Covid-19: 15 000 deregistered doctors are told, “Your NHS needs you”BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1152 (Published 20 March 2020) Cite this as: BMJ 2020;368:m1152
All rapid responses
Criticisms of GP at Hand experience has no relationship to the proposed video consultation during COVID-19
I refer to Dr Yeung’s recent rapid response (ref 1)
I too share his reservations and concerns with the expansion of medical staff workforce by enlisting the help of recently deregistered doctors, hiring locum doctors as well as final year medical students being ‘fast tracked’ into the NHS workforce.
The situation is interesting, particularly for the latter groups. Discussions relating to deployment of these students according to their skill set is a tacit acknowledgment that not all medical students have the same skill set towards the end of their medical education. While some speculation related to earlier GMC registration as doctors for those who “completed their final exams” in which the universities regarded them as medical graduates; if not, they may be able to work as physician assistants. Other students not yet completing the final exams may be placed in other roles depending on their previous healthcare occupation prior to medical school enrolment. Those without these qualifiers will require upskilling, it was admitted.
Junior healthcare workers pressed into service without adequate preparation and support may pose additional risks to themselves, patients and other healthcare workers, particularly in a healthcare crisis involving communicable diseases. Even for an experienced trainee, supposedly under supervision, the courts of the land are uncompromising in their expectations as reflected by the proceedings against Dr Bawa-Garba, an experienced trainee performing the work of 3 doctors on one crucial day. Even if exempt from persecution (and legal responsibility) the mental health damage from an adverse event may prove to be career ending and soul destroying. Similar concerns regarding abilities and personal wellbeing have been raised by students themselves (Ref 2)
I would this opportunity to respond to Dr Yeung’s comment on video consultation in which he wrote: “Use of video consultations has been suggested to reduce risk of contagion and broaden patients’ access to healthcare.<8> It is somewhat ironic that only 3 years ago GP at Hand digital primary care service had been heavily criticized and blocked for further expansion.”
The GP at Hand service was controversial; although the proponents claim credit for reducing emergency department attendance in the area during its operation, it was found to have drawn a skewed patient group, predominantly a younger (often healthier) population from the local GP practices, and possibly beyond the service area. The service was found to have disproportionately higher than expected consultation rates despite having high proportion of registered patients of younger age. (Ref 3) Furthermore, a significant underreported finding of the Ipsos MORI study of this service is as follows:
“BGPaH experiences higher de-registration rates than the London average, with patients most commonly de registering after two weeks. NHS England analysis has shown that BGPaH experiences a higher de-registration rate than the London average; one in four (28%) of patients have de-registered from the service since July 2017, compared to the London average of one in six. Of individuals who have signed up in the first four months, over one in three have de-registered.
"This analysis also shows that 44% of those who de-registered did so within two months of signing up, with patients most commonly de-registering after two weeks.” (Ref 4)
As “it was not possible to invite de-registered patients to take part in the patient survey but a very small number had de-registered between the survey being sent out and the patient responding”, it is quite possible that the high satisfaction rates reported mostly by patients who remained registered with the service is not a true reflection of the satisfaction rates without representation of those who had de registered for various reasons.
Therefore it was uncertain if the [GP at Hand] model is affordable, sustainable or reproducible without significant changes at other locations.
There is no irony in the criticism of GP at Hand Model then or now, nor was the proposal of video conferencing at this extraordinary time in conflict with the findings by the Ipsos MORI report, as the purposes of introducing this service to reduce unnecessary direct contact and travel during the COVID-19 pandemic is not the same as the original role of the GP at Hand experiment.
Fellow readers might like to read the referenced report.
Competing interests: No competing interests
Imagine if you see an advertisement like this: “Our neighbourhood is experiencing high volume of violent crimes. We would like to invite retired officers to come back from retirement. We have a new program that can fast track our cadets. However, you are all required to obtain your own protective equipment to fight against these crimes.”
I wonder who would respond to this insincere advertisement. That is exactly what the NHS is doing now to fight against COVID-19: recruiting deregistered doctors<1> and fast-tracking medical students to be employed by the NHS<2><3>, but failing to providing adequate personal protective equipment (PPE).<4><5> I appreciate the complimentary indemnity offered to retired doctors to cover against clinical negligence liabilities,<1> but what about the new graduates who would be put in the frontline? The NHS is known for its blame culture where junior trainees, rather than senior consultants or the entire healthcare team, are prone to litigation.<6><7>
Helping labour shortage is not always a morally rewarding experience. During the junior doctor strike in 2016, I naively went to work as usual for the sake of patient safety. In return, I was being shouted at for not promptly completing discharge letters, left by my colleagues who went on strike. A co-worker of mine almost quitted that day due to the verbal abuses initiated from other health workers. I am concerned how our new graduates could cope with the frustration-aggression-displacement they may experience in this current stressful situation.
What if our locum doctors contracted COVID-19 during face-to-face consultations? It is unclear whether they would receive any compensation. Use of video consultations has been suggested to reduce risk of contagion and broaden patients’ access to healthcare.<8> It is somewhat ironic that only 3 years ago GP at Hand digital primary care service had been heavily criticized and blocked for further expansion.
Despite the challenges, I still want to see adequate workforce to cope with the work shortage pressure. I can only hope that NHS administrators would respect these additional recruits, who are risking their health and wellbeing to save the NHS.
1. Dyer C. Covid-19: 15 000 deregistered doctors are told, "Your NHS needs you". BMJ. 2020;368:m1152.
2. Iacobucci G. Covid-19: medical schools are urged to fast-track final year students. BMJ. 2020;368:m1064.
3. Mahase E. Covid-19: medical students to be employed by NHS as part of epidemic response. BMJ. 2020;368:m1156.
4. Rimmer A. Covid-19: GPs call for same personal protective equipment as hospital doctors. BMJ. 2020;368:m1055.
5. 'Not fit for purpose': UK medics condemn covid-19 protection. London, UK: The Guardian; 2020 Mar 16; cited [Mar 23, 2020]. Available from: https://www.theguardian.com/society/2020/mar/16/not-fit-for-purpose-uk-m....
6. Rimmer A. Bawa-Garba case: "When something goes wrong in healthcare there is never one person to blame". BMJ. 2017;359:j5721.
7. Wise J. Survey of UK doctors highlights blame culture within the NHS. BMJ. 2018;362:k4001.
8. Video consultations: Information for GPs. London, UK: British Journal of General Practice; 2020 Mar 16; cited [Mar 23, 2020]. Available from: https://bjgp.org/sites/default/files/advanced-pages/20Mar_COVID_VideoCon....
Competing interests: I have been paid for working in primary and secondary care, but not for writing this letter.
The exercise of emergency powers by the Registrar of the General Medical Council (GMC) under the terms of Section 18A of the Medical Act (1983) [ http://www.legislation.gov.uk/ukpga/1983/54/section/18A ] is undeniably warranted under the circumstances of the Covid-19 pandemic. The GMC rightly recognises potential concerns about the health of returning doctors [ https://www.gmc-uk.org/registration-and-licensing/temporary-registration... ], and as Clare Dyer points out they are, as expected, an older population and therefore with likely significant co-morbidity. The same considerations would apply to the 50,000 nurses, as well as other health care professionals such as scientists who have been called for.
Although these returning recruits would be ‘surveyed … regarding the type of role they could fill', explicit reassurances are needed that those provisionally accepted especially for ‘face to face’ clinical roles will have suitable and sufficient risk management. They clearly need a rapid but adequate questionnaire based pre-placement screen with the option of at least telephonic follow up by an occupational health professional. This assessment would obviously include a history of relevant recent Covid-19 symptoms or exposure, as well as of relevant comorbidities to ensure that their recruitment in that role does not pose unacceptable risks to them, their colleagues or their patients. Additionally, while the explicit commitment to ‘full induction and online training' is welcome, those accepted for ‘face to face’ clinical roles would need 'hands on' training in, and fit testing of Personal Protective Equipment (PPE) -- notably, FFP3 respirators -- especially in the light of many concerns [https://www.bmj.com/content/368/bmj.m1099 ] about the paucity of protection which the NHS is legally mandated to provide. Moreover, once validated antibody tests for Covid-19 are available, these ‘face to face' recruitees would need at least as high a priority for testing as extant exposed NHS staff.
Competing interests: No competing interests
On Friday 20th March our secretary of state for health Matt Hancock wrote to 65,000 retired doctors and nurses seeking their return to the NHS for help in managing our rapidly evolving coronavirus pandemic. Who are these workers?
• 15,000 doctors who have left the register or given up their licence to practise within the past three years, have a UK address, are fully qualified and experienced, and are in good standing. Their average age is 53.5 years, and around a third are aged 44 or under.
• More than 50,000 nurses whose registration has lapsed in the past three years.
Evidence this week from Italy shows that these workers need to be particularly careful: since 11th March there have been 20 deaths of doctors caused by COVID-19, of which 16 are from Lombardy and of note 19 male and all are above 57 years old.
In China, the WHO has reported that the individuals at highest risk for severe COVID-19 disease and death is for people: aged over 60 years; with underlying cardiac and respiratory diseases; male gender compared to female (crude fatality rate, CFR 4.7% vs. 2.8%) and retirees (CFR 8.9%).
In Italy, the mean age of patients dying of COVID-2019 infection was 78.5 years (median 80, range 31-103, IQR 73 -85). COVID-19 has infected over 2,700 health workers in Italy, 8.3% of the country’s total cases. In the last 12 days alone, the Lombardy region (which accounts for 68% of deaths of the whole country) of Italy has lost 16 doctors to the Coronavirus (5; Table1 below). The number is increasing and involving other regions of the country, Emilia-Romagna, Marche and Campania, with the number reaching 20 to date. The median age was 66 years, ranging from 57 to 80, 19 out of 20 were male.
Table 1: Demographic characteristics of doctors who have died from severe COVID-19 disease between 11th and 23rd March in Italy.
Reported Doctor Death (DD/MM/YYYY) Age at Death
(years) Gender City of Italy Region of Italy
(11/03/2020) 67 Male Como Lombardy
(12/03/2020) 73 Male Como Lombardy
(13/03/2020) 64 Male Lodi Lombardy
(13/03/2020) 80 Male Como Lombardy
(13/03/2020) 80 Male Bergamo Lombardy
(15/03/2020) 71 Male Como Lombardy
(16/03/2020) 87 Female Bergamo Lombardy
(16/03/2020) 65 Male Bergamo Lombardy
(16/03/2020) 66 Male Cremona Lombardy
(17/03/2020) 61 Male Lodi Lombardy
(17/03/2020) 65 Male Mantova Lombardy
(18/03/2020) 57 Male Lodi Lombardy
(18/03/2020) 63 Male Naples Campania
(18/03/2020) 66 Male Bergamo Lombardy
(19/03/2020) 61 Male Parma Emilia-Romagna
(19/03/2020) 67 Male Macerata Marche
(19/03/2020) 73 Male Bergamo Lombardy
(19/3/2020) 69 Male Bergamo Lombardy
(21/03/2020) 65 Male Lodi Lombardy
(21/03/2020) 65 Male Naples Campania
- Protecting health workers against COVID-19 helps everybody: Tedros Adhanom Ghebreyesus, director-general of the World health Organization, said on Friday 14th March “health workers are the glue that holds the health system and outbreak response together. But we need to know more about this figure, including the time period and circumstances in which the health workers became sick”.
- A high viral load increases the risk of death and PPE can reduce this risk.
- Data from both China and Italy are in accordance regarding who is at greatest risk of death.
Whilst we support Mr Hancock’s drive to increase NHS staff numbers with the return of retired health workers, it is imperative that this vulnerable group receives maximal PPE if they are being exposed to patients or the hospital environment. Currently, the lack of sufficient PPE raises grave concern.
1. Novel CPERE. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China. Zhonghua liu xing bing xue za zhi= Zhonghua liuxingbingxue zazhi. 2020;41(2):145.
2. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. Jama. 2020.
3. Wu C, Chen X, Cai Y, Zhou X, Xu S, Huang H, et al. Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China. JAMA Internal Medicine. 2020.
4. Sanita’ ISd. Characteristics of COVID-19 patients dying in Italy. Report based on available data on March 20th. 2020 [Available from: https://www.epicentro.iss.it/coronavirus/bollettino/Report-COVID-2019_20....
5. FNOMCeO. Fndodmcedo. Elenco dei Medici caduti nel corso dell’epidemia di Covid-19. 2020 [Available from: https://portale.fnomceo.it/elenco-dei-medici-caduti-nel-corso-dellepidem....
Competing interests: No competing interests