has had a communicated have become highly trial in his presentation—and, as an controversial reception, and the draft sensitive issues. example of the role of media coverage, guidance expresses concerns about The BMJ has spoken to clinicians a quote from the Guardian journalist

474 26 June 2021 | the bmj DOES EXERCISE MAKE PATIENTS WORSE? Ben Marsh was an NHS consultant We added paediatrician who “ran half marathons to relax” before a measure contracting viral pericarditis in of fatigue 2017. He went back to work after when six months but developed more monitoring severe symptoms and has not outcomes recovered despite “extensive Sally Singh professional input.” For some people with low level very aware of these concerns, as boom and bust. But it’s certainly not Rob Barker-Davies is a squadron postviral fatigue, Marsh explains well as the risk of PEM and the all long covid patients who get PEM, leader, postdoctoral researcher, and that rest in the early stages, followed ME/CFS literature. and there is another set of patients registrar in rehabilitation, sport, and by a gradual increase in activity with Away from the fire and fury of for whom exercise is appropriate.” exercise medicine at the Defence or without psychological support, social media, they are quietly The key is careful screening, Medical Rehabilitation Centre. He can be appropriate. “However, working out how best to treat each assessment, and individualised told a BMJ webinar on long covid, for some people this approach is patient without causing harm. treatments, explains Rogers, “We are not advocating fixed detrimental to their health,” he Results are—predictably, given the as “it’s not one size fits all.” increments in activity or assuming adds. “The flaw is that this other early stage of the research—mixed. Difficulties may arise, she says, linear resolution of symptoms.” He side of rehab is rarely understood Sally Singh, professor where services are not funded to describes the programme offered by practitioners or explained to the of pulmonary and cardiac screen patients properly. at the centre as “symptom titrated patient. There is a need to screen rehabilitation at the University of physical activity,” as opposed to patients with fatigue during rehab Leicester, says she was “aware Diverse groups graded exercise therapy. for PEM [post-exertional malaise].” of the rhetoric around exercise Paul Whitaker, a respiratory “We mustn’t shirk away from The NHS’s Your Covid Recovery making people worse, and it was consultant who set up the first long the key training principle of website tells patients to gradually an absolute priority that we didn’t covid clinic in Yorkshire, told The BMJ progression,” he says. “But . . . build up to 30 minutes’ activity do that, which is why we added he had studied CFS and postviral we need to understand the effect five days a week and not to give up in a measure of fatigue when literature and was aware of the ME/ of the change we’ve made before if they have setbacks. It does not monitoring outcomes.” CFS views around exercise from proceeding. Otherwise we risk warn of PEM. She studied 30 patients who took the outset. “For my longstanding a stepwise deterioration.” His Marsh thinks that it should. He part in an individually tailored six patients with long covid who fulfil patients, who as military personnel says physical therapy should be week rehabilitation programme of the criteria for CFS, they do seem to are fitter and younger than average, treated like a medicine or surgery. “If aerobic exercise, strength training, get worse with strenuous aerobic also need educating on managing you take a drug you have to be told and educational discussions. Of the exercise,” he says. “However, long their activity to avoid “boom and the side effects and what to look out 30 participants only one patient, covid patients are a very diverse bust,” he says. for,” he says. Asked whether over- a stroke survivor, did not improve group, and there are many others Barker-Davies draws a comparison emphasising side effects may risk either exercise capacity or fatigue, who do need an exercise based between long covid symptoms and causing them, he responds, “There while four reported an increase in regimen.” Defining which groups those of “over-training syndrome,” may be a small number of people fatigue but also in exercise capacity. will benefit from exercise remains a where athletes over-exercise and with a psychological vulnerability Meanwhile, in the community challenge. can experience fatigue, depression, who somatise, but that does not rehabilitation arm of the Oxford tachycardia, insomnia, and justify failing to make doctors and long covid clinic, Rachael Rogers, Long covid irritability. He explains that possible patients aware of the risks.” a CFS/ME specialist who works patients causes of over-training syndrome— alongside a respiratory medicine are a very such as autonomic dysregulation, Mixed results consultant, has seen some patients diverse increased inflammatory cytokines, The BMJ has spoken to other with PEM. She says, “We are not and dysregulation of the doctors and healthcare advocating exercise for them—we group hypothalamus—are all mechanisms professionals helping long covid try to establish a baseline of activity Paul that have also been proposed as patients and found them to be that stops the relapsing pattern, the Whitaker explanations for long covid.

George Monbiot—set the hares comments section, “As someone who in January by the Canadian Institute running. In April Monbiot wrote a is lying in bed, yet again unable to of Musculoskeletal Health and follow-up piece that began, “A super- work and in agony due to long covid, Arthritis. Her remarks are not publicly spreader has been identifi ed . . . it’s I fi nd this professor’s comments so available, but Greenhalgh says that me.” He went on to rehash criticisms hurtful. This is a serious physical she summarised the controversy and of the Pace trial without mentioning illness, not some social hysteria.” that her position was misrepresented that they had been investigated by the Other doctors who have entered as pro-GET; however, other attendees Health Research Authority. the debate have quickly found say that she went beyond this and Many readers castigated Sharpe for themselves under fi re. Trish criticised CFS/ME activists. suggesting that the disease was “all Greenhalgh, professor of primary A short while later she received an in the mind” or created by the media, care at Oxford University, commented email from the organiser of another while others defended him on the on exercise and the Pace trial at a online conference at which she was same basis. One patient said in the public webinar on long covid, hosted due to speak about long covid. An ME the bmj | 26 June 2021 475 advocate had contacted the organiser “looked down the barrel of the to complain about Greenhalgh’s ME/CFS gun and disarmed it,” participation on the basis of her Garner found that the CFS/ME “maligning characterisation” of CFS/ community, which had embraced ME patients and her “promotion of him, turned on him. And, having discredited and harmful research.” previously criticised Cochrane’s The message concluded, “Dr recommendation of exercise Greenhalgh is a patient safety threat therapy, he added fuel to the fl ames to all Canadians living with ME and when he called for more research long covid,” and it asked for her on GET and claimed trials had not removal from the speaker line-up. Weeks turned into months. A CFS/ harmed patients. The organiser told Greenhalgh it ME advocate wrote an open letter to His theory was that rest and knew people in the UK with similar people with long covid telling them pacing, as advocated by CFS/ experiences who had subsequently to “brace yourself,” as “you might ME charities, were as vital as refused to have anything more to do not end up being sick for a couple of convalescence in the fi rst few with CFS/ME. months or a year or even fi ve years. months but symptom monitoring Think decades. Maybe even the rest may become counterproductive. For In the spotlight of your life.” Garner says he became such patients, he said, gradually But few opinions on long covid have stressed, locked into a pattern Part of my increasing physical activity would be proved as contentious as those of Paul of symptom monitoring and an recovery has benefi cial. This was interpreted as an Garner, professor at the Liverpool unconscious fear of “overdoing it.” been around order forcing exercise on unwilling School of Tropical Medicine. A few He then spoke to a recovered patients and was rejected by the CFS/ months after contracting the virus CFS/ME patient, who committed to changing ME community. in March 2020, and after a period helping him recover. Core to this was my thoughts Garner says some advocates actively of fatigue and other symptoms of a compelling explanation of what was around body oppose research on exercise. “They long covid, Garner, who had been happening in relation to the brain and signals believe the disease lasts for life,” he extremely fi t, felt a little better, went body, which, he says, “changed my Paul Garner says. “They reject any research that for a long cycle ride, and took part understanding of the symptoms I was examines psychological approaches in a high impact exercise class. He experiencing.” The support included a to treatment or that evaluates the immediately relapsed. credible explanation of his symptoms, role of progressive physical activity Experiencing fatigue and what he his hope of recovery, and techniques in recovery in ME/CFS, and I would describes as “brain fog,” he found to reduce his symptoms and stress. assume by extension to long covid.” the medical literature and guidance He went on a short bike ride and “pretty hopeless” on convalescence, then, under physician supervision, Not against “exercise” while the CFS/ME literature was increased the ride lengths over The ME Association’s website “very helpful.” It explained that he several weeks—a process he says carries a statement from its medical was experiencing “post-exertional was essentially GET. “It stopped me Our view is adviser, Charles Shepherd, that malaise”: a hallmark symptom of doing too much,” he says. “It was very that graded “the percentage of people who ME/CFS in which exercise triggers a gradual.” He progressed to full health exercise can recover [from severe ME/CFS] and worsening of symptoms. within a few weeks. be harmful return to full normal health is small Garner took advice to accept the Garner believes the non- Charles and . . . ‘spontaneous recovery’ is limits imposed by the virus. The ME specifi c concept of post-exertional Shepherd almost unheard of.” Association recommends “pacing”: malaise can cause patients to fear Shepherd told The BMJ, “We have slowly building up activity levels overexertion. He also suggests the never issued anything to say that the while monitoring one’s response malaise after exercise is normal early prognosis indications for long covid to exertion and limiting activities on but that it then becomes a learnt are the same as ME. I fear that some accordingly to prevent post-exertional automatic brain response. “I think it do have a long term condition, but malaise. It says vigorous exercise is really important not to emphasise it’s also clear that many people are should be avoided until some time post-exertional malaise as if it is a recovering.” after complete recovery. disease,” he explains. “Early on I ME/CFS advocates say He attempted pacing but struggled got suckered into it as something Garner’s experience has acquired to discover a pattern between his that might never go away. Part of my We will disproportionate importance while activities and symptoms that might recovery has been around changing being essentially a single anecdotal screen trial help him recover. Three months after my thoughts around diff erent body account from a person who never contracting covid, he says, he was signals. If you see any signal as participants fulfi lled the criteria for an ME/CFS unable to get out of bed for more abnormal, the most minor feelings for post diagnosis. Shepherd suggests Garner than a few hours a day. “I kept trying get exaggerated by your brain, and exertional has received so much media attention to convince myself I was getting you take to your bed.” malaise because his account seems to confi rm better, but I wasn’t, and I became too Perhaps unsurprisingly, having Gordon a long held theory about ME: that insecure to do anything,” he says. written in The BMJ that he had McGregor postviral patients were developing

476 26 June 2021 | the bmj abnormal beliefs and behaviours and COMMENTARY becoming deconditioned, which could be fi xed with CBT and GET. The ME Association’s view is that How power imbalances around there is an as yet poorly understood physiological explanation for ME/CFS long covid can harm patients and long covid, which may be linked to increased levels of infl ammatory CA Chew-Graham and colleagues argue that patients are still cytokines after initial infection. It believes research should focus on struggling to get their voices heard above doctors, a situation this process rather than on exercise that risks “structural iatrogenesis” and psychological therapies—and that any recommendation for exercise Social media platforms have brought Twitter and other social media are correcting should come with a health warning. together thousands of people with long this imbalance, although the results aren’t “We are not against exercise,” covid, allowing them to discuss, share, and always pleasant. Behind the Twitter “spats” Shepherd told The BMJ. “Our view is compare their experiences of relapsing and are thousands of individual patients with long that graded exercise can be harmful.” remitting symptoms. This phenomenon covid who believe that advocating for graded In a 2019 survey of more than has disrupted and flattened traditional exercise therapy rather than pacing to manage 2000 ME/CFS patients commissioned power structures, where doctors were fatigue in long covid may lead to management by the charity Forward ME, most always the experts and patients’ opinions regimens that make symptoms worse. patients reported worse symptoms were less valid. But power imbalances Knowledge production in this new condition after GET. In NICE’s recent draft remain, especially in the creation of health of long covid must therefore involve and guidelines on ME/CFS—which knowledge, where prominent names in engage patients and the public, not only to considered other research, as well medicine seem to get easy access to the ensure co-production of knowledge but also to as criticism of therapist delivered media—leaving less well resourced lay avoid top-down hierarchical service provision, treatments—a recommendation for people who are aff ected by long covid feeling which may make logical sense to people who GET/CBT has been removed, saying aggrieved and disempowered. have never experienced the condition but will that the evidence is mixed or unclear. Several research papers describe be totally inappropriate to those aff ected. Meanwhile, long covid researchers abnormalities confi rming pathophysiological Ultimately, toppling endemic power are also learning to live with the damage ranging from abnormal blood tests imbalances in medicine requires the input of increased level of scrutiny and to organ damage seen on MRI imaging or in people who have experienced the cognitive complaints that teams working on postmortem fi ndings. These publications dissonance of confronting personal and CFS/ME have come to expect. run counter to the tendency among many healthcare structural biases, so that those Gordon McGregor, a clinical doctors to put long covid symptoms down providing healthcare fully comprehend the exercise physiologist, is leading the to anxiety or to attribute other psychological lived realities of the individuals they seek to University of Warwick’s Regain trial, a labels, which then allows them to avoid serve. This is work that cannot be avoided. National Institute for Health Research investigating symptoms to look for organic CA Chew-Graham , GP and professor of general practice funded study on whether physical pathology.Organic disease processes are research activity with psychological support clearly at work. This has been recognised by AU Lokugamage, consultant obstetrician and benefi ts long covid patients who were recent interim guidance from the US Centers gynaecologist and honorary associate professor, admitted to hospital. He told The BMJ for Disease Control on managing people with University College London and Whittington Hospital that he had engaged with a number long covid. NHS Trust, London of CFS/ME patient and advocacy We don’t deny that all symptoms will have FK Simpson, founding member of Long Covid Kids and groups. “We had constructive a psychological impact on the individual, and LongCovidSOS and lecturer in psychology, Coventry University conversations and made a number of we would not wish psychological impacts to amendments to the trial protocol as a be stigmatised or ignored, but organic illness result,” he says. “We will be screening must be investigated and should be excluded participants regularly for PEM [post- only aft er appropriate investigation. People exertional malaise].” with long covid describe feeling “gaslighted” However, some individuals who because the opinions of a few have tended believe that physical activity should to dominate the evolution of treatment, be avoided at all costs remain deeply investigation, and a growing knowledge base. unhappy and have emailed McGregor, We believe this is a form of “structural colleagues, and funders with iatrogenesis,” where patients are harmed by their views. “The impact has been power imbalances in the bureaucratic and tangible,” he says, “but the research cultural systems within medicine. Narratives is continuing.” on social media reveal research produced by Melanie Newman, journalist , London patients themselves has encountered more [email protected] obstacles to publication, with journals claiming Cite this as: BMJ 2021;373:n1559 that it comes from the “wrong sort of expert.” the bmj | 26 June 2021 477 FEATURE Vaccine outreach: “local knowledge, contacts, and credibility really matter”

Emma Wilkinson looks at initiatives to tackle poorer vaccination uptake for underserved groups

n East Sussex the rates of those who he says. Sometimes it can be small things, have had their fi rst and second doses such as organising transport, that get people of covid-19 vaccine are 80% and 65%, over the line, he adds. respectively. Conversely, in Newham in Gulnaz Hussain is chief executive of the I east London the rates are 44% and 26%, Firvale Community Hub, a Sheffi eld charity according to the government dashboard. working to improve social equality. The areas Given the higher transmissibility of the it covers are some of the city’s most deprived delta variant and lower vaccine uptake and were hit hard by covid—yet people often among those most vulnerable to covid, this weren’t accessing public health information. disparity is worrying, says Farzana Hussain, a “We’ve done a lot of work around

GP in Newham. ROUSSEAU/PA/ALAMY STEFAN vaccination. We had a health coordinator who Early on she noticed that only about half We had to debunk myths around was making sure the messages were getting of her patients aged over 65 were coming [the vaccine] containing animal out. We also opened a vaccine helpline that forward for vaccination and so she started to products Farzana Hussain is available in community languages. As we call them one by one. “I wanted to ask if they move to younger age groups, we’re doing had any questions and I found there was a lot Medical Association, says it boils down work with youth centres and youth clubs.” of misinformation. The overarching concern to a matter of trust and helping people to back then was about safety and we had to navigate the contradictory advice they’ve Every opportunity debunk myths around it containing animal been hearing. “We’ve been trying to recognise Hussain says they use every opportunity to products,” she said. “Looking at my practice that we’re not operating in a vacuum and we provide information, often when people are levels we now have around 80% of the over have to validate concerns around inequality seeking advice on welfare or immigration. 65s vaccinated. It’s the rate of younger people and inequity. But there was also targeted “We’re able to convince them and we can with long term conditions that’s not as high, disinformation about things like whether speak to other family members who might although we’re still above average.” the vaccine is halal or whether the vaccines be saying not to get the vaccine.” The hub The concerns have changed over time, she contained aborted fetal cells.” ran a successful vaccine clinic for the Roma adds. “Younger people are more worried about He believes a local response is key but says community and has plans for others. fertility. As we move down the cohorts, it’s it is resource intensive. As time has passed Ade Williams, a community pharmacist more ‘why should I have it, I’m not at risk.’” it’s not so much the fringe views people are in Bristol, has worked across social media airing but legitimate concerns about safety, and in person to dispel vaccine myths. He Keeping it local eff ectiveness, and side eff ects. “We’re not has spoken to faith groups and the Traveller Reports from community level suggest that going to undo decades, if not centuries, of community, and most recently been involved vaccine confi dence among ethnic minorities inequalities in 18 months,” he adds. “There’s in eff orts to promote the vaccine through pubs is improving. The national picture, however, a lot of institutional memory about being used and hairdressers. Uptake in the city is just suggests that more work needs to be done. and abused, for want of a better phrase.” under 60%, with 40% having had two doses. Samia Latif, consultant in communicable In Sheffi eld, the city council and clinical Williams runs a vaccination site in a church disease control and chair of Public Health commissioning group have invested and from day one has encouraged people to England’s Black and Minority Ethnic Network, £300 000 in more than 30 community groups. pop in, take a look, and ask questions. “Some says that in December a consortium of more There have been pop-up clinics in mosques, people have anxiety about vaccination itself than 40 ethnic minority health networks hostels, and a supermarket, and a vaccine so that helps,” he says. “Sometimes people worked to identify the concerns in their bus which has travelled to areas of high are struggling to navigate the booking system. communities and share good practice. “Covid deprivation. Sheffi eld has about 66% uptake “Everyone has questions about safety and made everyone realise that you can’t leave of a fi rst dose but it remains low among some fertility,” he adds. “I’ve also had to reassure anyone behind. We knew we needed to talk communities including black African and people they will not be compelled to have it, to these communities and understand their African Caribbean populations. our system will always give you a choice.” concerns but also they needed to trust the The investment in community groups has He says it’s important not to get frustrated person the message is coming from,” she says, led to “incredible message delivery about but to have compassion for populations where stressing these are not “hard to reach” groups eff ectiveness and safety in ways that are far health inequalities have never been tackled. but historically underserved populations. more nuanced,” says Greg Fell, the city’s Emma Wilkinson, freelance journalist, Sheffield Salman Waqar, a GP who has worked on director of public health. “Local knowledge, [email protected] vaccine initiatives with the British Islamic contacts, and credibility really, really matter,” Cite this as: BMJ 2021;373:n1547

478 26 June 2021 | the bmj