Doctors’ personal and professional lives have altered significantly since the COVID-19 pandemic recalibrated the UK and its health service.
They have risked themselves on the front line, often cut off from their families and friends. Work patterns have altered for better or worse.
For some, working from home has highlighted the pressures of life in the NHS before the pandemic. ‘The lack of a daily commute, the comfortable and quiet working environment, and the challenges of adapting to new ways of working have all made me thrive,’ one consultant at Birmingham Women’s and Children’s NHS Foundation Trust says. ‘Sadly I think this speaks to the poor state I was in pre-lockdown.’
So, as lockdown eases, which of these new practices will become part of the ‘new normal’ in the NHS? What has the profession gained and lost? How can and should the profession adapt?
Below, doctors describe the new challenges of training, the fragility of locum work, and how eased pressures in some areas allowed medicine to be practised as it should be.
Walsall child and adolescent mental health specialty trainee 6 Ann Paraiso raises concerns about completing the competencies she needs to become a consultant. An ST3 in the south of England talks about the terror of watching a colleague die from COVID-19.
An emergency medicine consultant celebrates having the time to practise medicine while attendances dropped. A locum GP and mother writes about work drying up and the challenges of juggling her career with childcare.
Many of the issues raised are already being addressed by the BMA. It’s calling for better support for doctors who need childcare.
‘It’s only right that the Government supports them so that they can care for patients,’ its representative body chair Helena McKeown says.
Its Dr Diary app, which helps members to keep track of work patterns, has been updated. An ‘alert’ system flags when inputted workloads are out of kilter with job plans.
BMA sessional GPs committee chair Ben Molyneux says access to work for locum work is now improving from its previous fragile position. ‘However, there are a number of locums who are struggling financially with limited options,’ he adds.
The junior doctors committee is working hard to address trainees’ concerns.
The lives of doctors are sure to change further as lockdown eases and the country braces for further possible spikes and outbreaks in COVID-19 cases.
Doctors will do what they’ve always done to survive. They’ll adapt and learn and press to improve and support their profession and patient care.
The names marked * have been changed in the following piece
An assault on the senses
It’s a profound psychological challenge for an entire workforce to realise their own mortality while coming to terms with the fact they, their family or their colleagues may not make it through this.
The atmosphere in the hospital when our first colleague died from COVID is something I won’t soon forget. The terrified look in people’s eyes and the tension, every interaction with colleagues bombards your senses, as they talk of concerns, fears of the unknown.
That mantra of ‘most people are fine, they don’t become critically unwell’ is hard to keep up when all you see and hear about are those at the critically unwell end of the spectrum.
I’ve also seen a colleague, a nurse, well known throughout the hospital, surviving, after she was admitted weeks beforehand, very unwell. She was clapped out of the ward through the entire hospital to the front entrance.
Then there’s the effect on my personal life, on my wife. We are expecting our first child. It’s not the pregnancy we had planned for. She is unable to enjoy sharing this with her family. We are unable to plan where we will live as rotations are paused. We had planned to move nearer to family for support.
I’m unable to share in aspects of our pregnancy too, unable to be there with her at scans owing to social distancing. The hardest thing to deal with is the potential risk I come home with. We talked about living apart. Despite my wife having the final say in not wanting to move apart I still feel guilty at not putting up more of a fight. One thing is for sure though, I wouldn’t have mentally survived this without her.
David Jones* is an ST3 in the south of England
It can take months to settle into a new post but it’s been trickier for my latest one. You work very closely with your multidisciplinary team in child and adolescent mental health. Yet there are members of mine, nurses, psychologists, and secretaries, who I still haven’t met since starting in February.
This is my last post as a registrar before applying for a consultant post next year but there are worries that competencies might not be reached and that CCT [certificate of completion of training] might be put off. I was lucky enough to get assessments done when patients were coming in. My supervisor has been reassuring in our regular meetings via Microsoft Teams. But there are still lots of unknowns.
Virtual meetings are an absolute godsend. Why would you travel hours for a one-hour meeting? It can take two hours to get to one in Birmingham if stuck in traffic. It’s ridiculous you have to do that in this day and age.
Giving young people the option for telephone or virtual consultations could be a good thing to come out of this. It’s important that we see them and are able to monitor physical health. Virtual meetings or telephone contact may, however, increase contact without increasing pressure on the service.
Day-to-day work with patients and families has changed significantly. Unless it’s an emergency or urgent, we don’t bring them in. Contact is by telephone or virtually. I’m going to look into how this is for patients formally. Some say it’s the best thing ever because they don’t like face-to-face. People with autism or high anxiety can find it easier to communicate over the phone.
Others find it very distressing. I’ve not yet met some of the young people I work with. Introductions in consultations are now very different. It’s about reducing anxiety levels first.
With young people going back to school, I feel we may see a real spike in all kinds of crises. They are worried about COVID-19 and social distancing in schools and more up to date than we give them credit for.
We know that things won’t be the same and for young people that will be massive. I can’t even say as an adult – and parents can’t reassure their children – about how things will be. That’s a very abstract and hard concept to grasp, especially if you’re autistic or young.
Ann Paraiso is a specialty trainee 6 in child and adolescent mental health in Walsall
Caring in the secure estate
Much of my day used to be spent on the wards in the high security hospital where I work. I now step on to them briefly, with surgical mask and visor, and only for tasks which can’t be done remotely, such as medical emergencies or seclusion reviews.
Ward rounds are by video conference. With security an issue, laptops are placed at a safe distance from patients. They squint at the blurry images, trying to pick out which one is talking. It’s me. The background is computer-generated, obscuring my home. It’s strange, impersonal and very odd to be talking to high security patients from my living room.
Most of the patients’ usual activity has ceased as staff are required to work remotely where possible. There is no more woodwork, horticulture, or face-to-face therapy. For days on end, they set eyes only on nursing staff or their peers.
I am as ever impressed and inspired by colleagues of all disciplines for their ingenuity and resolve in providing as much support and activity as possible within the limits of these odd times.
We’ve opened a Nightingale Ward within the hospital for enhanced physical healthcare when general hospital care is inappropriate, no longer necessary, or unavailable; fortunately not an issue so far. It was opened in a timeframe that China might envy.
In line with national changes, we’re now moving gently towards more usual ways of working. They seem so long ago. Limited face-to-face work with patients is recommencing. While we remain behind masks at two metres removed, a semblance of normality is returning. It’s very welcome.
James Long* is a staff, associate specialist and specialty doctor in a high security mental health hospital
The new fragility of being a locum
‘You’re no longer needed,’ they told me the weekend after lockdown. Like many GP practices, their need for locums, like me, vanished overnight with COVID-19. Patients stopped coming to surgeries; partners and staff could not take holidays or time off for other work, such as minor surgery.
I always knew work as a locum was unpredictable or could end suddenly when I became one last summer. But I’d never considered the context of a pandemic.
There are very few shifts available now. You previously saw one or two people apply for a session. After lockdown, it was more like 25. Those that do come up are in hot COVID hubs. It worried me to do this face-to-face work with two school-age children and an emergency medicine consultant as a husband.
You don’t get sick pay as a locum and death-in-service payments are unfairly reduced if you die on a day when you’re not on shift.
This new fragility of locum work is unsettling and financially concerning. I’d feel stuck right now if I was the primary earner. It was more difficult to find work with the schools shut.
All those informal childcare arrangements you rely on as parents have disappeared. Family and friends can no longer share pick-ups while social distancing remains.
I’ve put in to work for NHS111, where the patients have gone. I hope it will start to replace some of my lost income. These are unprecedented times and there has been rebalancing. Work as a locum certainly feels more fragile.
Sally Lang* is a locum GP in east London
A transformed emergency department
I love emergency medicine and because of COVID-19 I’ve had the time and space to practise it properly – instead of being swamped as in recent years.
We’ve doubled the footprint of our emergency department. There were more doctors, when elective work was put on hold, and fewer attendances in line with national trends.
GPs and ambulances seem less likely to send or bring patients to hospital. There’s been a change in attitude from the public. People appear more accepting of care in the community; they’re becoming aware of the dangers of hospital. Daughters and sons are more willing to have their parent home as soon as possible. They are ready and willing to facilitate transport home. It’s made a huge difference to the number of patients attending the emergency department.
It has, however, been terrifying that we’ve had fewer attendances with significant conditions including heart attacks, strokes and appendicitis that shouldn’t have been affected by COVID-19 and the lockdown.
Also worryingly, we’ve seen fewer people suffering with domestic abuse than we expected. We know it’s likely to be more prolific during lockdown. We’ve found, however, that the quality of our domestic-abuse assessments has improved exponentially. We have had time to delve into issues and explore concerns in a holistic way, and to record this information in detail.
When juggling an overcrowded department – as was the case pre-COVID-19 – the team only had time to ask the basic, essential questions and notes were written in extreme haste.
Junior staff have had more time to take extended histories. Senior staff can spend more time with them and have more opportunity to review patients face to face. Junior staff learn by observing these interactions.
And so we can pass on better information to other services such as the police and independent domestic abuse advisers. They can then make more nuanced plans, and respond more promptly and appropriately.
We’ve had time to organise extra support or alternative plans for patients, so we can treat people effectively in the community, avoiding admissions.
Having time and space to practise true emergency medicine, like this, is good for patients and reduces other departments’ workloads, and bed occupancy. There’s been more beds for those who do need admission, so patients are not left waiting hours in the department before moving to wards. Patients have almost always been admitted within the four-hour standard.
Staff have also received amazing psychological support during this time. The stress of working in an overcrowded department – meaning staff can’t provide the standard of care they want to – has affected us for years. It is now more openly discussed and accepted.
We’ve got a ‘wobble room’ where you can go and just take a moment, breathe, sob, cry or think. We have access to meditation and mindfulness programmes and trained counsellors are at the end of a phone. We’ve had access to proper food at whatever time – even in the middle of the night. We’ve got emergency rotas with extra flexibility built in, in case of physical illness but they also allow people to admit psychological illness and say, ‘I can’t face coming in today, I just can’t’.
This time and space to practise emergency medicine, as it should be, has been a unique opportunity. There is a vast amount we can learn. What we’ve been doing in the first weeks of COVID-19 is not sustainable. We can’t keep cancelling elective procedures, asking staff to work in alternative areas and using every inch of space for emergency presentations forever.
But what we were doing before wasn’t sustainable either. Our emergency departments were swamped, the very definition of a major incident, like COVID-19, but without the whole system response and additional resources.
Susan White* is an emergency medicine consultant in the south-west of England
Safeguarding doctors’ rights and health
The BMA has kept close track of the many changes which came with COVID-19 and is leading efforts to safeguard doctors’ rights
The association last month reached an agreement with NHS Employers that flexible working practices, introduced to tackle COVID, do not become permanent by default. It has started talks on how junior doctors can be properly financially rewarded for increasing weekend on-calls to help battle the virus. Many have worked more than the one in two weekends which their contract allows.
As patient numbers in primary care start to return to previous levels, GPs are calling for secondary care referral pathways to be re-established. While continuing to use the digital technology so prevalent in lockdown, they want the pendulum to ‘swing back a little’, says BMA GPs committee chair Richard Vautrey.
‘General practice is built on long-term relationships and face-to-face contact,’ he adds. The committee is concerned about how mass vaccination programmes, such as for the flu, will be delivered with social distancing arrangements. Some demands on GP time is also increasing. Hospital clinics are expecting primary care to carry out investigations which they would otherwise do. There are concerns also about increasing home visits for shielding patients.
BMA junior doctors committee chair Sarah Hallett says the JDC is working with health education bodies on ‘no-fault’ ARCP (annual review of competence progression) outcomes when training has been adversely affected. It is also pushing for fair and equitable responses to disrupted recruitment in specialty training, and for doctors to start taking annual leave, and for that leave not to be lost. If it cannot be taken as leave, it should be available as pay.
The BMA staff, associate specialist and specialty doctors committee is raising concerns about on-call rotas becoming more onerous as working patterns change. In common with the rest of the BMA, it is raising alerts about the lack of PPE. ‘Black, Asian, and minority ethnic SAS doctors are also extremely concerned about the effect of COVID-19 and their health,’ says SASC chair Amit Kochhar.
Medical academics are being supported with their contracts – and ensuring they are properly paid – after being moved out of university and research to more frontline positions in the NHS, and back again, says BMA medical academic staff committee co-chair Peter Dangerfield.
The BMA public health medicine committee aims to learn from the vast international effort about how to rebuild capacity and capability at home where it has suffered from years of austerity cuts. It is keen to lead the debate about the future of public health when its response to the pandemic inevitably comes under heavy scrutiny.
BMA consultants committee chair Rob Harwood says consultants must be involved in redesigning health systems for the new normal. He will be calling for investment in hospital IT to help more doctors work from home. Consultants will press for staff to be given time to rest. ‘Many people gave up leave, worked in awful work patterns, took on all sorts of new responsibilities,’ he says. ‘We need to recognise that, despite the mountain of elective work.’