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Frontline stories: NHS

Carol Propper talks to Dr Melanie Cockroft, a trainee in anaesthetics and intensive care medicine in the NHS. Mel has been a doctor for the past 15 years and has been working in an intensive care unit throughout the Covid-19 pandemic.

CP: I imagine that your final year of training coinciding with the pandemic has made this an extraordinary year. Can you share some of your reflections on what it’s been like?

MC: Since the pandemic hit, it’s just been much busier and we haven’t had an opportunity to stop and reflect properly. In practical terms, how the intensive care unit (ICU) works has changed, as have the kind of patients we’re seeing.

During the first wave, the hospital stopped all services other than absolute emergencies, so we had predominantly Covid patients in intensive care. The rest of the hospital felt eerily quiet as there were no outpatients or visitors and many wards were less full. People were scared to come to hospital and GPs tried to manage more in the community rather than refer patients.

By the time the second wave hit, we had tried to resume as much of our normal service as possible to reduce waiting times. Since then, there has been an absolute drive to do as much urgent elective work as possible. But by definition, the patients that need that type of care are sick enough or need big enough operations to require intensive care as well. Having this mix of Covid and non-Covid patients brings additional complexities in terms of staffing and logistics because of the risk of infection.

Then, sadly, we’re already seeing things as of a consequence of the pandemic, which I suspect will continue for a few years. This isn’t just the direct effect of the virus, but a result of what has happened to people’s lives.

As well as clinical challenges, it’s also been emotionally challenging. In intensive care, we have spent years learning how to break bad news and communicate with families to guide them through probably the hardest times of their lives.  But families haven’t been able to come into the hospital, so we’ve had to do a lot of this by phone and often only invite them in at the end of their loved ones’ lives to say goodbye, which has been incredibly hard.

CP: As you’ve tried to keep urgent elective care going, are the non-Covid patients different from those you’d normally see?

MC: Many of the operations are less ‘elective’, but rather planned urgent operations. In some cases, the patients are less well when we are seeing them. For example, if someone was listed as needing an operation quite urgently in say March last year, but they weren’t able to have it until the autumn, there is a risk that their chronic condition will have progressed in that time.

CP: It sounds like you’ve had to cope with both Covid and,on average, sicker patients. We also went into the pandemic with a shortage of around 40,000-50,000 nurses and a very low number of critical care beds. How has that affected hospitals? Have there been any positive outcomes, for example imaginative use of resources? Or negative, in terms of staff morale, mental health and even burnout?

MC: I came back into the NHS in 2013 after working abroad for five years. The difference in that time was huge and year-on-year since it has felt worse. As you said, before the pandemic, there was already a shortage of nurses, doctors and other healthcare professionals.

Without wanting to sound too romantic about it, we’ve all worked together in these adverse settings for quite a few years, so we just have to get on and do our work. That’s what it’s felt like during the pandemic too.

The first wave seems like a blur now because we were treating a virus no one had managed before or knew the implications of, including for how long patients would need intensive care. We used information available from other countries to help guide us, but it was a bit of a best guess about how to reallocate staff and provide care.

In the summer, we were incredibly busy because of the increased non-Covid workload, but we were able to reflect on the first wave and make plans for the second. One of the main things we took away was that reallocation of staff wasn’t just about numbers. We’re all highly trained people and can be most helpful if we stick to our specialties. So, for example, putting doctors into nursing roles does not work – nurses do nursing much better!

Overall, the teams of people who have worked together have been amazing. We’ve had so many people from non-critical care specialities coming to ICU to help.  On one day you might have had an orthopaedic surgeon and ear, nose and throat (ENT) professor helping roll patients. Crucially, this allows us to keep working in our specific intensive care roles.  We’ve had nurses, doctors, physiotherapists and other members of the healthcare team come from all over the hospital to help on the ICU.

But over the last few weeks, as the Covid numbers have started to fall and elective operating is increasing again, it is very clear that there is no time to rest and recover from what has just happened. And we’re now starting to see the cracks in people who have maybe just tried to hold it together and get on with it, knowing that if they weren’t able to come to work, it would put extra stress on their colleagues.

I think the next couple of months will be hard – we’re still in lockdown which means that staff can’t leave work, go home and do something different. Everyone is struggling with something and worried about each other, so no one feels they can fully offload to anyone else. You almost need to find someone who has had a less bad day than you if you need to talk.

The team morale and team working has been phenomenal, and it has been a pleasure to be part of that kind of response to something. But it’s not finished yet and we’ve still got a lot to go through.

CP: You mention team-working, has this been organised by frontline medical staff? How much of a role has management had in the reorganisation of delivery?

MC: I’ve been involved with the reorganisation of junior staffing on ICU, but at my level the majority of the meetings I attend are clinician-lead.  Clearly, it has been a learning curve for everyone involved, and I think the most successful of changes are made in conjunction with both clinicians and management.  Clinical staff are on the frontline and see directly what works and what doesn’t, whereas management are key to keeping an overview of all the hospital’s services. 

It is a constant balance.  For example, there was lot of redeployment in the first wave, but as hospital services are doing everything they can to continue, we have had to manage in-house and rejig various resources.

CP: Looking forward, as we’re coming out of the third wave, what do you think are the key pressures? Case numbers are going down but there’s this huge back log of patients needing treatment, so how do you see the next year?

MC: The first thing is that we still don’t know the natural time course of the disease and the pandemic. We can make reasonable guesses based on other coronaviruses and other viral pandemics, but we don’t really know how Covid-19 will influence services from now on. Our best hope is that even if there are further strains or waves, vaccinations will reduce hospitalisation and pressures on services. But there’s always a risk that that doesn’t happen.

Logistically we will likely need to provide care for patients with Covid for a while to come, and to be able to keep these, and patients with other conditions, separate as the last thing we want is cross-infection of patients, especially those who are most vulnerable after big operations.

We also have a huge number of patients on waiting lists for both surgical procedures and other medical input. We want people to be treated as soon as possible because we see the effects of that not happening, but we need to do it in a way that doesn’t overwhelm staff who have just worked the busiest year of their lives.

It is going to be a fine balance to provide the care that people need and make sure that staff are looked after and are able to go back to working their normal rostered hours without doing the multiple extra shifts a month that they have been.

I think there will be people who leave the NHS after this, whether it be because they have delayed retirement or because their physical or mental health has changed during the pandemic. But I’ve also heard of people who have seen what the NHS has done this year and want to work here. Any additional recruitment would be amazing but will take many years to come through to the frontline. Intensive care physios, for example, are incredibly experienced and work for years to gain the expertise that really make a difference to our patients’ recovery. So it’s not the case that in two to three years’ time when people have finished university that staff will be replenished.

In reality, I’m not sure what the coming year holds. We say all the time that if there was a little fleet of NHS workers who had been given a holiday for the past year who could come back in and give us all a break for just two weeks it would be incredible. I don’t know is the honest answer and I’m sure that’s how everyone feels.

CP: It’s been fascinating talking to you, and I too wish there was a fleet of people waiting in the wings. I fear not but I hope you do get some rest regardless. Thank you for your time Mel.

Photo by SJ Objio on Unsplash
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