commentcomment “Language frames the way we see people. Getting it wrong can cause hurt” DAVID OLIVER “Medical unity is beginning to fracture, and resentment is growing” HELEN SALISBURY PLUS Consent during a pandemic; safely easing shielding THE BOTTOM LINE Partha Kar The NHS needs a Seacole statute had to read through the email a few times to or nudging has achieved little. The 2019 Workforce digest what a consultant had written to me. Race Equality Standard showed that white applicants “Confl ating covid with institutional racism were still “1.46 times more likely to be appointed among your friends and colleagues is utterly from shortlisting compared to BME applicants.” Ishameful,” it said. “Nobody knows the Another big step would be to ditch terms genetics of covid, but you see fi t to suggest that its such as BAME, which turn discrimination into a predilection for BAME [black and minority ethnic simplistic discussion about white and non-white people] is down to racism. Your views nauseate me— communities. The issues infl uencing attainment there is no room for them in today’s NHS.” and socioeconomic deprivation are fundamentally This was a response to my May BMJ column, in diff erent for someone who is black than for someone which I discussed whether racism was a factor in from India, Bangladesh, or China. the increased mortality from covid-19 among ethnic There’s no better moment to shift the dial from minorities. Subsequently, further investigations and conversations and cajoling to clearer data collection, a report from Public Health England have established open access to data based on area and authority, and that racism and discrimination may have contributed a commitment to a concept similar to the Rooney rule. to the increased risk. Yet, for this consultant, it was The “Seacole statute” has a ring to it, and it would be hurtful to even suggest racism in the NHS. a way to pay homage to a titan and pioneer in the fi ght It made me refl ect on a wider problem—and an for equality in healthcare. It’s worth thinking about . analogy with sexism. Many men responded indignantly Partha Kar, consultant in diabetes and endocrinology, to the MeToo movement. They missed the point Portsmouth Hospitals NHS Trust that it wasn’t about them. It was about listening and [email protected] refl ecting that there may be many colleagues whose Twitter @parthaskar views you’d not picked up on, not acted on, or ignored. Cite this as: BMJ 2020;369:m2583 It was about being vocal against the issue when observed and trying to bring an end to such a culture. Racism in the NHS isn’t much diff erent. You may not At an individual be racist, but to be indignant at the notion of the NHS level, it’s time having a race bias may simply refl ect your ignorance to be antiracist, or the bubble you inhabit. However, this sort of to speak up ignorance propagates the problem. When people see and be allies something that jars, they may remain silent or try to explain it away with “scientifi c” reasoning: cue the debate about vitamin D as the sole reason for greater mortality in the BAME population. If you can’t even accept that racism could be a problem in the amazing NHS, why try to solve it? At an individual level, it’s time to be antiracist, to speak up and be allies. At a policy level, it’s time for the NHS to start affi rmative action—something like the Rooney rule, a US National Football League policy requiring teams to interview ethnic minority candidates for senior roles. So far in the NHS, cajoling the bmj | 4 July 2020 21 PERSONAL VIEW Daniel Sokol , Rupen Dattani How should surgeons get consent in the pandemic? Now hospitals are resuming elective surgery, what should patients be told about about the perioperative risks of covid-19? he 70 year old patient has been pandemic, to our knowledge no formal Failure of surgeons to raise the risks waiting months for his elective guidance has been published by the GMC or of covid-19 during the consent process surgery. A few days before the the Royal College of Surgeons on obtaining is ethically and legally troubling operation, he has a swab test consent in such circumstances. T to detect any active covid-19 Following the case of Montgomery v older), and type of surgery (higher for major infection. It’s negative. Before the operation, Lanarkshire Health Board (2015) UKSC 11, surgery and emergency operations). the surgeon reminds him about the risks doctors must take reasonable care to ensure Although limited to a single study at an and benefi ts of the procedure, as well as the patients are aware of any material risks earlier point in the pandemic, these are reasonable alternatives. The patient agrees involved in the recommended treatment and worrying fi gures. We believe a reasonable and signs the consent form. any reasonable alternatives. A material risk person about to undergo elective surgery would The operation, performed under general is one to which a reasonable person in the attach signifi cance to the risk of complications anaesthetic, is uneventful but postoperatively patient’s position would be likely to attach and serious harm from covid-19. the patient develops severe respiratory signifi cance, or a risk that a doctor knows—or Given that a minuscule risk of death by complications that require admission to the should reasonably know—this particular anaesthetic is commonly shared with patients, intensive care unit. Retesting reveals covid-19. patient would probably consider signifi cant. we argue that patients who undergo elective The patient, who has sustained serious harm surgery should be told that, despite measures from the complications, sues the trust for Pulmonary complications to limit the risk of infection, there remains failure to obtain valid consent. He claims the An international cohort study in the Lancet a risk of contracting covid-19 in hospital, surgeon should have discussed risks related analysed the outcomes of 1128 patients whether before, during, or after the operation. to covid-19 and that, had he known, he would who had surgery between 1 January and 31 The surgeon should explain that, if the risk have waited until the pandemic had passed. March. Some 74% had emergency surgery eventuates, the impact on the patient’s health Many surgeons are now resuming elective and about 25% elective. Covid-19 infection is currently unknown but could at worst lead work, yet we are aware some make no was confi rmed preoperatively in about 26% of to complications that require intensive care mention of the additional risks related to patients. The study showed a 30 day mortality admission and, in a minority of cases, death. covid-19. Although the British Association of of nearly 24%, with pulmonary complications Along with a verbal explanation, we Spine Surgeons and some private hospitals occurring in 51% of all patients. The mortality recommend “covid-19 related complications” have produced information sheets for was associated with various factors, including is expressly stated as a risk to any surgery on patients undergoing surgery during the sex (higher for males), age (higher for 70 and the consent form. This practice should aff ord BMJ OPINION Helen Iliff, Ilora Finlay The threat to those most clinically vulnerable People generally want to be How can shielding was communicated from the beginning of considerate, but they need prompts be safely lowered as the covid-19 pandemic. On 16 March, the government advised those deemed to be homes, but also how to maintain the 2 m lockdown is eased? at increased risk to follow stringent social distancing that decreases risk. If shielding no distancing measures. A subset, believed to longer applies, support may diminish, just have the highest risk of mortality and severe as the general public relax infection control morbidity, were identified and sent a letter measures, further heightening their concerns asking them to “shield” for at least 12 weeks. of contracting covid-19 in the community. The government has now relaxed this Those returning to frontline healthcare guidance, but those who have been shielding have particular worries; data from the Office fear support will vanish, leaving them at for National Statistics show the risk of heightened risk in a second peak. acquiring covid-19 in hospital is between four Guidance recommends those who were and six times that in the community. Without shielding maintain social distancing, but herd immunity or a vaccine there is no easy those people may be less familiar with the answer. Clinicians urgently need enough high new etiquette, such as one way systems, protection PPE, preferably recyclable, to allow that has become embedded into normality. vulnerable staff to lower their shields while Their anxiety is not just around leaving their helping them to feel safe. 22 4 July 2020 | the bmj ACUTE PERSPECTIVE David Oliver Caring about language is not frivolous n February, the Daily Telegraph ’s “alcoholism.” The guide also urged us not Celia Walden used her column to to say “bed blocker” or “bed blocking” mock the Royal College of Nursing’s to describe patients stranded in hospital (RCN) style guide on the correct through no fault of their own. terminology and formats to use in I think that the RCN is right on this. Most I the surgeon a degree of legal protection. This nursing communications. NHS staff are women, especially in nursing. should continue until the pandemic recedes The piece was ostensibly light hearted, its “Older people” have said that they prefer and the risk becomes so negligible that no tone gently ribbing what Walden saw as the that term.