We’re barely out of summer and it’s busier in Den Langhor’s emergency department than the worst winter peak she has ever experienced.

It’s bad enough with rising COVID cases, an alarming RSV (respiratory syncytial virus) and long-untreated conditions turning into emergencies.

But now increasing numbers of patients are discarding their face coverings or treating them as a civil liberties issue.

In Dr Langhor’s department in north-west England, there are frequent Tannoy announcements that face coverings are still mandatory throughout the hospital.

Yet, she regularly has to remind people about the rules. ‘Most people put their masks on when they walk through the door, but some remove their masks in the waiting room,’ says Dr Langhor, consultant in emergency medicine.

‘The majority are compliant when you point out the rules, but I do find it incredibly frustrating when people are not taking the correct precautions to keep those around them safe. ‘I work with patients from zero to over 100 and I work with clinically vulnerable people every single day.

'They might have the option to avoid going to bars, restaurants, and supermarkets but they do not have a choice about whether or not to attend a healthcare facility if they’re unwell. We owe them respect and care.’

At the time of writing, it remains a legal requirement for people to wear a face covering in healthcare settings – and other indoor public spaces – in Scotland and Wales, unless they have an exemption.

In England and Northern Ireland, face masks are still mandatory in healthcare settings – but that rule is not legally enforceable.

Here, as restrictions have eased and face coverings have become a matter of personal choice in other public spaces, the messaging has become muddied.

And since ‘Freedom Day’ on 19 July, some patients have become more assertive. Doctors in Northern Ireland have reported rising numbers of patients refusing to wear face coverings and to have a COVID test in hospital before assessment or admission.

A number of GP practices have told the BMA they are being threatened with legal action under the Equalities Act for asking patients to wear a face covering.

Dr Langhor believes the absence of clear messaging on the guidelines in England is making matters worse – especially as misinformation is still vocal and rife.

‘Patients are hearing messaging that the previous COVID regulations have now been cancelled. They’re not reading the small print and the Government has not made any reasonable attempt to publicise the fact that, within healthcare facilities, the rules have to be different.

‘Meanwhile, we’re seeing people who don’t believe us when we tell them they’ve got COVID because “COVID’s not real” – even when they have breathing difficulties. All the misinformation, mostly on social media, has unfortunately contributed to the way people behave.’

By contrast, strong statements on face coverings in Scotland have spared healthcare workers this tussle. First minister Nicola Sturgeon has explicitly linked them to the need to avoid ‘shielding by default’ for the most clinically vulnerable.

Jon Carter is an emergency medicine consultant in south-east Scotland where patients have largely been compliant, even if they have to be handed a mask at the door.

‘I don’t know if it’s because we are a smaller country and have a different sense of identity, or if it’s just easier for Nicola Sturgeon to access the Scottish public with her tweets and broadcasts,’ says Dr Carter.

‘But I do think the Scottish Government has been clear in explaining the rules with their broadcasts.’

Some hospitals in England have anticipated confusion and headed it off early.

At David Strain’s hospital in the south-west, where he is clinical lead on COVID services, they acted fast to keep control of messaging around face coverings.

New artwork explaining masks are still mandatory to protect the most vulnerable is displayed on every TV screen in the hospital and on banners at the entrance where volunteers hand out fluid-resistant surgical masks.

‘On the day that it was announced that face masks were being dropped in most public spaces, we had that conversation with our management team,’ says Dr Strain.

‘It had to be new artwork – not just the same “Hands, face, space” – in case people thought it had just been left up there. The artwork was on every single screen in the hospital by that evening. And, because it’s seen as the norm, we’ve not had any problems at all with people saying no.’

Dr Strain is in no doubt about the continuing need for masks as rising COVID cases in his area converge with winter pressures such as flu.

‘Vaccination is preventing people from dying, for the most part, but it’s not stopping transmission as much as we originally hoped, so masks are a good way of keeping infection levels down,’ says Dr Strain.

‘I hope mask-wearing and some degree of physical distancing this winter will be enough to stop us ending up in another lockdown.’

NHS England gave GPs the option of denying face-to-face treatment to patients who refuse to wear a face covering in a directive in August 2020.

Many doctors would baulk at such a draconian step. But, to deny themselves this option leaves them shouldering all the risk and the responsibility for protecting others.

BELL: ‘If someone without a mask infects me, I could infect the whole workforce’

So, if a patient with suspected COVID refuses to wear a mask, they are treated as if they have the virus.

Dr Langhor’s hospital has six negative-pressure isolation rooms where they could be seen by staff wearing FFP3 masks – but not every facility has this option.

For GP Alice Bell, things were much easier before when the law was clear and staff in her London practice could insist on mask-wearing.

Now, despite clear signage in reception in English and Turkish about face coverings being mandatory, patients are increasingly coming into the surgery without one.

Staff in reception have a supply of masks and ask visitors to wear one, and the majority of patients do. But ambiguity around the rules in patients’ minds exposes the doctors to moral dilemmas, as well as physical risk.

Despite unprecedented workloads, GPs are still facing unfair criticism in the media and, for Dr Bell, the need to build bridges with patients can sometimes take precedence – even at the cost of her own discomfort.

‘If a patient is struggling with mental health problems, which unfortunately is more rife than ever, and starts to cry during the consultation, it is very difficult to enforce that they wear a mask whilst they’re crying. GP surgeries are meant to be familiar, safe spaces.

‘I feel in a very difficult position ethically because of my duty of care to the patient in front of me, and the need to build rapport so we can communicate well. But, equally, I have a duty of care to everyone else in the surgery, and if someone without a mask infects me, I could infect the whole workforce.’

Dr Bell still wears a mask in public even when it’s optional.

‘Wearing face coverings in healthcare settings is a constant reminder that this pandemic is still ongoing, even if people can behave more normally outside,’ she says.

Few doctors seeing COVID patients, in fact, can afford themselves the luxury of ‘living normally’ outside the workplace just yet.

‘At the very start of COVID, even before the first lockdown, I cut myself off from society,’ says Dr Langhor. ‘I stopped going to the gym, to the supermarket and all public places: I didn’t visit my family, I didn’t visit friends. Because all I could think was, I could be carrying COVID, I could pass it to someone and they might die. I don’t think that worry is going to go away.’