Second wave | new COVID-19 survey | exams return

I ended my last bulletin with the words ‘These bulletins will go back to being monthly for the moment but obviously if needed we will increase the frequency again. My next bulletin will be on 5 October.’ Famous last words – we need to increase the frequency again (or strictly speaking, not decrease it yet).

I have been writing this bulletin over the past couple of days, and the news conference by Professor Chris Whitty and Sir Patrick Vallance this morning is a timely adjunct (thankfully the electronic presses can be held to allow last-minute editing). The CMO presented compelling data on the increase in hospital admissions over the past 2 weeks and the reasons why non-pharmaceutical interventions (NPIs) are as important now as ever. I fully support their position and recommendations.

It’s raining again – the second wave

We have all watched the increase in cases in the UK with growing alarm. There has been an increase in hospital admissions, but at much lower levels compared with daily cases than seen in the first wave. There has been much speculation in the trinity of medical, mainstream and social media about why this is. To me, it is pretty simple. We are now looking at a wave in high definition, whereas before we were looking at it through a glass, darkly.

By the middle of April, past the first wave peak, we were only doing around 20,000 tests a day and many of these were in hospitalised patients and staff. Of these, around 5,000 were positive. This was just the tip of the iceberg of cases and while we will never know for sure how many were infected in that wave, seroprevalence data suggest that it was around 7–10% of the UK population. The UK Biobank data are helpful in showing the geographical spread and differences between groups (accepting that it is a slightly skewed population).

Currently we are testing 200,000 people a day and detecting 4,500 cases. Almost all of these tests are being done in the community or on asymptomatic people in health or social care settings. Large numbers of people under the age of 25 are being tested, a rarity during the first wave. We are therefore looking at other bits of the iceberg as well as the tip.

To compare the two waves is not easy, but the Office for National Statistics (ONS) has a method that gives us some insight. The ONS has modelled estimates of the percentage of the population testing positive each week, based on who is being tested and the results. They currently estimate this at 0.1% of the population, compared with 0.5% in mid-April. The current rates in those aged over 50 are well below 0.1%, and in 17–24-year-olds they are well over 0.5%. The ONS has broken down their rates by area of the country and age group; their graphs are well worth a peruse.

We are therefore looking at the second wave much earlier in its progress than we were able to look at the first wave, and are at a tipping point. All of the graphs are going in the wrong direction and unless the NPI manoeuvres work, we should expect the older age groups to start to succumb and be hospitalised, and deaths to increase. Obviously things are different this time, with improved treatments and awareness of those at most risk. However, public (and that includes all of us) behaviours now will be the most critical to deciding how the second hand we have been dealt will play out.

Take the long way home – staff absence and testing delays

There has also been much noise in the system over the past 2 weeks, as NHS staff with family members with symptoms have had to self-isolate and await testing and test results. This reached such a point that it required governmental intervention to improve access to testing for NHS staff. I’m not convinced that the problem is fixed. I have seen many colleagues in my own hospital have to self-isolate with family members and spend many hours on the phone or internet trying to get a test. In the peak of the first wave we saw a similar pattern, with ‘sickness’ rates for physicians due to having household contacts with COVID-19 approaching 7%.

Most colleagues have been off for many days only to get the news that the swab was negative and that their snotty, feverish child was not a danger to the lives of others. I have had the opportunity to put this current situation to Matt Hancock and I think he gets it. We had a falling-out in the first week of April over the issue but have made up, and he now knows that our data are very helpful to understanding the reality of the situation.

We have set up a brief survey to provide contemporaneous data on this issue. It is short, open for just 24 hours, and will take only a couple of minutes. It would be brilliant if you could complete this survey here. If you would rather read on for the moment, there will be another link at the end of this bulletin.

Crisis? What crisis? – the impact of COVID-19 on medical research charities

The pandemic has had a major impact on all charities, including those in the medical sector. This has been crystallised this week in the statement from the British Heart Foundation. They have seen a 50% reduction in their income, as shops have had to close and fundraising events have been cancelled. This has necessitated a downsizing and restructuring, and should be a wake-up call to anyone who wasn’t aware of the crisis facing the charity sector and medical research.

The impacts are far-reaching beyond charity restructuring. COVID-19 has had a very positive effect on related research and this should be seen as a good thing. Non-COVID research, though, is in a much darker place. In the first wave, many clinical research projects were suspended, staff and lab space repurposed and new applications for funding suspended. The impact in my specialty on inflammatory bowel disease trials was significant and while things are slowly coming back online, some studies may never recover.

The poor financial health of medical research charities means that future grant funding will be much reduced for years to come. This is bad for the UK health system, trainees and patients. It is right that much focus has been put on ‘fighting’ COVID-19, but non-COVID disease has not gone away and is casting an ever-lengthening shadow as time goes on.

As a charity with income from many sources, the RCP has not been immune to the financial impacts of COVID-19. This has meant that we are having to do some hard thinking about our plans for the next couple of years. We are in a reasonable financial position compared to many, but there are some tough decisions to be made. Meetings around the budgeting process are framed with a quote from the vice president of the White Star Line shipping company in 1912: ‘We place absolute confidence in the Titanic. We believe that the boat is unsinkable.’ Now is not the time for hubris and at our AGM on Thursday, I will be clear about the challenges facing us as a charity.

I am very open to ideas as to how we might raise additional funds to support our work through the next few years. We have made major strides forward in the past few years in modernising ourselves, developing our membership and how we are positioned to fulfil our charitable aims. Our vision remains to improve health and healthcare for everyone.

The logistical song – the MRCP(UK) and PA national exams are back

Last Tuesday we held the first sitting of the MRCP(UK) part 1 exam since lockdown. This was not an easy point to get to and there were lots of logistical issues (and yes, I know I’ve played fast and loose with the title to this section – Messrs Hodgson and Davies will understand).

We (the RCP, the Royal College of Physicians and Surgeons of Glasgow and the Royal College of Physicians of Edinburgh) have been thinking about moving to online provision of the MRCP(UK) written exams for a while, but the failure of the equivalent Australasian online exam a couple of years ago has led to some caution. COVID-19 caused a further rethink. The ability to have large numbers of candidates in exam halls was limited and some venues that we have traditionally used were closed. Despite these issues, we managed to deliver the exam to over 5,000 candidates, 2,300 of these in the UK with 459 of the UK candidates doing the exam online. This was apparently the largest-ever sitting of this exam.

It went well, but not perfectly. Huge thanks must go to all the staff in the Federation exams, digital and comms teams and all three colleges. Right up to the last couple of weeks, centres were pulling out and alternatives were having to be found for rightly distraught candidates. The foresight of the team to create some additional capacity in the online provision and ensuring the legal clarity of the exam as an essential professional activity mitigated much of this, but unfortunately we could not prevent some candidates not being able to sit the exam. While this was a very small number, we are truly sorry about this.

The emotional impact on trainees created by these cancellations and logistical problems cannot be understated and I am grateful to those of you who have supported trainees through this. Some cancelled candidates did not want to sit the exam online and for them, as well as others who were unable to complete this sitting, we are looking at another sitting later this year.

The online exam went well, although there were problems for some with Wi-Fi connections and formatting of a dozen questions (which will be taken into account when processing the results). The experience from other colleges with online exams in the past couple of months showed a significant problem for about 6% of candidates and while we did better than this, there is much we will learn for the future about the tribulations of exams in a COVID-19 world.

The physician associate (PA) national exams are also underway and the OSCE exams are in full flow in Liverpool. As the number of candidates per sitting is much reduced, the exams are running over 4 weeks, which is a huge undertaking for all involved. It does show, though, that OSCE exams are possible and that we need not lose the bedside skills assessments that are so important in medicine.

Give a little bit – differential attainment

While talking about exams, the RCP has been working with BAPIO (the British Association of Physicians of Indian Origin) to understand how we might reduce differential attainment (or differential award, DA) in postgraduate examinations. In case you were not aware of the scale of this issue, a UK graduate is 30–40% more likely to pass postgraduate medical exams than an overseas graduate, and even among UK graduates there is a 10–15% difference between white candidates and BAME candidates.

The reasons for this are complex and well known. Doing something about it is much more difficult. Our rather disconnected training system and lack of systemic support for those who are not in training posts are part of the problem. As an educational supervisor, I get to know my trainees for a year, but rarely get much from the system about their previous progress or am asked by later parts of the system what my trainee and I had learned together.

Reducing DA will require early identification of those who need support, much improved communication between different parts of the system, improved feedback from exams and workplace-based assessments and a little bit more time for supervisors to bring this all together. I will continue to push for trusts to recognise the importance of time and support for educational and clinical supervisors to allow this.

Last week, with BAPIO, we (the RCP) hosted a joint workshop with many of the main players in the postgraduate training space and the NHS to focus on how we can take this agenda forward. It was a positive meeting and I am hopeful we can make some progress quickly.

Goodbye stranger – proposing for FRCP

One thing I have learned over the pandemic is the huge contribution that many members have made to both the NHS and the RCP. Proposing individuals for FRCP is one way to show how they are valued by colleagues, and I’m often surprised how many excellent physicians are not FRCP simply because no one has ever thought to propose them.

Proposal is relatively simple and we do not need the works of Tolstoy to describe someone’s achievements. If fellows can see who in their departments should be recognised this way, that would be brilliant. The closing date for the next round of proposals is 1 November, so if you can get nominations in before then it would be much appreciated.

Dreamer … and finally

Listening to people interviewed on the radio or on television (I think I’m still allowed to use that term) about their experiences of trying to get tests currently fills me with a slight dread. We know that the PCR tests miss up to 30% of positive cases. Therefore when people say ‘Thankfully I’ve had the all clear’ I can’t help thinking that for many this is not true, and wonder about the implications for those they come into contact with.

The tests we have currently are far from perfect. I know some dream of a world where we do millions of tests a day. We are a million miles away from that, or at least 239,000.

Talking of testing, the survey can be found here.

Stay safe.

Each month the president writes a bulletin for fellows and members, keeping you up-to-date with the RCP’s views on current issues facing physicians, and alerting you to new RCP initiatives, policy documents and events. For up to date features and more information, visit My RCP.