Pause to proceed: clearing the backlog created by COVID-19 requires a careful plan

The pressures COVID-19 has placed on doctors are unprecedented, and without a carefully thought out plan to return to business as usual, many will not be able to cope. Tim Tonkin reports

Location: UK
Published: Tuesday 13 April 2021
fatigue illo

‘It’s only since I went on maternity leave that I quite realised how tired I was,’ explains London GP Rammya Mathew.

‘Whilst you’re in it [work] you’re not even getting a chance to stop and think about how the situation is affecting you.

‘Once you step out of that environment you have a chance to look back, reflect and digest a bit of what has happened,’ says the GP. ‘It’s been a year like no other and not everyone has had the chance to even recognise or realise that.’

COVID-19 has tested the resolve and endurance of the health service, and its staff, like no other public health challenge in NHS history.

The focus is on COVID but the backlog of elective care is on the radar
Dr Mathew

Fighting the pandemic has at times felt like total war, necessitating that access to many non-COVID and elective services be limited across primary and secondary care, to free up capacity.

mathew rammaya MATHEW: No chance to pause and reflect

Meanwhile doctors, as with all healthcare staff, have been required to go above and beyond in their duty of care to patients on a daily basis and for more than a year.

While the growing number of vaccinations and falling rates of infection attest that these sacrifices have not been in vain, they do not change the fact that doctors, incredible as they are, are still human beings with physical and mental breaking points.

While efforts against the pandemic continue, attention is already starting to shift towards the vast backlog of unmet elective care that continued to stack up during the course of last year, and is now casting a vast shadow over the heads of an already exhausted workforce.

The extent of Dr Mathew’s mental and physical fatigue is one that many doctors can relate to, and an issue that the BMA has become increasingly concerned about over the past 12 months, particularly in light of what is anticipated as the next huge challenge facing the NHS: tackling the non-COVID backlog.

Recovery vision

To highlight the need for doctors and other healthcare staff to be given an opportunity to pause, rest and reflect on everything they have endured over the past year, the association launched a report Rest, restore, recover: Getting UK health services back on track.

At its core, the paper emphasises how pushing the NHS to return to business as usual in an unrealistic timeframe will put further pressure on exhausted staff and ultimately ‘make it harder for the NHS to recover and provide timely and safe care to patients who need it’.

In doing so, the BMA says the Government and employers must put staff’s safety and mental wellbeing at the centre of their plans for rebuilding the health service by implementing measures to expand system capacity and workforce.

No time to acknowledge what people have gone through
Dr Mathew

The report also calls for ministers to be frank and honest with the public on what can realistically be achieved by staff tasked with tackling the NHS backlog during the immediate post-COVID era.

Failure to do so, it warns, will likely result in worsening morale, burnout and sickness absence among doctors, ultimately making the job of tackling postponed procedures and unmet care needs that much harder.

‘I think we’re in an in-between moment. Largely the focus is still on COVID but definitely the backlog of elective care is on the radar and we all know that it is coming,’ explains Dr Mathew.

‘Patients have been incredibly patient and understanding during COVID. Lots of people have had their care set back multiple times and have been left struggling for a very long time. Expectations are now increasing and we’re still quite powerless in terms of being able to action that.

‘I worry that, given the pressures that there are from all ends, we [doctors] could well just fall into the trap of just being asked to get on with the work and there’s no kind of time to pause or reflect and acknowledge what people have gone through during the pandemic.’

Fatigue compounded

Consultant in paediatric sleep medicine Mike Farquhar has written extensively on the issue of how tiredness in the workplace affects doctors and has previously worked with the association in developing its fatigue and facilities charter.

He says that fatigue and burnout were already huge issues in the NHS even before the pandemic struck and acknowledges that unless steps are taken now to address this, the potential consequences for the health service could be dire.

‘For the last year, the vast majority of NHS staff have been working above and beyond and a lot of people have been burning up their reserves in order to keep doing that,’ Dr Farquhar says.

‘If we keep pushing people, who are already exhausted, into more all that will happen is that they will work less efficiently, get more stressed, burn out and [potentially] leave the NHS, which means the problem of addressing unmet need becomes even greater.’

If we keep pushing people all that will happen is that they will work less efficiently
Dr Farquhar

While acknowledging that there is no single solution to the issue of staff fatigue, Dr Farquhar points to actions already being taken in his workplace that chime with the BMA’s calls for staff risk assessments to incorporate discussions about mental health, and for employers to ensure timely access to occupational health and psychological support.

FARQUHAR FARQUHAR: ‘People have been through traumatic experiences’

‘I’m lucky enough to work for a trust that I think has really put looking after staff at the forefront of everything we’ve done in response to the pandemic,’ he says.

‘[For example] We’ve employed additional psychologists whose role is 100 per cent to support staff. Lots of people have been through very stressful and traumatic experiences over the last year … so putting in the support to staff to make sure that we’re identifying that and we’re giving people the space and time to reflect and address the consequences I think is really important.’

Drop targets

In addition to increased support in the workplace, the BMA’s report urges the Government to not only support the development of COVID recovery plans at local levels, but for an end to crude practices such as threatening trusts with financial penalties if they fail to meet elective care targets.

‘I think there is an argument for saying that we appreciate the waiting lists are severe ,we appreciate people suffer the longer they’re on the waiting lists and the longer care is delayed, but actually maybe it’s better that we aim to get to 75 or 80 per cent of our pre-pandemic levels of activity and then use that time to make sure that staff rotate around and get decent periods of time to rest and recuperate,’ says Dr Farquhar.

‘This is [already] being done locally and some trusts are already looking at things like this, but at the end of the day it comes down to somebody having to justify waiting lists so it’s always a very difficult thing to do given that many trusts’ income is relative to how well they perform on some of these metrics.’

As funding and resources have been central to the NHS’ ability to respond to COVID, so will they be to measures designed to increase system capacity in any post-COVID recovery plan.

The BMA’s report calls for the Government to commit to fund a ‘rapid expansion’ of diagnostic services across all of the health service and to allow employers to bring in additional or locum staff to help maintain capacity while existing staff are on leave or sick.

Flexible working

Dr Mathew says that the post-pandemic era will be a time to consider how care is reorganised and delivered in the future. This will include taking more flexible approaches to work.

‘One of the worries is that there’s been lots of help and resources given to fight the immediate crisis of the pandemic but is that going to continue long enough for us to recover and address all this backlog?’ she asks.

‘Care is going to look very different and we need, as much as we can, to allow ourselves the time and space to deliver care in the way we want to and meet people’s needs. We need some freedom in the way we operate in order to do that.’

London-based foundation year 2 Yousef Eltuhamy is one of thousands of young doctors who have faced a baptism of fire owing to COVID-19.

He says, during last year, he felt his mental health being undermined by the changing dynamic at his workplace, which left him constantly adapting to meet the day-to-day requirements of his job, and leaving him never sure of what he was doing.

‘When the first wave of the pandemic hit, I was eight months into my career as a doctor. Overall it has been a very difficult time,’ he says.

‘The rotas were changed, were more intensive and less respectful of weekends. It meant that getting that recuperation time was very difficult. The work itself was at times exceptionally difficult.

‘Thankfully, that has improved as the cases [of COVID] have gone down but that sort of damage to resilience and reserve persists. While the edge has been taken off as cases have gone down, there is still a long-term impact of having worked through the pandemic so far.’

Getting that recuperation time was very difficult
Dr Eltuhamy

He says that failing to give doctors time to take stock and recover will further reinforce the notion their efforts are not recognised or appreciated, something that could ultimately undermine an already ailing NHS workforce.

‘I don’t feel particularly valued as an individual in the NHS,’ he says.

‘It feels like I am just a number on a rota a lot of the time. Even though I’ve had a supportive experience in my foundation programme so far, there have been moments where it is clear I am actually just filling a rota gap.

‘When you compare this to places like Australia or New Zealand it becomes very obvious that the balance of quality of life and actually feeling valued and useful is more on the side of potentially leaving the NHS either temporarily or permanently.’

Do more

Highlighting the BMA’s report, however, Dr Eltuhamy believes there are many things that can be achieved by the Government and employers that would allow staff opportunities to recover while also improving morale and ultimately the care available to patients.

‘I think employers can do a lot more to help make their staff feel more valued and help retain those staff, whether it’s doctors, nurses or anyone in the workforce,’ he says.

‘I’d like to see employers moving away from online yoga webinars to things that can make a genuine difference such as ensuring adequate staffing, having more flexible working and evidence-based workforce planning, having clean and comfortable rest spaces for people during their shifts. Most importantly making people feel valued and changing the culture in the hospital to make every member of staff in that hospital feel valued, their work recognised and appropriately compensated.’

 Yousef Eltuhamy ELTUHAMY: ‘Damage to resilience persists’

Speaking about the report, BMA council chair Chaand Nagpaul says that while doctors understand the importance of addressing the NHS clinical backlog, but any approach to such a huge undertaking has to be taken appropriately.

If left unchecked, he warns that the levels of exhaustion and burnout among ‘talented and committed healthcare professionals’ could undermine the health service’s ability to deliver care.

‘As our report lays out, this realistic approach must be complemented with a dedicated effort to attract more staff into the NHS, not only to help bring down the numbers of patients on the waiting list, but to fill gaps for existing staff taking time to recuperate.

'The wellbeing of our healthcare workforce must be viewed as a priority for the effectiveness of the NHS. This report gives a stark warning to Government: to ignore the threat posed by burnout is to put future services and patient care
at risk.’ 

Illustration by Simon Grant