According to a release in the British Medical Journal (BMJ), the BMA’s review into the UK’s management of the pandemic found that the government failed in its duty of care to protect doctors and other healthcare staff from avoidable harm.
On May 19, the BMA published the first two reports of its five-part review into the lessons learnt from the COVID-19 pandemic, which will inform its submission to the upcoming public inquiry.
The reports lay bare doctors’ often traumatic experience, with stark personal testimonies and data collected through real time surveys revealing an “exhausted” profession that was let down, left underprotected, and in need of more support to meet unrelenting service pressures.
Ministers must make doctors’ wellbeing a “critical priority” while learning lessons from the “devastating” harms and policy mistakes, the BMA said.
The UK was forewarned of the coronavirus as early as December 2019, and by February 2020 Italy’s deadly toll had dramatically signaled what the UK could face.
But the BMA said that the UK was underprepared and had failed to learn key lessons from previous pandemic preparedness exercises, including the need to maintain stockpiles of personal protective equipment. Chronic underfunding of the NHS and public health had left the UK “brutally exposed,” with “too few staff, too few beds, and buildings that were unsuitable for full implementation of recommended infection control policies,” it said.
In the future, maintaining continuous and transparent assessments of workforce shortages and future staffing requirements “is the only way to ensure that governments take accountability for providing safe staffing levels and adequate funds and resources to health services so they can deliver safe patient care at all times,” the BMA said.
Many healthcare staff were left unprotected because of critical shortages of personal protective equipment and became infected at a higher rate than the rest of the population. An “alarmingly high” 81% of respondents said they believed they were only partly or not at all protected during the first wave.
Basic PPE such as masks, eye visors, and gowns were not available routinely. Staff dealing with patients often had to go without PPE, reuse single use items, or use homemade or donated items.
“We made our own and bought our own when we could find any—we depended on friends sourcing FFP3 masks, my son’s school 3D printing visors,” one SAS doctor said.
Many doctors reported being pressured to work without adequate protection, while some felt unable to challenge management on the issue. Women struggled to find well-fitting masks, as they were largely manufactured to suit white male faces and physiques.
The situation improved after the first wave, but for much of the pandemic staff were inadequately protected, the BMA said.
Infection prevention and control guidance
Infection prevention and control (IPC) was inadequate, while IPC guidance was “poorly communicated and difficult to implement,” the BMA concluded.
Doctors told the inquiry that updated guidance was slow to be issued and that, when it was, it was contradictory and spread across different documents. “This led to inconsistencies in the level of protection afforded to different kinds of medical professionals,” the report said.
One consultant said, “Some colleagues started wearing fluid resistant masks early in March, only to be threatened by management with disciplinary action due to scaremongering the rest of the department.”
The BMA heard that the government drastically overestimated the UK’s capacity to test at the pace and scale needed as SARS-CoV-2 began circulating widely in the community.
Ministers abandoned contact tracing early in the pandemic and later had to set up NHS Test and Trace at major cost to the taxpayer.
Medical professionals said they were unable to test incoming patients, which made determining covid-19 positive patients difficult and meant that doctors often came into contact with patients who had tested positive without the recommended PPE. This, in turn—given the shortage of tests available for medical professionals in the early stages—may have meant that they unwittingly transmitted the virus to their patients and colleagues. “This lack of testing capacity was undoubtedly a significant factor in the high levels of nosocomial spread we saw during the first wave of the pandemic,” the BMA said.
Risk assessment and inequalities
Two thirds (64%) of the respondents surveyed by the BMA said that by May 2020 they had not been risk assessed for contact with SARS-CoV-2. Some 48% of respondents from an ethnic minority group and 35% of their white colleagues said that risk assessments had been mostly or completely ineffective.
Doctors with a disability or long-term condition said they felt less protected than other groups, with some being told that they were not allowed to work remotely. Some disabled doctors were “made to feel like a burden” to the NHS and were not always adequately supported. Clinically extremely vulnerable staff were in a particularly “unenviable position” and some doctors were not supported by their place of work, the BMA said. “I have received pressure from my line manager to return to environment verging on harassment,” a public health consultant in this group said.
Deaths among staff
During the first wave hundreds of healthcare workers and more than 50 doctors died after becoming infected, as medical professionals were “too often left unprotected and exposed, suggesting these deaths were not inevitable,” the BMA said.
Nearly all (95%) of the doctors who died in April 2020 were from ethnic minority groups (which make up 44% of NHS medical staff), indicating deep race inequalities in the NHS workforce. “We are calling for the experiences of ethnic minority doctors to be examined closely by the public inquiries into COVID-19,” said the BMA.
It added that there might have been fewer deaths among patients and doctors if services had been better staffed when the pandemic began. Staff may have felt pressured to work even when unwell, because of understaffing of services, this sense of responsibility may have led them to inadvertently spread the virus further.
A significant minority of respondents who had COVID-19 said that they were now dealing with severe ongoing symptoms and needed extensive support. One junior doctor said, “I caught COVID-19 in March 2020 from a colleague at work. I have been mostly bedbound since. My life as I knew it had ended. These are supposed to be the best years of my life, but I’m spending them alone, in bed, feeling like I’m dying almost all the time.”
Around 11% of respondents who had developed long covid 19 were at some point unable to work full time or at all, while 51% reported that, though they were still able to work, their quality of life was affected. The BMA said, “Had we been better able to protect staff we may have seen fewer long term absences due to long covid and consequently, less capacity lost to health services.”
Medical work during the pandemic caused physical harm beyond covid-19 infection.
The BMA’s chair of council, Chaand Nagpaul, said, “Alongside the acute mental and emotional trauma, physical exhaustion, and the toil of long hours in full PPE, lack of rest and higher workloads have been relentless.” Nearly 60% of respondents in April 2021 said their level of fatigue or exhaustion during the pandemic was higher than normal.
The BMA said that high levels of staff burnout and stress were a threat to healthcare in a chronically understaffed service. “The medical profession is exhausted and needs to be supported. If this does not happen, we risk more doctors leaving, which is a threat to patient safety we cannot afford,” it said. “Health services in the UK need good occupational health systems that can act quickly to protect staff both during and outside health emergencies.”
Mental health and emotional wellbeing
In addition to burnout and overwork, many doctors experienced difficulties because of grief and trauma. “Doctors saw levels of illness and death they were never trained for,” said Nagpaul. “Psychologically it was one of the worst periods of my life,” one SAS doctor said. “I received private therapy throughout the pandemic and that helped tremendously but I have felt suicidal at times.”
Another doctor described being “horrified” at having to care for friends and colleagues in the intensive treatment unit.
Calls to the BMA’s counselling service rose by more than a third (37%) in the first year of the pandemic, and several survey respondents said they had left or would soon be leaving the profession. A reported decline in good mental health was more common among female (56%) than in male respondents (46%) and more common among those with a disability or long term condition (69%) than those without (48%). Psychological support services must be made available to “staff at all levels,” the BMA said.
Anxiety and moral injury
More than half (53%) of doctors said that insufficient staffing to treat all patients suitably was one of the leading causes of their moral distress, followed by individual mental fatigue (41%).
“I have seen some difficult things in the past few years. I have made some decisions that I would not have had to make in pre-pandemic times. These have all caused me significant moral injury,” said a salaried GP in Scotland.
Another doctor said, “I have flashbacks to wheeling patients to an overfull morgue and denying relatives entry to the emergency department during the first wave as their relatives were dying.”
The impact on the mental health of staff worsened as the pandemic progressed. From February 2021 to January 2022 the BMA’s counselling service received 173% more calls than in February 2019 to January 2020.
Many doctors reported anxiety or depression. In some cases, anxiety was exacerbated by worries about mistakes and liability, for example, if they were working remotely or in an unfamiliar area without adequate training.
Given the social distancing restrictions designed to contain the virus, isolation often compounded doctors’ mental and emotional suffering. “I went home and cried a lot. I was away from my family as I didn’t want to put them at risk. I lost my personal support network, and there was no support at all from work,” said a locum junior doctor in England.
Lack of support
The BMA said the government had failed to express support for doctors, contributing to perceptions among the public and media that doctors were not seeing patients when needed. This was damaging and “cannot be ignored in the face of reported instances of abuse rising from 10% in August 2020 to 48% barely a year later,” it said.
At best, medical professionals were “unhelpfully branded as heroes and heroines,” capable of withstanding any pressure, as opposed to “fallible human beings doing their best in the circumstances.”
Disabled doctors said they wanted to see an end to the perception that doctors are superhuman and capable of working relentlessly whatever the circumstances.
The BMA urged the government to examine the extent to which the system was able to financially support staff who had any short- or long-term health effects.
Research shows that 40% of doctors in training were unable to gain enough experience in non-urgent and scheduled care to fulfil the competencies required for progression in their career, and nearly 30% said the same about urgent and unscheduled care. “Until these competencies are met, doctors cannot and will not be able to progress at the usual speed,” said the BMA.
The vaccination campaign and rollout are regarded as one of the few successes of the response to the pandemic, benefiting staff and patients and generating professional pride.
Morale improved at the outset of the crisis, the BMA said, though it has waned since. In May 2020 65% of respondents agreed that there was a greater sense of team working, 45% agreed they felt more valued as a doctor, and 47% agreed they felt less burdened by bureaucracy. For some doctors, such as those with a disability or long-term condition, remote working (where it had been facilitated by an employer) has been “hugely beneficial.”