‘I have no confidence in the preparations the NHS is making. Mortality among medical staff looking after COVID-19 patients is high. What support do we have? A quick fit test and off you go. I don’t recall signing up to a game of Russian roulette.’
This was the warning, blunt but clear, posted in mid-March, to a BMA online portal – a week before the UK locked down to stem the spread of the deadly virus.
‘I have been asking for PPE [personal protective equipment] for the last six weeks,’ said a GP, again, weeks before lockdown. ‘I’m very worried about getting COVID-19 and passing it on to my son who has asthma,’ said another. ‘The lack of clarity about PPE is alarming.’
Yet more than a month after lockdown began, despite these and repeated, similarly clear calls for proper protection, reports of shortages continue to flood in.
The BMA snapshot survey at the end of April found a third of doctors working in high-risk areas had experienced shortages or no supply at all of surgical scrubs and long-sleeved disposable gowns.
One in five reported shortages of the FFP3 (filtering facepiece 3) masks worn in areas where AGP (aerosol-generating procedures) are carried out.
Another alarming finding was that one in three respondents had often or sometimes felt pressured to see patients in AGP areas without adequate protection.
‘The PPE situation is an outrage for all staff. Lives lost for want of visors, masks, and eye protection,’ one respondent said. ‘Senior management team have tried to shut me up when I raised serious concerns,’ said another. Others told of their stress. ‘What is going to happen to my kids if I die? Who will take care of them? I’ve no family here.’
Pressure to work
These findings from the third regular BMA tracker survey point to some improvement in access to PPE following the Government’s well-publicised effort to tackle the supply-chain fiasco. The first survey, in early April, found more than half of all respondents had experienced shortages of FFP3 masks or felt pressured – often or sometimes – to work in risky AGP areas without adequate protection.
There has been a big national push on PPE. It’s now headed by the Conservative peer who ran the 2012 Olympics, Paul Deighton, a former investment banker. The Army’s been drafted in and a private delivery firm, Clipper Logistics, has been contracted.
Yet there’s some way to go before the supply becomes reliable, as our survey indicates.
The BMA has called for ministers to take whatever action is necessary to scale up production in the UK. It has urged health secretary Matt Hancock to explore overseas suppliers and tap into EU joint-purchasing arrangements.
It is still unclear if it will. In March, Cabinet Office minister Penny Mordaunt told Parliament the Government had ‘chosen other routes’. In response to contested reports that it missed chances to tap them, the Department of Health and Social Care told The Times it ‘will consider participating’ in EU procurement.
With huge public support for NHS staff, their struggle and stress in accessing PPE is a major political issue and headline news, fuelled by a rising pyre of evidence.
As this wealth of evidence grows, under pressure from this historic pandemic, some hidden gaps in protective gear for the diverse NHS workforce are revealed.
Female doctors are struggling to find masks that fit, leaving some with sores and ulcers when forced to work long shifts with those that don’t, says BMA consultants committee deputy chair Helen Fidler.
‘PPE is too often neither personal nor protective for women. It doesn’t work as it should, because the wearer is the “wrong” gender,’ (see, ‘Don’t say sorry for being female’ below).
Hundreds of female doctors have failed their ‘fit test’ for protective masks, they told the BMA’s survey. While the proportion (8.5 per cent) who failed the test is only marginally higher than their male colleagues (7 per cent), other recent surveys point to a bigger divide. One by union Prospect, last month, found 16.7 per cent of female respondents had problems with poorly fitting respiratory equipment compared with 7.6 per cent of men.
NHS staff who fail ‘fit tests’ are often offered no alternative, according to many postings to the online portal.
‘Failed fit testing for the two types of mask we had. Told we don’t have any more respirator masks despite asking daily for a week,’ one doctor said. ‘FFP3 won’t be suitable for me as I wear a headscarf,’ said another.
‘No alternatives have been given to me. We are expected to work on COVID wards during on-calls with insufficient PPE.’
Fatin Izagaren, a paediatrics specialty trainee 5 at Frimley Park Hospital, Surrey, who is deaf and lip reads, has also struggled, so far in vain, to get transparent masks. ‘Friends in other hospitals are considering going off sick, they feel so stressed, and isolated,’ she says.
Fear of repercussions
The BMA’s third tracker survey underlined a worrying finding also seen in the previous two: that doctors with BAME (black, Asian, and minority ethnic) backgrounds are disproportionately affected by shortages.
More than double the proportion of BAME doctors (44 per cent) have felt pressured to see patients in AGP areas without adequate protection often or sometimes. This compares with 21 per cent who identified as white. BAME doctors were also more likely than white colleagues to cite ‘fear’ as a reason for not reporting or speaking out about shortages.
BMA staff, associate specialist and specialty doctors committee chair Amit Kochhar says doctors must be encouraged to challenge managers who stop them wearing PPE.
‘We suffer too much from “presenteeism”. We don’t like to let the system down in any way. But we must ensure that we look after our own health too.’
Following a strongly worded letter from BMA council chair Chaand Nagpaul, NHS England has told hospital employers to ‘risk assess staff at potentially greater risk and make appropriate arrangements accordingly’ because of evidence BAME people are being disproportionately affected.
As the politicians and the nation applaud NHS workers each week, many are struggling to get the PPE they need to help fight this deadly virus.
Weeks and weeks into lockdown and months since the first clear warnings, many are arriving at work in the sure knowledge they still aren’t protected.
Don’t say sorry for being female
Consider this paradox.
Most healthcare workers are, like me, female. Yet the gear that we get to shield ourselves against a new, deadly virus has been designed for men.
And like me, you may have heard that your female colleagues have failed ‘fit tests’ for masks meant to seal on to their face for risky clinical settings. You’ll know they are sometimes left with no alternative protection, just the knowledge theirs doesn’t work.
Or like me, you’ve seen the sore or even ulcerated faces of doctors and nurses you work with every day as they pull fasteners too tight on ill-fitting PPE (personal protective equipment) masks for punishing 12-hour shifts.
You’ve heard from friends put in the invidious position of being called to help patients in extremis with COVID-19, with only a mask they’ve been told doesn’t fit to protect them.
One female friend even apologised for having a ‘small, funny face’. Some of us still do not recognise discrimination, which is what this obviously is. PPE is too often neither personal nor protective for women. It doesn’t work as it should, because the wearer is the ‘wrong’ gender.
This seems another example of what the author and journalist Caroline Criado-Perez describes in her book, Invisible Women – that a world designed on the male template is one that discriminates.
We shouldn’t apologise. We should be angry and demand immediate action.
We’ve known for three years, from a TUC survey in 2017 that PPE is often a poor fit for women. From the BMA’s own surveys of thousands of doctors, we know that access to adequate PPE is already a problem for more than half of all doctors and now we are hearing that even when available it isn’t designed to fit the majority of the workforce. The Government was warned six years ago of the need for more research on PPE fit to protect staff against viruses.
There really seems no excuse for the situation we’re in. The Government must get a grip on the size of the situation its female workforce is in.
Helen Fidler is the deputy chair of the BMA consultants committee
Discrimination, it’s transparent
As a paediatric registrar who is deaf, I rely on lip-reading to communicate with my team and patients. Lip-reading helps make sense of words that sound similar. With a lifetime’s battle to get to where I am now, it’s just been a thing to overcome, but not usually a huge problem.
Before COVID-19, people could pull masks down to talk. But we can’t do that since masks became part of our new national uniform.
As a registrar, I want to lead my team and support my junior doctors. Adding masks makes this difficult. It’s like being a given sheet music with occasional notes forgotten; reliance on lip-reading becomes obvious. The solution is a mask with a transparent window but there are no transparent masks manufactured in the UK.
The procurement team at my trust and Surrey Heartlands clinical commissioning group have been searching for masks in the UK and abroad. The much-publicised transparent masks designed by a US student are not of the fluid-resistant standard required. I’m working with a small design company to develop mask prototypes but it’s a nowhere near a viable product yet.
We’re all in this for the long-haul. We need manufacturers to step forward to mass-produce transparent masks. These are not just needed for deaf healthcare professionals, but also for patients with hearing loss. Domain 3 of the GMC’s Good Medical Practice guidance highlights the importance of communication. We cannot ignore this issue and must all work together to push for a long-term solution.
Fatin Izagaren is a paediatric specialty trainee 5 at Frimley Park Hospital in Surrey