The emergency department at Whipps Cross Hospital in London is normally bustling – the usual mix of people needing serious care, others looking for support or guidance and those with nowhere else to go.
In these warmer months, the 26-bed paediatrics ward should have at least 10 to 15 patients needing care at any one time.
However, much of Nadia Audhali’s workplace has felt eerily quiet for weeks. When surveying the scene during the coronavirus crisis, paediatric registrar Dr Audhali has found a waiting room empty of children and a quiet ward with just two, three or four patients in beds.
There are similar stories of rapid change, and potential consequences, across the NHS as efforts to meet the threat of the virus have resulted in very different workplaces and working lives for doctors in all specialties and settings.
NHS England chief executive Sir Simon Stevens said in late March that the NHS had transformed rapidly.
The NHS has proven itself to be adaptable and agile and staff have shown their bravery and brilliance in often desperate circumstances. But the NHS becoming, in large part, the National COVID Service has affected patients and staff far and wide – and questions are now being asked about how it can return to normality.
Patients staying away
For Dr Audhali the effects of change are obvious – and deeply concerning. Parents have been keeping their children away from hospital, for fear of contracting the virus.
‘We are losing chances to intervene earlier… we might be storing up trauma for the future,’ Dr Audhali says. ‘I would have thought there would be a knock-on effect.’
Maternity services have been affected too, Dr Audhali says. ‘These are very vulnerable times for women and I think all this has been quite mentally traumatic.’
These are not just concerns for the present but worries about the future difficulty being stored up. As Dr Audhali says: ‘People may be deteriorating or getting new problems and their threshold to come to medical attention is so much higher. These are all lost chances to intervene.’
West Midlands clinical oncology consultant Jyotirup Goswami tells The Doctor his trust had continued with many operations and was trying to keep any potential backlog as minimal as possible, but that patients on multiple lines of chemotherapy had seen their treatment delayed or deferred over concerns for their vulnerability to COVID-19 in hospital.
Dr Goswami says some surgical procedures had been delayed with surgeons working in other environments, and screening numbers were ‘lower than usual’.
‘Going forward it will be a real job putting the waiting list back in some sort of shape, especially with surgery,’ he says. ‘A lot of trusts haven’t been able to perform major cancer surgery for some time and that is a concern.’
In general practice life has changed considerably. Doctors are largely working from home using video software and online consultations – with the move showing the benefits and limitations of this sort of work. But it is patient care as well as the working environment that has been affected by the virus. Patients’ understanding in not flooding the NHS, and also their unwillingness to access services during the pandemic, are likely to have a major effect.
We might be storing up trauma for the futureNadia Audhali
Merseyside GP Rob Barnett outlines his concerns about patients with potential cancer.
Dr Barnett says: ‘We haven’t been able to refer for eight weeks and of course we understand the reasons for that but practices have been hanging on to patients when they should have been referring them. This has made things very difficult for colleagues. The fact that we’ve not been able to organise simple investigations like ultrasound scans has put pressure on the system.’
Dr Barnett says a lack of visual cues from patients while working remotely, as well as issues such as translation, could contribute to the problem, too. And NHS organisation has also proved a concern for Dr Barnett, with GPs told to work on bank holidays but services such as blood sample couriers not aligned – ‘it’s worse than one arm doesn’t know what the other arm is doing… both arms are completely disconnected from the body in this command-and-control environment’.
Dr Barnett adds: ‘Clearly we are having to deal with a backlog of problems and that’s going to take time to work through the system.’
York GP David Hartley found similar issues with blocks on X-rays, ultrasounds and other investigations – and the knock-on for patients who desperately need endoscopies or other investigations, and doctors who feel ‘increased stress and pressure’.
We are having to deal with a backlog of problemsRob Barnett
In Dr Hartley’s and Dr Barnett’s surgeries the demand from patients is growing – and the key will be whether this continuing demand is from patients who have been sitting on symptoms that need much more urgent investigation or treatment.
And with even minor interventions such as ear syringing proving hard to provide, the knock-on effects for health could be widespread.
Dr Hartley says: ‘We have been seeing two sorts [of patients] – those who have sat on symptoms and regular folk with chronic conditions who have anxieties and things. But at the moment we don’t really have anywhere to send them to investigate. With a cold medical hat on it will be interesting to see if we see a spike in late presentations later this year.’
Dr Hartley says most patients are able to take delays ‘on the chin’, but ultimately the concern is where those delays leave patients and the NHS.
Routine work waits
So, what are the solutions to this potential crisis, particularly in general practice? For many GPs the answers are resources and prioritisation of the opening up of necessary avenues of treatment and investigation. And genuine permission from the powers that be to start routine work, rather than politicians and health leaders simply focusing all their efforts on testing would also be welcome.
‘There needs to be a significant push to allow routine work to start,’ Dr Hartley says. ‘That’s not just hospital investigation but in general practice too. We need to be told to start the routine monitoring of complex elderly patients on multiple medications and check what is happening with potassium and sodium levels and all that sort of thing. We need permission to start routine work again, to get lab results through again.’
Dr Barnett agrees: ‘The question is how safe is it for GPs to be sitting on things before patients get seen in the hospital? There’s no doubt that the things we haven’t been able to have caused a great deal of anxiety for patients and doctors.’
For Dr Barnett ramping up of services and investigations supported by proper investment and influenced by the views of clinicians in primary and secondary care is crucial.
It will be a real job putting the waiting list back in some sort of shapeJyotirup Goswami
The effect of this virus is felt across society – and in few areas more so than the care sector. Nadra Ahmed, executive chair of the National Care Association, says it has been a difficult time for care homes where some of society’s most vulnerable people have faced a challenging period of solitude and loneliness.
Ms Ahmed says getting back to some of the most important aspects of pre-pandemic times – like human interaction, care and attention, nutritional and medical support – while ensuring a ensuring a safe environment is vital. Ms Ahmed says ‘a regime of regular testing for residents and staff as well as families who visit’ will be required in absence of a treatment or vaccine.
There are other vital priorities the National Care Association has identified for the sector: PPE regularly available in care settings with costs at pre-pandemic levels; a more joined-up relationship with clinicians and primary care; the care workforce to be acknowledged and recognised as professionals; funding levels for social care increased; and a secretary of state for social care post to be created.
Care England chief executive Professor Martin Green says: ‘When we get back to normal the care sector will need better support from primary care, we will need technology that will enable doctors to do virtual rounds, we will need increased contact from district nurses and from some of the other professions allied to medicine such as physios and occupational therapists. This pandemic has taught us that health and social care are two interdependent systems and they cannot go back to their previous silos.’
Issues the NHS will be unpicking for months, and perhaps years to come, are wide-ranging and complex. The majority of doctors The Doctor has spoken to fear the effect on current and future mental health, and the possibility that society is storing up great trauma, and in areas such as public health delayed vaccinations and a whole variety of other issues are a cause for great concern.
Guidance from the BMA suggests health leaders should be ‘realistic and cautious’ about restarting shelved NHS work and rebalancing COVID and non-COVID capacity.
The guidance says there must be adequate PPE (personal protective equipment) for health and care workers, decisions about staffing levels and redeployment must be safe and made with employee representatives and measures must be taken to safeguard staff wellbeing.
It also suggests clarity must be given to healthcare workers about the future contractual position and plans to restore training and career development and calls for ‘effective and transparent’ public communication so that patients know what they can and cannot expect, increased remote working where clinically appropriate, local decisions to be guided by clinical expertise.
How safe is it for GPs to be sitting on things before patients get seen in the hospital?Rob Barnett
For BMA deputy council chair David Wrigley the key to restarting services is that health managers do not force doctors back to their old normal.
‘The important thing to say is that doctors don’t necessarily want things to return to “normal”,’ he says.
He adds: ‘There are no quick solutions here – it needs discussion, it needs resource and for everyone to work in the same way. Most of all it needs managers and people in the remote bodies overseeing the NHS to speak to those of us working on the ground.’
It is perhaps the case that the future effect of the coronavirus crisis will not be known for many months, if not years, but the instincts and experiences doctors are having now must be the driving force behind the decisions made in the coming weeks if tragic cases and worrying trends in so many areas of healthcare are to be averted.
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