Tackling the Covid-19 outbreak: tales from the frontline

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I have been a visiting fellow at The King’s Fund since 2013, but an NHS hospital doctor far longer. I qualified in 1989 and worked all round the country as a junior doctor, completing all my postgraduate examinations and have been a consultant since 1998 in two different trusts. Right now, I am in the thick of the Covid-19 (coronavirus) pandemic on the shop floor of the acute NHS. Despite all the other roles I have taken on in medical leadership, I have always been largely a jobbing clinician. In 31 years, I have never experienced anything like this.

If you are familiar with my work for the Fund, or other outlets like my British Medical Journal column, you will be used to me discussing policy or scientific evidence or models of care in a fairly dry and dispassionate way. But having experienced the fight against Covid-19 on the front line, I wanted to write something more personal about what it’s like to work in a hospital right now.

I was seeing the same reports as the rest of you, back in January, about the spread of the coronavirus in China and hoping it didn’t come our way, but didn’t give it too much thought as a consultant physician in a big busy district hospital. Things began to hit home for me at the Nuffield Trust Health Policy Summit on 28 February. The Health Secretary, NHS Chief Executive and Chief Medical Officer all spoke at the event. A dozen national health correspondents were present. They were only allowed one Covid-19 question between all for each man. Their answers were calm, low key and designed to reassure, and gave the media little to report. The stated strategy at the time was to ‘Contain, delay, mitigate and research’ the pandemic. Six weeks later, along with the empty roads, schools, offices and streets, our working lives on the NHS frontline have been transformed.

'It has been a remarkable illustration of what can happen if you allow and support frontline staff steeped in service delivery experience to get on with it.'

General practitioners have reorganised their work to provide the majority of consultations online or by phone, minimising contact and travel for patients, as well as organising testing and ‘hot’ centres for patients who might have Covid-19. District nurses and other community health and social care staff have had to support more people at home. Personal protective equipment (PPE) has been lacking.

Partly due to the funding and new permissions in the Coronavirus Act and partly out of duty and collaborative spirit, care homes have been taking more new residents and more returnees from acute hospital – even those who have tested positive for Covid-19 – and are trying to keep more acutely ill or dying patients out of hospital while struggling with having to care for so many residents in isolation, with staff sickness and no families visiting. They too have struggled for PPE and have felt at risk.

As for us in general hospitals, the response has been quite extraordinary started well before the legislation or the key letter sent out in March to trust leaders from Simon Stevens and NHS Chief Operating Officer, Amanda Pritchard. We have cancelled swathes of elective work, moved many outpatient consultations to remote phone and digital models and freed up so many beds that the 95+ per cent bed occupancy has been reduced to 60 or 70 per cent. We have also doubled, tripled or even quadrupled intensive care capacity by redeploying staff and bed areas.

We have swiftly separated our acute front door streams into ‘hot’ patients (people with proven or suspected Covid-19) and ‘cold’ patients (everyone else) and started to test more and get results back more quickly; and created hot and cold areas on wards beyond accident and emergency. Although as the numbers grew, we accepted that initially negative patients would begin to test positive for Covid-19. We have made and followed through escalation plans and increased our oxygen supplies and ability to care for people on non-invasive ventilation, one step below the requirements of an intensive care unit (ICU). We have suspended much of the usual administrative and appraisal work, inspection regimes and rotation of doctors in training grades, doubled and tripled the number of senior and junior doctors on rotas and changed many job plans to accommodate temporary new roles.

All of this has been driven, bottom–up by clinicians, clinical and operational managers within weeks. And as yet the service is still coping. It has been a remarkable illustration of what can happen if you allow and support frontline staff steeped in service delivery experience to get on with it. It has also been a remarkable demonstration of the values of NHS and of those working in social care. There is no question that we staff in daily contact with patients are scared. We know full well that 1 in 10 Covid-19 patients admitted in Italy were doctors, nurses and allied professionals. We know that colleagues from across NHS and social care have been dying or admitted to ICU. We worry we could infect our own families or be unwitting ‘spreaders’ to patients if we have been asymptomatic.

We have struggled to access testing and the right PPE, and some of the advice on both has been confusing and unconvincing. We have seen patients struggling and dying. They are often confused, with no family visitors to reassure them, and often unable to understand why they have been seemingly abandoned by families and why all the staff are dressed in such an intimidating way and less able to communicate, touch or reassure them.

'When this is all over, we must not forget the structural issues around workforce gaps, sustainable social care and public health funding and the number of hospital and ICU beds that were there before the crisis.'

Yet through all this, we have turned up to work every day, surrounded by infection, in and out of restrictive gear and feel frustrated if we can’t come in due to self -isolation. We are sustained by professionalism, loyalty to our patients and to our colleagues and by the dark humour of camaraderie in the face of adversity. The 13 per cent of NHS clinical staff who were trained overseas have been integral to the whole effort.

The outpourings of appreciation from the public have meant a great deal to us all, and we in turn appreciate other key workers who are keeping the national show on the road. But when this is all over, we must not forget the structural issues around workforce gaps, sustainable social care and public health funding and the number of hospital and ICU beds that were there before the crisis. And we should learn from those things that have gone so well so far, and those that could have been handled better.

I am proud to work on the NHS front line and never regretted my decision to be an NHS doctor.

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Comments

Elizabeth

Position
Epidemiologist and member of public,
Comment date
24 April 2020

David Oliver's blog is humbling for the rest of us. We must not forget that there are long-term changes needed to enable a health service that does not get over-stretched and gives good mental health support to those who are facing such frightening situations.

Experto Crede

Comment date
25 April 2020

Speaking for all frontline, thank you.
2012 disorganization NHS decimated by creating a 'free market' with some NHS services becoming emergency services only as in MH. It fragmented and took billions out of the system.

But, in relation to PPE and equipment and resources, it also meant that each GP surgery, each hospital Trust became in essence businesses directly employing staff and seemingly the govt argument has been they, as the employers, had the legal duty to protect their employees by purchasing what was needed. We all hope to God numbers are kept of how many NHS frontline workers die but wonder, then what happens? Is there a public health law duty of care a government has towards front line and public? If nothing else hope the can't do responses of senior managers and exec are now gone for good given can do gets things done. Thank you

Karen Taylor

Position
research Director,
Organisation
Deloitte Centre for Health Solutions
Comment date
27 April 2020

Thanks so much David - your well articulated insights resonate with everything I have seen and heard at my Trust where I'm a NED - albeit my information has come through digital channels not first hand like yours! As you say, some actions were taken early and without direction from the Centre - including staff testing, Oxygen capacity and PPE, Throughout I have been humbled by and proud of our executive leadership and indeed the commitment and caring shown by all of our staff, from cleaners and caterers to clinicians. We have discussed how we can ensure that we capture the lessons and embed the things that worked well,, as I'm sure everyone is doing. One thing i hope we can continue is the collaboration, support and sharing between hospitals, social care, primary care and care homes etc An integrated approach which has proved far too elusive for far too long , the response to this pandemic has shown that where there's a will there's a way.

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