Graham Ash

Dr Graham Ash is a Member of the Royal College of Physicians of Edinburgh. He is a former Consultant in General Psychiatry and Liaison Psychiatry, and now works part-time as a tribunal member for the Ministry of Justice, England. He is the Honourary Archivist at the Royal College of Psychiatrists.

This interview took place on 19 October 2020.

Issues with the audio and video quality are due to problems with the internet connection at the time of recording.

Timestamps

00:59 - The effect of coronavirus pandemic on working hours and practices

01:37 - Comments on availability of medicines, medical equipment, and Personal Protective Equipment (PPE)

03:15 - Treating patients with mental health difficulties during the pandemic

06:03 - Structure of tribunals and hearings carried out online

08:31 - Long-term mental health effects of the pandemic and lockdown

11:18 - Long-term effects of the pandemic on the NHS

13:53 - Government response and public response to the pandemic

18:56 - Personal experience of coronavirus (family and colleagues)

22:04 - Effect of the pandemic and lockdown on home-life routines

24:23 - Thoughts on wellbeing and mental health support given to medical professionals

27:18 - Views on finding information surrounding the pandemic

31:18 - Closing comments on the future of coronavirus pandemic

Transcription

Interview:

Okay, so could you start off by just giving your name, your College membership status, and your medical specialty, please?

Graham Ash:

Yes, my name is Graham Ash. I am a Member of the College, have been for over a number of years. I was formerly a consultant in general psychiatry and liaison psychiatry. I now work part-time as a tribunal member for the Ministry of Justice in England. I'm also honorary archivist at the Royal College of Psychiatrists.

Interview:

Thank you. So could you describe how the coronavirus pandemic has affected your working hours and your medical practice?

Graham Ash:

Yes, it has changed it quite dramatically. All the work that I was doing before March of this year has switched from face-to-face assessments of patients and tribunal hearings to online video hearings. So everything now is being done online.

Interview:

Thank you. So have you experienced any particular shortages of medical equipment or the technology you need to do your work? And if you haven't, do you have any comments on the shortages that have been experienced?

Graham Ash:

I haven't personally, because it wouldn't have affected me unless we continue to do face-to-face assessments on mental health wards. But the decision was made by, it was made centrally that those would stop. So it hasn't been a personal issue. On the other hand, I was following the problems with PPE nationally and also locally. My sister-in-law is an advanced practitioner at our local general hospital, with involvement work with COVID patients, and it's fairly clear that there were shortages at the local hospital. So I wrote directly to our MP, really, this would have been mid-April, asking him to sort of consider what was going on locally and whether there was sufficient PPE in, at our local hospitals. And of course, as one does, I guess I received a reply saying that everything was fine. Unfortunately, my sister-in-law got COVID after that, so I'm not sure if it was really.

Interview:

Thank you. So without giving specific names of individuals, are there any particular patients experiences you could share which illustrate the complexities of dealing with patients under lockdown and coronavirus conditions?

Graham Ash:

Yes, my practice is restricted to mental health. The last tribunal that I took part in at a hospital was on the Thursday before the lockdown was announced. So I think it was actually, it was either the day before the lockdown was announced or it would have been two days if it was a Monday, I can't remember exactly. But within a few days of lockdown and it was a fairly scary experience, because of circumstances I had to walk across the hospital, large general hospital, sort of at the end of the afternoon. And it was at that point, hospital was almost deserted, and felt as if it had sort of quite unpleasant atmosphere, as though something was going to happen. In the tribunal itself, we unusually had to consider whether or not the patient would be safer in hospital or at home. Patient was asking to be discharged home. And in fact, we discharged him on the grounds that he would be less at risk at home from COVID than if he would remain in hospital. And that was the sort of balance that we made, which is unusual decision. Since then, in the video conferences that I've taken part in, we've come across a number of patients who quite clearly have deteriorated because of their isolation. So these are people who have an existing severe mental illness and who have deteriorated for a number of reasons, either directly because they've become very isolated and have had difficulty tolerating that, or because they've been cut, they've been able to, been unable to access their usual support from a mental health team and have become unwell simply because they've stopped medication or some other problems have risen. But it's been apparent that people have experienced poor health because of their isolation at home.

Interview:

Thank you. So you mentioned the sort of a different outcome for a patient than they might normally have, i.e. being discharged when they might not have been otherwise. So were there other changes to doing hearings or tribunals online? Is it just a case of replicating what you do in the real world, in the online world? Or are there fundamental changes about who is present and how those meetings are structured?

Graham Ash:

Yes, that's a very good point. The attempt has been to as far as possible replicate a real life hearing. The difficulties are that, what's referred to as connectivity, that those people who are connecting to the tribunal software from outside a hospital tend to connect fairly easily, whereas the clinical staff and patient who are by definition in hospital often have difficulty connecting. So we've had quite a number of hybrid conferences, hybrid tribunals where the panel can see each other online on the screen but the patient or the clinical staff have had to dial in and are speaking on the phone. So the problems with, problems for patients and some extent for the clinical staff in accessing the system that's being used, although actually it's a very good system and certainly superior to sort of the common video systems that are in use like Zoom, but it just, but it's just the problem when you've got you've got sort of often 8, perhaps 10 people, trying to connect. It's inevitable that there's problems. I mean, the other problems are simply that the tribunal has become very, very long. So a tribunal that would last for an hour often goes on, takes 2 hours, perhaps longer even. It's not ideal, but on the other hand, it does have certain advantages. It's a lot quicker to get to and get back again.

Interview:

Thank you. So do you have any thoughts on what the longer term mental health implications of the pandemic and the lockdown will be in coming weeks, months and even years?

Graham Ash:

Yes. I became quite, well, interested in this when the lockdown began. Because one of the sort of questions I was trying to ask myself really was what, in terms of my role as archivist, what should an archivist be doing in the middle of a pandemic, which I think is obviously my side, that's something that we're doing just at the moment. What I turned to was to look at Spanish flu as the nearest sort of comparator. And with the librarian at the Royal College of Psychiatrists we put together a sort of scoping review, if you like, or narrative review of publications about Spanish flu and mental health. And I think what became clear was that there's certainly a risk that there will be an increase in the number of people developing psychosis. So the people who have COVID may be more at risk of developing psychosis, as seemed to be the case with Spanish flu. There's no evidence for that at the moment, but it's obviously matters being, there's a study that's observing that. Then, as I mentioned, there are problems for people with established mental illness - that they're likely to suffer worse health than they would have done otherwise. And it's almost inevitable that's going to be the case. Plus the fact that, plus the wider population, people who haven't previously had problems with severe mental illness, it's very likely that once the restrictions are eventually relaxed, that there will be lots of people who suffer from problems like agoraphobia, phobias about contamination, anxiety and so on. There's also then of course the problems of staff. It's very well described at the moment. I was concerned about people becoming burnt out, developing PTSD because of their experiences looking after people with COVID. There is, I think [you never forget before that], but I think it would be delayed. It was not going to be a parent initiative immediately.

Interview:

Thank you. So in a similar sort of vein, do you have any thoughts on what the long-term impact on the NHS will be? Do you think there will be changes to how things are structured or funded as a result of the COVID pandemic?

Graham Ash:

Yes, you would like to think so, whether that will happen, it’s difficult to say, isn't it, really? I think there's going to be certain resistance to change that will come into play. I mean, there's lots of talk after the first wave about needing to restructure, change things. And then, of course, things are, we're now facing a second wave, so-called, and it's unlikely it's going to be able to, changes are going to be made until we're in a better position. And of course, we don't quite know politically what will happen at that point. I think that it's fairly clear that public health needs to be strengthened because it's fairly obvious. There's no need for any Royal Commission to see that the way that public health was allowed to, was run down since the 2007 Act, at least in England. That’s the NHS Act. That surely has to be reversed because it's clear with this pandemic that, you know, the first line is having public health services, I would have thought. Consequences for everything else, I can't speak for anything else apart from mental health. I think one can see that they'll very, very likely to be greater use of tele sort of tele medicine, if you like, than previously. We'll probably again, you know, it's what, it's like everything that was probably going to happen anyway, but this will have brought it forward by a number of years. But I think, you know, talking about the video, the problems with videos for mental health tribunals I think what that brings into play is the fact that the NHS IT stock is really often rather obsolescent and perhaps inadequate and needs to be replaced if that's going to work effectively.

Interview:

Thank you. So following on from that, do you have any comments on how the government responded to the pandemic, you know, the rules and regulations that were brought in, either the UK government or the Scottish government?

Graham Ash:

Sure, I’ll talk about both. Start with the UK or sort of government in England, I guess, really. Yes, I think that there's some fundamental errors really. I think firstly, the delays that are obvious in taking action throughout the pandemic, but beginning, perhaps from January this year, when it became evident that COVID was spreading, the sort of the long lag before actions were taken. It was quite problematic. So, there's a need to consider how that can be prevented in, should it be required in the future. Sorry, I've just lost the thread of the question. I'm sorry, could you?

Interview:

Do you have any comments on how the governments responded to it, both the UK government and the Scottish government?

Graham Ash:

Yes, sure. I think the other critical issue I think is the use of rules and law and sort of quasi law rather than an attempt to educate the public and at least in the first instance, because what concerns me rather, particularly in England, is that people have been sort of bombarded with three word or so phrases that are meant to encapsulate the actions that they're required to take without any underlying, without being given any underlying understanding of the reasons for that. And I think although they might seem very obvious, I'm not sure that they are to everybody. And I think there's a, unfortunately in the English character particularly, there's a strong sort of tendency to resist being told what to do and to do the opposite. And so I think, for instance, with mask wearing, the exhortation to wear masks has led it certainly initially to a lot resistance. To me, the scientific evidence is fairly compelling. I did a short online course and part of that was just simply watching one of the videos from one of the experiments that show droplet exhalation and the effect of wearing a mask as opposed to not wearing a mask. And I think that was so visually compelling that you sort of think, well, there's no argument about this. But on the other hand, being told to wear a mask as people are hasn't really seemed to be all that successful at least certainly not [part of] where I am. So I think that the tendency to go down the legal route and to overemphasise the balance between health and against economic interests and tendency to follow economic interests rather than health interests has led us into quite a lot of difficulty. That's the sort of, you know, the picture that as it seems to have been in England. I think the Scottish government, I have watched quite a lot of the briefings that have been given in Scotland, I think has taken a far better route. I think it's far clearer from the briefings from the First Minister in Scotland and the Scottish chief medical officers and so on. I think their briefings are far clearer and I think a far less are inclined to tell people what to do rather than explain to people what they need to do and ask them to do it. It's a difference in approach that might not, perhaps not easy to explain, but seems to me far better. I certainly think that's what's happening, that's reflected in the polls about public opinion in England and Scotland.

Interview:

Thank you very much. So the next questions I'm going to ask you are more about the personal impact of COVID on you. And just a reminder that if there is anything you don't feel comfortable answering, please just say and you won't be pressed on it. So, I'm not Paxman. So have you had or do of any colleagues, friends or family members without giving names of individuals who have personal experience of contracting coronavirus? And if you're comfortable doing so, could you describe those experiences?

Graham Ash:

Yeah, I mean, the closest would be my sister-in-law, who is, as I said before, is an advanced practitioner. She's a nursing advanced practitioner. Works on acute admissions ward, medical acute admissions ward, and was found to be positive when she returned to work after a weekend. She'd had a few days off. We had been to visit her the day before and she went back to work. I think it was part of the, at that point it was part of the protocol for staff to be tested for, when they returned to work and she was, like I said, she was positive and was off work for a couple of weeks after that. Fortunately, she wasn't too unwell with it. And she's made quite good recovery, she's back at work now and so on. A colleague of mine who is fairly prominent in the Royal College of Psychiatry in fact announced to the faculty that he's an executive of that he had COVID and he works in liaison psychiatry so he's involved in assessing patients in general hospitals. My own sister who lives near London had developed COVID and in fact had a pain syndrome following that. So I'm not quite sure whether she's been followed up. There's a corona, it's called coronerve, it's called the coronerve surveillance study. I suggested that her GP referred her to that, but I don't know if she's been followed up with that, but she's recovered from that now but she was quite unwell for about a month. Our next-door neighbours who are both, well, yes, I mean, both doctors, one who is GP developed COVID. We know that because she was to test positive. Two other neighbours also thought they had COVID, we don't know whether they did or not, but they sort of self-isolated. So it's been around.

Interview:

Thank you. So could you describe how your home life routines have been impacted by the pandemic and the lockdown?

Graham Ash:

Yes, sure. I guess the biggest difference is that the days that I work, I usually work one or two days doing tribunals a week, that instead of going out to the hospital to do the tribunal and now do the tribunal sitting where I am now at home. So I don't leave the house, for work reasons I don't leave the house. For sort of, well in fact for other purposes, we have quite considerably restricted our time going, outings from home. But when the lockdown, during the lockdown, we would go out once or perhaps twice a week to go shopping and that would be about it. We've maintained a sort of practice of going out for a reasonable walk each day, since the golf courses we reopened we carried on playing golf about once a week. I say that's about that's about it really. I think we're in a strange position where, if we'd had perhaps more family responsibilities, we would have been affected a lot more, I think. I guess the other sort of social issue is that we belong to a synagogue in in Manchester and that has been closed throughout the lockdown, still is. So we keep in contact with other people from our community by Zoom. That's, you know, that's, otherwise that would have been an outing each, usually once a week or so.

Interview:

Thank you. So given everything you said about the professional and personal impact of COVID and the lockdown. Do you think there is sufficient support for the mental health of medical practitioners? And do you think there's anything more that is needed at times like this to support medical practitioners?

Graham Ash:

Sure, yes. Well, I would surmise not, you know, that there's a need for more, although, you know, obviously don't have, don't have evidence for that to just, it would just really be from a sort of medical common sense point of view that you would expect it because the stress and strain on clinical staff is obviously a lot greater. I mean, I've worked in the past in, not infectious diseases, but I worked in a equivalent of a virology lab for six months at one time. And you certainly know the difference between working in an environment where you, where you, are potentially at risk of acquiring infection and one way you're not, you're not concerned about that. And I think really that, the, I think, although one gets used to it, I would imagine that this underlying concern for staff about acquiring infection, but also more, I think perhaps more of, of more concern [seems to be and one sees this] quite a lot on television, it's really dealing with patients, people who are very sick and when people die, it seems very distressing for people, the fact that there's been no contact allowed between relatives and people who are in their last hours of life. So really quite a serious situation and I imagine one that's very difficult for people to deal with. I know, I, as it were, signed up to become a mentor or a counsellor for doctors. A scheme was set up. It was a sort of second wave scheme after the first call for volunteers to go and go back to work. But i fact, I've never heard anything from that scheme. So [one wonders] really quite what's happening there. I'm not terribly surprised [it was not terribly well organised].

Interview:

No comment from me. So finally, where do you look for accurate information on the pandemic? And do you have any comments on the use of social media and the internet to disseminate information to the public?

Graham Ash:

Right. Yes, where I go… [for] sort of general education, as it were. I found the webinars that the colleges organised, I found those very helpful, particularly in the early phases of the pandemic. I've got a very clear memory of intensive care consultant from, I think, Brescia in North Italy, gave a very dramatic presentation. I say dramatic, he wasn't dramatic, it was the situation that was dramatic about the, about the experience in Italy, particularly with intensive care for patients. The Royal Society of Medicine in London have been running a COVID webinar series and I have tended to watch that and that's I think fairly authoritative because most of the speakers are pretty high level. Where we go beyond that is it sort of starts off, it's like The Lancet COVID collection and so on. I think there are also difficulties at the moment aren’t there because even published information is [of] variable quality. [I have] a personal contact who's an epidemiologist and writes his own blog that where he reviews whatever, you know, whatever happens to be going on, which I think is quite useful. Don't take that as being 100% reliable, but he's writing from a professional point of view as an epidemiologist. I think the newspapers can be useful, television. I think that the really concerning things are some of the information that goes around on social media. Things like the QAnon, not sure what you call it really, whether that's a conspiracy or whatever it is, but some of the information that's available and can come from any sort of source, I think can be quite harmful. Yeah, I'm not sure, I'm just trying to think if there's anything else that I've used really. I think that's, I think that’s been the main source. I mean, I've done a fair amount of literature searching myself, but that's I think that's open, you know, open to any anyone who's got access to Medline and so on to do, I would say, but it's not necessarily something that I'm not quite sure if you can get onto Medline and so on if you don't have access medically somewhere or the other. So yeah, there's [never] been a shortage of information, that's for sure.

Interview:

No, absolutely. So we're about to wrap up, but is there anything else you'd like to say that you haven't had the opportunity to say or a conclusion that you'd like to give?

Graham Ash:

I think we're, we're in this for a bit of a while to come, I would think. I mean, I think really it will take it, I think it takes a little time for the penny to drop and for systems to change, but I think that at the moment we're still coming out of the phase of expecting that this is all going to go away. And I think you asked before about changes in the NHS, I think really until it's generally conceded that COVID's with us for a time, we're not going to see that change. And I'm not desperate hopeful about vaccines. And there will be vaccines, but of course we don't know as yet what effects those vaccines will have. So it may all be that, I think we're, you know, we've I think we've been advised recently that there could be a vaccine as early as beginning of next year, but I suspect that that's going to simply reduce the severity of the infection and the mortality rather than reduce the spread. So we've still got a way to go, I think.