COVID-19: refusing to treat where PPE is inadequate

This guidance sets out the process for doctors to follow to identify whether your PPE is adequate and what you can do if it is not.

Location: UK
Audience: All doctors
Updated: Friday 3 July 2020
COVID emergency support

If you need emergency support on COVID-related issues out of normal opening hours, you can call us 24/7 on 0300 123 1233.

A lack of PPE puts both doctors and patients at risk of contracting a potentially fatal infection. It also presents doctors with challenging decisions about whether to provide treatment in the absence of effective PPE.

The BMA has raised serious concerns regarding the further amendment to PHE guidelines undertaken on 17 April. We continue to press the government to resolve this dire situation.

This guidance sets out the process to follow to identify whether your PPE is adequate and the steps you can take if it is not.

BMA advisers and local representatives are here to support you at each stage of the process set out below – please contact us for further help and guidance.

You should not face a disciplinary process or detriment if you are confronted with serious and imminent danger in your workplace. We will robustly defend your employment rights to ensure your protection.

We recognise that you may be facing a situation where you have to make an urgent decision. Where possible, you should get in touch with us first. 

Remember: there are limits to the risks you can be expected to expose yourself to. You are under no obligation to provide high-risk services without appropriate safety and protection. You can refuse to treat patients if your PPE is inadequate, you are at high risk of infection and there is no other way of delivering the care.

The law also requires you and your employer to protect your safety and the safety of others. Employers must provide a safe system of work, which includes provision of appropriate PPE. If you have the employment status of 'employee' you are also specifically protected under employment law to take steps to avoid serious and imminent danger in your workplace without fear of detriment or dismissal.

 

I am concerned my PPE is inadequate. What should I do?

Circumstances differ and you may need to make a decision urgently.

Where time permits and where appropriate to your situation, the BMA recommends you consider the following steps:

  1. identify the level of PPE you need
  2. raise your concerns with your manager or practice partner
  3. ask your organisation to take action
  4. risk assess using your professional judgement
  5. decide whether to proceed with the PPE offered or refuse to treat.

You may not have time to go through the steps recommended above or they may not all be suitable in your particular circumstances.

Ultimately, and in all situations, you should exercise your professional judgement in deciding whether to proceed to treat or to refuse, having considered all reasonable methods of managing and mitigating risk, taking into account your individual situation and circumstances.

Identify the level of PPE you need

First, identify whether you have appropriate PPE for the setting in which you are working. See our guidance – what PPE should I expect to have for different clinical settings?

Raise with your manager or practice partner

Where you reasonably believe that your protective equipment is inadequate for the setting you are in, you need to raise this urgently with your managers or practice partners and press for adequate PPE before you undertake treatment. Employers and contracting bodies are under an obligation to provide you with appropriate PPE.

Ask your organisation to take action

In England

If your manager cannot assist, you should normally escalate to the clinical lead, medical director or another senior clinician. In a GP practice you should escalate this to your CCG. Depending on the circumstances, it may be appropriate to ask them to urgently contact the National Supply Disruption Line to obtain the identified PPE. They can do this where there is a clinical emergency. This is defined as where care has to stop or change due to supply of PPE.

Our advisers can help you make the request, which can be done by email or even text. You should explain the details of your situation and that in your professional judgement it is unsafe.

Management should be asked to:

  • urgently contact the NSDL specifying a time frame for doing this
  • let you know when the NSDL respond, how much PPE will be available and by when
  • say that if PPE supplies are not provided, you will be considering whether you face a situation of serious and imminent danger and whether to take action to protect yourself.

In Scotland

Scottish Government have introduced new measures to improve the distribution of PPE, including a single point of contact for all health boards to manage local PPE supply and distribution. In the event of shortfall you should write to your manager and ask then to make urgent contact with the single point of contact to organise re-supply.

The Scottish Government also has a dedicated email address for staff, MSPs or members of the public to raise specific supply issues. It will be monitored continuously and allow them to act to resolve any specific supply issues more quickly.

In Northern Ireland

You can report PPE concerns to [email protected]. The email account will be monitored and the anonymity of staff who report to it will be protected.

If offered alternatives or where PPE is being reused (England only)

Where there are shortages, trusts are required to have an agreed action plan to support the implementation of guidance published on 17 April. This covers the reuse of PPE and alternatives to fluid resistant gowns in high risk areas.

The BMA considers that the agreed action plan should be publicly and immediately accessible to all doctors, eg on an intranet. Please contact your LNC chair or BMA IRO (industrial relations officer) if you do not have access to the plan.

You should read the trust’s plan. Measures being put in place, for example access to showers in or near doffing areas or removal of spent PPE to avoid reuse, will be key to informing your risk assessment.

In all situations, risk assess using your professional judgement

If you believe adequate PPE is still not being provided, or you are not satisfied with your organisation’s or CCG's plan to support reuse and/or alternative PPE, you need to consider your own safety and that of your patients.

The GMC does not expect you to provide care without regard to your safety and that of others.

Read the complete GMC guidance

In the absence of appropriate PPE, the factors to take into consideration when making decisions about whether to treat include:

  • whether the treatment can be delayed or provided differently, such as remotely
  • whether additional steps can be taken to minimise the risk of transmission
  • whether you are at higher risk from infection than others (for example, if you have a health condition or other vulnerability that puts you more at risk)
  • what course of action will give rise to the least harm in the circumstances.

The BMA’s view is that GMC guidance does not prevent a doctor from refusing to treat patients if their PPE is inadequate, they are at high risk of infection and there is no other way of delivering the care.

Protect yourself

If you have exhausted all reasonable methods to manage and mitigate risk, taking into account your circumstances and situation, but you still do not have appropriate PPE to nationally recognised standards for the setting you are in, you do not have to undertake patient treatment until this is resolved.

Wherever time permits, contact the BMA before making your decision.

In some cases, you may also decline to undertake patient treatment if your personal circumstances (including your health condition, disability or other special circumstances) even where the PPE offered is in line with recognised standards but is not adequate for you.

Keep a record

If you do decide not to treat you should keep a record of your decisions, the reasons behind them and how you sought to manage safety concerns. You should also use local incident reporting procedures.

Contact us

We appreciate that refusing to treat patients is not an easy decision. The BMA is here to support you at every stage of this process.

You should not face a disciplinary process or detriment if you are confronted with serious and imminent danger in your workplace. We will robustly defend your employment rights to ensure your protection.

We would also recommend that you alert your defence organisation.

 

If I refuse to provide treatment due to inadequate PPE, how might the GMC respond if a complaint is made?

To reassure the profession, the GMC has stated that doctors are not going to be held unfairly to account for difficult decisions made in challenging circumstances. Through a joint statement from the statutory regulators of health and care professionals, it advises:

‘We recognise that the individuals on our registers may feel anxious about how context is taken into account when concerns are raised about their decisions and actions in very challenging circumstances. Where a concern is raised about a registered professional, it will always be considered on the specific facts of the case, taking into account the factors relevant to the environment in which the professional is working. We would also take account of any relevant information about resource, guidelines or protocols in place at the time.’

Any concerns that are raised with the GMC will continue to be judged against the overarching guidance set out in GMP (Good Medical Practice), which provides a framework for ethical decision making in a wide range of situations. Doctors should continue to follow this guidance as far as is practical in the circumstances.

Notwithstanding the above if you have concerns in relation to a potential GMC referral you should contact your defence organisation for advice.

 

Can I speak out on PPE issues?

The BMA’ s view is that it is vital that healthcare workers are able to raise concerns about their safety and patients’ safety without fear of reprimands or even disciplinary action.

If doctors are being asked to work without adequate PPE then this is putting their health, their lives and patient lives at risk. It is the duty of those healthcare workers and their colleagues to insist on such matters being addressed.

Healthcare workers should generally raise their concerns with their employer first and speaking to the media should be a last resort. Raising such concerns may amount to whistleblowing.

BMA guidance on raising concerns states 'You have a professional duty, under Good Medical Practice (paragraph 25), to raise concerns about anything that impacts patient safety or could impact patient safety.” Whistleblowing protections only apply to disclosures to the press in limited circumstances so advice should be sought first.

BMA members should be assured that they will be supported in challenging attempts by employers to prevent them from speaking out about PPE issues in their workplace.

Need help? For 24/7 emergency COVID advice please call us. For all other non-emergency enquiries normal opening times apply.
Sign up for COVID-19 updates from the BMA

Enter your details and you will receive emails informing you about:

  • COVID-19 guidance
  • News and blogs about COVID-19
  • Information on BMA support
  • Updates on your working situation during the pandemic

You can unsubscribe to these emails at any time.

Sign up for email updates