From the eye of the storm to the ward round: How to restart the NHS

As we move out of lockdown, with many of us enjoying picnics, barbecues and a good walk spoiled on the golf courses of Scotland this weekend, thoughts in healthcare are starting to turn towards the tricky problem of restarting the NHS.

Forth Valley Royal Hospital in Larbert, Falkirk. Picture: Michael Gillen
Forth Valley Royal Hospital in Larbert, Falkirk. Picture: Michael Gillen

The myriad issues this presents 
grow more urgent by the day with the total figure of planned operations down 31.9 per cent in March and official figures showing the number of people dying from cancer is already 5 per cent higher than average since UK lockdown 
began.

So, the big question is: “How do you do it?”

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It is widely recognised that there are several problems to address. The main concerns are managing infection control; reassuring a public who were reluctant to contact GPs and head to A&E departments; looking after the safety of staff and patients; and the retention and recruitment of staff.

Doctors and nursing unions are faced with helping an increasingly exhausted workforce who are overdue a well-deserved rest; cope with the existing pandemic and mounting demands for services to return to some kind of normal; and all this played out against the backdrop of a possible second wave of the virus expected to strike next winter.

Key to all of this is the management of expectations at a time when the former “target culture” is thrown out the window in terms of referral to treatment time. People will have no option but to face up to the possibility of a far longer wait for non-life-threatening elective surgery.

To make matters worse there is a huge recruitment crisis looming, as staff who may have put off retirement to help deal with coronavirus decide to call it a day and many question whether a role in the NHS is still for them given all they’ve been through.

Issues around travel within the UK and abroad compound the staffing problems with people who would have taken jobs with the NHS in Scotland finding that mobility in healthcare employment is going to be limited for some time to come.

The problems facing healthcare are multi-layered, something Dr Lewis Morrison, the chairman of the British Medical Association (Scotland) is all too aware of.

He told Scotland on Sunday: “There’s a real risk that if we put a message out saying ‘business as usual’ the referrals will come in their thousands and the waiting times will build up very, very rapidly.

“So, something will need to be done in terms of managing people’s expectations – including things like targets.

“I think the primary aim of whatever we do to start restoring healthcare services has to be the safety and health of both the patients and staff.

“There’s a careful balance to be struck there between those who clearly need to access healthcare for things that would deteriorate or cause people harm.

“People who have concerns about their health in the arena of potential cancer or vascular disease or if they’ve had symptoms that might indicate a stroke then they should not delay contacting healthcare in those situations.

“There’s a layer below that – the kind of things people would go to their GP about or be referred to hospital for, which aren’t immediate or very serious.”

The management of infection control and the impact on capacity brought about by social distancing in hospitals, general practice, social care and other settings will require expansion of personal protective equipment (PPE) and the need for additional staff to provide the time for required “deep cleaning” of equipment and facilities.

Marion O’Neill, Cancer Research UK’s head of external affairs in Scotland, says the innovative hard work that has been going on during the pandemic will need to be integrated into the recovery plan which she says is urgently needed from the Scottish Government to get cancer services back on track.

“As part of this plan, protecting diagnosis and treatment areas from the virus must be a priority,” she said. “This would involve a rolling programme of universal Covid-19 testing combined with adequate PPE.

“We’ve already seen alternative arrangements for checking in at hospital, reconfiguration of waiting rooms to allow for social distancing, as well as using technology to provide patients with home consultations.

“We also know some hospital appointments may take longer as safety procedures may slow down completion of tasks and turnaround times between each patient visit.

“Adequate patient information on what to expect when people arrive at hospital is also important to build public confidence and support attendance.”

The increased use of digital technology is oft-touted by politicians as a “catch-all” solution to dealing with problems around GP visits that may lead to hospital referral.

Morrison says there is an upside to remote, telephone-based consultation that can cut down on the need for travel to medical practices or hospitals.

However, he warns that there are other patients, particularly older people, where the new systems can fall down.

“At its most basic healthcare is about physical interaction with other human beings,” he said.

“My experience of doing remote telephone-based outpatient reviews is that it works fine for some patients but there are others that it doesn’t work for.

“Some older people are tech savvy but there’s the non-verbal part of the consultation that is really important.

“We are taught that as doctors a lot in our communication skills training, that the non-verbal is as important. Even if you’re doing video consultations, we’re not picking up on the same things.

“There are patients who have visual or hearing problems that can be a bit of a barrier.

“There are some patients that I actually need to put a hand on and examine because you can’t do that over the phone or on Skype.”

The new NHS Scotland Test and Protect initiative was rolled out across the country this week as the Scottish Government ramps up its approach to testing as part of coming out of lockdown measures.

Under the system, people will need to isolate with their household as soon as they have symptoms and get tested straight away.

If they have a positive test result, they will be asked to provide details of all recent close contacts to NHS contact tracers, and those people will be contacted and asked to isolate for 14 days.

Morrison said the Scottish Government and the Health Secretary, Jeane Freeman, were being “very cautious” about a return to pre-lockdown activity levels urging that it was “very early in terms of conversations on how to restore NHS services”.

“There’s the potential for a big chunk of a healthcare team to get a phone call saying one or more of you has been in contact with somebody who is potentially a Covid risk,” he said.

“That extra element of what happens to healthcare teams if a proportion of them are told to isolate emphasises that at short notice a certain part of the NHS in the coming weeks might have more immediate staffing problems.”

The pandemic has exposed pre-existing weaknesses, including long-term under-investment in health and care services and flaws around social care.

So, the question of “How do you restart the NHS?” is certainly multi-layered and not without its problems to seek.

A piecemeal approach appears to be the way forward with gradual steps as opposed to an “open for business” message.

Theresa Fyffe, director of the Royal College of Nursing in Scotland, said there appeared to be a willingness from the Scottish Government, NHS boards and health and social care partnerships to learn from the service changes that have had to happen during the pandemic.

She added: “We expect the use of PPE to continue for the foreseeable future and the support for supplies to both health and care services need to be maintained.

“There is a place for learning from other countries, not only in terms of service recovery and delivery but also about the personal impact on the workforce and how to support staff following such an intense period.

“Mobilisation plans need to consider the impact the pandemic has had on the nursing and wider workforce.

“The RCN has been clear that routine testing is necessary to protect nursing staff and those they are caring for. Health boards and care homes need to plan for the impact that increased testing and the test, trace, isolate strategy will have on the availability of nursing staff.

“We need to see testing that is easy to access and available to all nursing staff wherever they work.”

Throughout the pandemic New Zealand under the leadership of prime minister Jacinda Ardern has been held up as a shining example of how to do things correctly and navigate a way through the crisis.

The Cancer Society of New Zealand has worked closely with the country’s cancer control agency and district health boards to communicate with and support people with cancer to ensure they would still have access to the services they need, within a safe and protective environment.

This included transport to hospitals and accommodation while undergoing cancer treatment.

New Zealand has focused on determining what data is available at local area level and what treatment centres, not just for cancer, can provide during the crisis.

They collected relevant data in relation to the delivery of both outpatient and inpatient services, monitored changes in the volume of cancer registrations and looked at changes in the frequency of laboratory and pathological messaging to the New Zealand Cancer Registry.

It is, however, a different story in other countries hardest hit by coronavirus, where staff are experiencing extreme exhaustion and burnout.

In Italy medics are struggling to deal with the ordeal they have come through as the country moves on to Phase 2 after lockdown.

Martina Benedetti is an intensive care nurse in Tuscany and still refuses to see family and friends as she fears she could infect them.

She told the BBC: “I even social distance from my husband. We sleep in separate rooms. Every time I try to go for a walk, I feel anxious and I have to go back home immediately. I’m not sure I want to be a nurse anymore.

“I’ve seen more people die in the past two months than in the whole six years.”

Morrison sees problems in recruiting staff into healthcare which was difficult long before the Covid-19 crisis.

He said it’s not simply a case of saying “Scotland is open, come and work for us”, and is as much about restoring confidence and making the NHS an attractive place to work.

He added: “The UK has been a nation with a big number of Covid infections and the mortality that went with that – on the world stage we are right there near the top of the table in terms of Covid.

“Now asking people to come to a country where there’s less risk of Covid to one where we’ve had a major outbreak of Covid – there’s that.

“What’s almost been forgotten about in the background of all this is the potential effect on recruitment of Brexit. We’re in the transition period and we’re not sure whether that will get extended.

“Going out to the international market looking for doctors or nurses is a big challenge right now.”

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