Letter of protest to Kazakhstan ambassador over repression of protests

Sunday 9th January 2022.

Ambassador Erlan Idrissov,

125, Pall Mall

St James

London

SW1Y 5EA

Dear Ambassador Idrissov

Doctors in Unite branch of the UK and Ireland trade union Unite is writing to you to protest at the brutal repression of demonstrators throughout Kazakhstan and the state of emergency in Almaty and Mangistau. It is a basic human right to be able to demonstrate. Kazakhstan is once again revealing itself as an old fashioned dictatorship rather than a modern democracy.

We reject the ‘official’ view of the demonstrations as being led by “extremists, terrorists and radicals” which is put forward on your website. The demonstrators are ordinary working-class people – men, women and young people who have seen their standards of living cut, while the privileged elite and oligarchs at the top of Kazakh society enjoy a lavish lifestyle. The demonstrators recognise that for the last thirty years Nazarbayev and his family and friends have corruptly run the country at the expense of the workers. Tokayev is nothing but a puppet of Nazarbayev, which is why many of the demonstrators have been shouting “Down with the old Man”.

The use of tear gas and other methods of repression must stop immediately. As Trade Unionists, we will be taking these issues up with UK companies that invest and work in Kazakhstan.

We urge you to end the repression now. This needs to be accompanied by a commitment to allow freedom of association and the recognition of genuinely free and independent trade unions and political parties, including those that challenge the ruling elite in Kazakhstan.

Yours faithfully.

Dr Jackie Applebee

Chair of Doctors in Unite.

DOCTORS IN UNITE SUBMISSION ON THE FUTURE OF GENERAL PRACTICE TO THE PARLIAMENTARY HEALTH AND SOCIAL CARE COMMITTEE

The Health and Social Care Committee has launched an enquiry into the future of general practice, “examining the key challenges facing general practice over the next five years as well as the biggest current and ongoing barriers to access to general practice.” Further information can be found here. This is the submission Doctors in Unite have made to the enquiry.

Main barriers to accessing general practice and how can these be tackled

General practice is not synonymous with primary care, the primary care team is essential to General Practitioners being able to concentrate on the areas where they are especially skilled.

The major barrier to accessing general practice is quite simply that the system has been massively under-resourced for the job it is being asked to do.

To what extent does the Government and NHS England’s plan for improving access for patients and supporting general practice address these barriers?

It goes nowhere near what is needed.

What are the impacts when patients are unable to access general practice using their preferred method?

They do not get the help they need.

They attend Accident and Emergency departments.

Excess non-Covid deaths observed during the pandemic.

Inequality in health grows.

Some patients may be distressed by not being able to access general practice in person at a time of their choice. This is sometimes unavoidable as the general practice resource has to be effectively rationed, and distributed in a needs based way. With effective triage systems this should cause no harm.

What role does having a named GP – and being able to see that GP – play in providing patients with the continuity of care they need?

Reference Norway study

The ability to develop long term relationships in general practice is essential for the full benefits of this speciality. Continuity is not needed for everything, but the greater the complexity of someone’s problems, the greater the value of continuity. Access systems need to be flexible enough to provide continuity where it is going to add value.

What are the main challenges facing general practice in the next 5 years?

Keeping the show on the road.

In one Vocational Training Scheme in London last year 26 GPs were trained, but only 2 took up permanent GP posts. Retention is a huge problem both for younger GPs not taking up work or leaving the profession, and for older GPs retiring early.

Serious firefighting is needed now, or the remaining GPs will not be able to deliver the service and it will collapse, to the detriment of the whole health service.

It will be years before enough GPs come on line to handle the workload well. GPs and their teams know what would help them survive – ask them (via Local Medical Committees) and fund what is needed without targets – the target is the survival of General Practice as a speciality within the NHS.

One third of GP premises are no longer fit for purpose and have no space for expanding teams. There needs to be significant investment in premises.

How does regional variation shape the challenges facing general practice in different parts of England, including rural areas?

 Each team will have its own needs for survival, for example some may need more receptionists, with good training provided, some will need more secretarial and administrative staff, some will need new phone systems, all will need high quality IT systems including rapid IT support. The recruitment situation in each area will differ, some may have been unable to recruit nurses, but can recruit physiotherapists, others can recruit paramedics but not mental health workers.

What part should general practice play in the prevention agenda?

General Practice, within the primary care team, is just one cog in the big wheel of the wider societal promotion of good health, and prevention of ill health. Public health input is fundamental to the planning of services, and national policies that combat poverty, and loneliness, procure decent housing, reduce pollution, stop climate destruction, facilitate exercise and enable healthy diets are vital. General practice can not prevent mental ill health, or provide conditions in which those who are vulnerable, disabled or suffer from complex multi-morbidities can lead fulfilling lives whether in or out of work. If Governments are serious about the prevention agenda, then tackling the social determinants of ill-health is essential.

General Practice can work with others to the make the best use of local opportunities to provide help and support, but it is no good having a Social Prescriber when the support services that used to be provided by Local Authorities have been cut to destruction.

General Practitioners are well placed to pick up early problems of illnesses, and, in partnership with patients, help to prevent some of the complications of longterm illness, for example in Diabetes management.

General Practitioners can also protect patients from over-investigation and over-medicalisation of their problems, through judicious and personalised use of investigations, referrals and treatments.

The development of a National Occupational Health Service would potentially make a big difference to the ability of workplaces to be places that contribute to the health promotion and ill-health prevention agenda, and would have a reach beyond that available to general practice.

What can be done to reduce bureaucracy and burnout, and improve morale, in general practice?

There would be a huge difference if QOF targets and incentive schemes and routine inspections were immediately suspended until a new contract can be agreed.

Pension taxation issues for General Practitioners approaching the lifetime allowance need to be sorted.

NHSE and Government messaging must switch to supporting the incredible work of GPs and the primary health care teams, instead of the current scapegoating.

Restoration of Local Authority cutbacks so support services could be reinstated.

Boosting NHS secondary care capacity for the long term, with investment to meet predicted needs, rather than short term funding of cherry picked private secondary care.

Significantly improve mental health resourcing.

Fund secretarial support for Consultant colleagues so that direct communication is easier (this is the sort of thing that makes a real difference to “integrated care” rather than a whole NHS reorganisation)

How can the current model of general practice be improved to make it more sustainable in the longterm in particular?

Is the traditional partnership model in general practice sustainable given recruitment challenges, the prioritisation of integrated care, and the shift towards salaried GP posts?

The traditional partnership model has become increasingly problematic as the available funding has been restricted, and increasingly tied to attaining targets that may not be relevant or achievable in some populations. It has had the great strengths of encouraging long-term commitment to a population, and innovation, although these do not depend on the contractual mechanism, but can be facilitated by appropriate organisational culture.

In the present climate we believe that the Independent Contractor option needs to remain, with a significantly improved contract offer, to prevent a huge loss of current GPs. In the longer term we believe that, in the right circumstances, a more attractive salaried service similar to that agreed by hospital Consultants, could be developed.

Do the current contracting and payment systems in general practice encourage proactive, personalised, coordinated and integrated care?

A preferable contractual system would be one in which GPs would have sufficient time allocated to do their work within a working day. Time should be built into the workplan for personal development, supervision and education, with the option of time for management work, research, training and public health work. Overstretched GPs cannot provide optimal care.

General Practitioners do not need to be the employers of other members of the primary health care team.

General Practitioners need to be relieved of the necessity of being the owners or leaseholders of the buildings within which they work, they should be offered a fairly priced buy-out or take over if they are current owners or leaseholders.

Any salaried General Practitioner Contract will require the Contract holder to be an NHS body, with National Terms and Conditions, working within an NHS which has been reinstated as a fully publicly funded and publicly provided service. By definition private providers have the profit motive as a demand on their service development, which will always be unhelpful in the context of the NHS.

 Line managers for GPs should be clinician peers, or those with extensive understanding of primary care teams.

There needs to be developed provision of comprehensive multidisciplinary primary care teams, with local health service management based on neighbourhoods, with local accountability driving bigger system planning and resource allocation decisions. General Practitioners would be amongst the team members, but not necessarily leading the team.

Has the development of Primary Care Networks improved the delivery of proactive, personalised, coordinated and integrated care and reduced the administrative burden on GPs?

Unfortunately the development of Primary Care Networks has been significantly hampered by the centralised prescription of what the funds can be used for. The specified Additional Roles staff are often not available for recruitment, and the money cannot be used to meet alternative local needs. There is a pool of fully trained General Practitioners who are leaving the profession because they cannot find work that is attractive enough to retain them, while at the same time Primary Care Networks are prevented from creating bespoke posts that could keep their skills and cover unmet need.

The Networks have certainly not reduced any administrative burden on GPs, those involved in running them have been, to the contrary, heavily burdened and inadequately recompensed for the huge workload of recruitment and management.

The Networks need resources for structured training and induction for new staff, as well as ongoing supervision and mentoring.

To what extent has general practice been able to work in effective partnerships with other professions within primary care and beyond to free more GP time for patient care?

General Practitioners ability to work in effective partnership with other professions is constrained by the overall workload. Co-location of other professions massively improves effective partnerships, and the reduction of this over the years has been damaging. Conversations with co-located professionals can happen when they need to, when people are in the same building. Large multidisciplinary meetings have a very limited role. Problems of IT lack of interoperability reduce the potential for IT communication solutions. In the fast moving world of acute patient care there is no substitute for a timely care planning discussion which cannot wait for a routine scheduled meeting.

Dr Brian Colston

Pioneering GP who helped transform primary health care in Britain

Photo courtesy of The Guardian

My friend Brian Colston, who has died aged 99, was one of a generation of pioneering GPs who helped to transform primary health care in Britain. Over more than 40 years he developed a range of innovative services of national significance in Birmingham’s inner city.

Working out of small, cramped premises on the Lee Bank estate, Brian led the development of preventive health care in the city. His innovative work included dedicated asthma and diabetes clinics; contraceptive advice and family planning services; attached social worker schemes; and a day hostel for the city centre homeless and people with addictions. The practice also established one of the first patient association groups in the country.

Born in Bristol to Margaret (nee Moore), a teacher, and Edward Colston, an undertaker, Brian attended Bristol grammar school.

He spent the second world war in the Royal Signals serving in east Asia. Then the Forces Education Scheme enabled him to study medicine at the University of Bristol. There he met Enid Furnival, whom he married in 1951. After he qualified as a doctor in 1956 they moved to Birmingham, where Brian spent the whole of his professional life.

After many years in the practice, Brian secured funding for a new purpose-built health centre on Lee Bank, which opened in 1985, embracing the comprehensive range of services that he saw as the core of his vision of good primary health care.

He was also actively involved with Birmingham health authority and the Medical Practitioners’ Union and played a key role in setting up a GP-led maternity ward to assist safer maternity care. He was also involved in the establishment of the Birmingham pregnancy advisory service, which, in 1968, became the British Pregnancy Advisory Service, at a time when – despite the passing of the 1967 Abortion Act – safe, legal abortions were still difficult for many women to access. As a mark of his many achievements, in 1989 he was appointed OBE.

After retiring in 1991 he moved to Devon to enjoy his passion for sailing, as well as gardening and photography, before returning to Birmingham with Enid to spend his last years. He was a thoughtful, kind and generous man who dedicated his life to the health and wellbeing of the people of inner-city Birmingham.

Brian is survived by Enid, their three children, Lucy, Simon and Nicola, and six grandchildren. His eldest son, Tim, died in 2014.

Jon Bloomfield (printed in the Guardian 1 November 2021)

Photo courtesy of the BMJ

Nicola Colston (published in BMJ 29 October 2021)

Infection Control guidance and airborne transmission

Guidelines are fundamentally flawed and putting health care workers and patients at serious risk

  • UK infection control guidelines are not fit for purpose.  IPC authorities are increasingly isolated in their view that Covid-19 is spread by droplets and not through the air, a position which is directly contradicted now by official government policy.  What follows is a more detailed look at the issues, which demonstrates how unscientific, out of touch and indeed hazardous the guidelines are for health workers and patients.
  • There is widespread consensus that the guidelines are fundamentally flawed and not fit for purpose.  Many expert scientists and health professionals have spoken out publicly about them, and repeatedly asked for them to be changed.  The Royal College of Nurses calls the guidance  “fundamentally flawed”, while the British Medical Association wrote to the prime minister in February 2021 along with 16 health organisations, stating the guidance needs revision as it fails to take into account airborne spread or recommend airborne mitigations.  To date 26 different health organisations have called for airborne protections for staff, to no avail.
  • IPC is isolated in its view that airborne transmission does not occur.  The Department for Education is putting in place airborne mitigations (CO2 monitors and air filtration units) in schools and the Department of Health and Social Care has just embarked on a major health education drive for the public to improve ventilation in their homes over the festive period to limit airborne transmission.  Newly updated guidance from the government says airborne transmission is a very significant way that the virus circulates.  The idea that airborne transmission occurs everywhere else, but stops at the hospital front door is ludicrous.
  • IPC’s belief that airborne spread is only a risk from certain aerosol generating procedures (AGPs) has now been thoroughly discredited by numerous clinical studies.  Not only do so-called AGPs not constitute additional risk, a patient with Covid who is actively coughing produces far more aerosols.  Experts are now openly calling for us to stop using the term AGP altogether. This review article in the Lancet states:

“We propose an end to the term aerosol generating procedure, as it is neither accurate (aerosol is not generated above a cough for many of these procedures), implies aerosol emission is only from specific procedures (rather than being generated during normal respiratory events), potentially misidentifies the source of infection risk, and applies a binary definition to a situation that is more complex. Instead, we propose that clinicians follow an evidence-based framework that accounts for the major drivers of risk, with a focus on physical exposure to patients with suspected or confirmed COVID-19 as the critical component.”

  • There is widespread dismay and frustration by health trade unions, numerous health organisations and large sections of the medical and scientific community at the refusal of IPC to amend the guidance.  Concerted efforts for well over a year to get IPC to change have proved futile, despite overwhelming evidence of airborne transmission, and the multiple criticisms of the failings of the guidelines from clinicians and scientists.
  • In practice IPC’s policies have failed comprehensively to protect health and social care workers – more than 1,500 of whom have died from Covid, according to former Health Secretary Matt Hancock, and over 120,000 health workers and 30,000 social care workers have long Covid according to the ONS. These figures predate the onset of delta Covid, which is more infectious and can lead to more serious disease; the figures now are therefore likely to be higher, despite most HCWs now being vaccinated.
  • There has also been wholesale failure to keep patients in hospital safe from Covid infection.  Tens of thousands of patients have been infected while they were in hospital for other health conditions.  During the terrible second wave last winter, an average of 20% of Covid infections were hospital acquired; this dropped substantially over the summer, but the rate is now over 8% and rising.
  • Over 11,600 patients have died from hospital acquired Covid-19 infection,  according to a recent article in the Daily Telegraph.  This is an indictment of infection control in our hospitals and a national scandal.  
  • An NHS spokesperson said in response to the Telegraph article that staff had “rigorously followed UK Health Security Agency (formerly PHE) infection prevention control guidance”.  No doubt this is true, therefore the inescapable conclusion is that it is the guidance which is comprehensively failing to protect staff and patients.  Until we have guidance which accepts the predominance of airborne transmission, and that this is a risk everywhere in our hospitals, thousands more patients will get infected with Covid in hospital and many will die.  Health workers will also continue to get infected and some of them will die.  More handwashing and surface cleaning is futile while no measures are taken against air infected with Covid-19 from patients and staff who have the virus.  Wherever there is shared air, there is risk of transmission, and this includes non-clinical areas such as staff rest rooms, offices, change rooms, storage areas, reception and waiting areas etc.
  • To date seventeen NHS Trusts are known to have gone beyond the guidance and issued their staff with respiratory PPE to protect them and patients against hospital acquired infections.  The great majority of Trusts (there are 223) have not.  As this study comparing hospital acquired infections in the different trusts shows, the wearing of respiratory protective equipment by staff in contact with Covid patients, compared with wearing surgical masks, significantly reduces hospital acquired infections.
  • The same “droplet-not-aerosol” IPC guidance also applies to ambulance staff, i.e. they must wear surgical masks and not respiratory masks.  Ambulance workers are probably one of the most at-risk groups of health workers: they enter the homes of sick patients who are known to be Covid positive, who are often actively symptomatic (e.g. coughing and therefore producing large amounts of aerosols with virus into the air), and they are in the earlier stages of the disease which we know is the time of greatest Covid infectivity.  It is hard to imagine a scenario which is more high risk “red-zone” than this, yet staff are still issued poorly fitting surgical masks as standard.  Unsurprisingly in February 2021 the GMB union reported that one third of ambulance staff had been infected; it is likely that many more will have been since the onset of delta Covid. 
  • IPC guidance also gets the basic physics of aerosols wrong.  It states that only aerosols particles 5mm (microns) in size or smaller remain airborne.  This is wrong – particles up to 50-100mm can remain suspended and travel long distances through the air.  The bottom line is that the laws of physics greatly favour airborne transmission over droplet transmission – see here for a detailed explanation.  Despite fluid dynamics scientists (the people who proved airborne transmission and revolutionised our understanding of the transmission of respiratory pathogens) repeatedly pointing out that IPC doctors are flouting the laws of physics, IPC remains obdurate.
  • So glaring has been IPC’s intransigence on airborne transmission, there is now a growing literature being published on the matter, examining why this may be happening.  This recent paper is an interesting review of reasons, pointing to historical errors, scientific vested interests, ideological manipulation and do-the-minimum policy making, while this paper gives an international perspective of the origin of droplet-dogma and how it continues to bedevil current policy.