DISCLAIMER: I do not intend for these blogs to be seen as giving clinical advice nor as judging public health policy but rather to recount the lived experiences of family medicine physicians from across the world. I recommend you still follow your local guidance.
The Nightingale Hospitals – six critical care units across the UK to cater for the over-spill from hospital ITU’s – was the innovation of the current government to prepare for the first wave of the pandemic. It opened on the 3rd April amidst great acclaim but it wasn’t short of critics who felt that it was an unnecessary use of limited resources. With an estimated £220 million to set up all six hospitals and £15 million to run for one month with a shady government response on disclosure of the private companies involved, was this money better spent on care homes and community care or was it an opportunity for private industry to profit during a pandemic? The Track-and-Trace system is also not without its controversies – the governments’ wrangling with Apple and Google over the decentralisation of data to avoid privacy breaches has overshadowed its launch and now it appears that the government are ready to postpone or discard the system altogether.
It was in this setting, that I get to speak to Dr Hareen de Silva whom I had met on the RCGP circuit in my capacity as Chair of the RCGP JIC and his on the RCGP First5 committee. At the beginning of the year, he had quit his job as a salaried GP, packed up his things, moved out of Sheffield and was in Costa Rica for an expedition medicine trip. He had just returned on the 21st March and was starting his preparation for his next expedition with the Royal Society of Birds to Gough island when lockdown was called on the 23rd March. Coronavirus has cleared many of our diaries but more so for Hareen with his next expedition medicine trip cancelled leaving him with no job and no abode. Lucky for him, Hareen signed up for the Nightingale Hospital in London through an agency and commenced his first shift on the 18th April. We know that locum GPs have been struggling during lockdown to secure jobs and some have had to apply for the Self-Employment Income Support Scheme which seems insane during a pandemic so Hareen is aware that there were many blessings to be counted.
The Nightingale Hospital in London had repurposed the ExCel Centre which is normally an exhibition centre and venue for conferences. It was set up for 500 beds with the potential to be expanded to 4000 if need be. I have wondered what dystopia we needed to have reached for 4000 to be an acceptable number of overflow ITU patients but I guess better to be safe than sorry or was it a knee-jerk reaction to show our might? Hareen gives me the lay-of-the-land. There were 42 patients per “ward”; 21 patients per consultant; 10 patients per middle and intermediate grade doctors with anaesthetic or ITU experience, even if not current; six patients per ITU nurse and ward doctor (made up of F3’s and GPs with no ITU experience); two patients per non-ITU nurse deployed from elsewhere; and each patient had a clinical support worker (who was a clinical staff member of the NHS but not a nurse or a doctor e.g. podiatrists, dentists, audiologists). The patients would have their obs done hourly and an ABG done every two hours from the arterial lines as well as their personal care by their clinical support worker. There were proning teams led by the physios and a separate turning team. Hareen describes these moments being quite fraught because any of the multiple lines could get dislodged every time that the patient was proned or even turned for a wash. Physically, it was tough – 30,000 steps a day and a break every four hours for an opportunity to doff the sweltering PPE to sit down with the other doctors or eat in the 24-hour canteen before heading back in. The shifts were tough – two days on, two nights on and the rest of the week off on repeat – clearly drawn up by someone who had never had to do night shifts before. This was not going to be an easy situation to work in.
Despite the physical stamina required, Hareen recalled that he really enjoyed his time working there. Not only had he missed the banter but he had forgotten how great it was to work in a team. As a GP, you are your own agent and there are benefits from being an independent practitioner but we can often miss out on the communal aspect of being part of a firm and the ability to share the burden which is more commonplace in hospital settings. Working in a team definitely lightens this load but it does need good collaborative and communication skills. I am struck by the fact that Hareen had a communication station during his training day for the Nightingale which involved being taught how to do succinct handovers with appropriate hand signals to counteract the muffling caused by face masks. I’ve often thought that we communicate badly within the NHS – think of the times that people have been rude on the phone or start screaming at you when you answer a bleep. We are taught a lot about communicating with patients but barely ever on how to talk with each other. I had a non-medical friend tell me recently that they had to listen to a very terse conversation between an anaesthetist and a midwife during the delivery of her baby behind the soundproof curtains which was hugely uncomfortable for the couple but, sadly, is something that I can imagine happening in our day-to-day. Perhaps we forget that patients are more observant than we think and treating colleagues with a sharp tongue can create a toxic environment which ultimately affects the patient pathway. From this conversation, I am really struck by the constructive team atmosphere at the Nightingale. I’ve spoken to a couple of other people who had worked there and generally the experience has been positive. One nurse said that she liked the way that there was real can-do attitude amongst the nurses and, if you didn’t know something, you weren’t made to feel any less. Hareen also says that there was a flat hierarchy and that you could openly discuss your concerns with the consultant without fear of humiliation. I think that says more about our ritualistic behaviour as healthcare staff where our daily practice is about bravado and hiding our insecurities. Colleagues in humanitarian work are often trained in frustration management or team communication because there is an awareness that emotions run high in times of stress and it is disappointing to see that we lack this understanding in the NHS. Seeing so many of my hospital and GP colleagues consider leaving the NHS due to their disillusionment, I often wonder if there are ways that we could create a healthier work environment. We’ve been accused of the NHS being a bullying institution but it is undoubtedly a setting that has been allowed to fester in its unhealthy ways. Hareen and I also talked about psychological PPE, another concept taught at the Nightingale, which is about protecting your well-being in a traumatic time. There were wellbeing teams outside the clinical areas, staffed by furloughed airline staff or retired critical care nurses, who had volunteered so that you could have a chat with a friendly face. The contract for staff was a maximum of six weeks to avoid the physical and emotional burnout. The wellbeing of the staff was finally being recognised as an important factor for good patient care. The stories of the training and working that Hareen regales me with is reassuring as it suggests that we are recognising that healthy teams leads to healthy patients and I can only hope that this is rolled out across the NHS.
Hareen is now working for Track-and-Trace, which went live on the 28th May. It is the British epidemiological tool to trace anyone who has been in contact with a positive case. The aim is to trace the people that they have been in contact with, advise them to self-isolate and to reduce the magical R number. It is run by SITEL, an IT service provider, who provides the remote working platform. He is provided with a secure server on his laptop and he uses his own headset for the telephone consultations.
I ask him how it works. A contact is sent an email or a text message initially to advise them to complete the survey themselves on line. If they haven’t filled it in after a few days, then the Track-and-Trace team call them. A typical consultation involves him asking for their consent and availability for a 30 minute conversation, a symptom history, their whereabouts in the last 48 hours and a diary of contacts. If the exposed person works in an institution, this gets escalated to Public Health England. At the end of the call , Hareen would end with general advice re 111 and public health advice. He doesn’t think any one has lied to him but he informs me that he knows that some people have declined to disclose their whereabouts to colleagues before. Perhaps they are worried about the social judgement or are trying to protect friends and family, who knows? There was a problem in Seoul where they found it challenging to track a cluster that had occurred in a nightclub which they suspect is because no one wanted to reveal that they had visited an LGBTQ establishment in the conservative society. I have been really struck by the level of social judgement I have seen in the time of Corona. I believe it is a very British thing to be bound by societal expectations (think what would the neighbours say) but the coronavirus has made us all inspect others of their social choices. Whether this is about your neighbours having a barbecue or your housemate sneaking off to see their boyfriend, it has given us all an excuse to judge each other. To me, the reticence of disclosing one’s whereabouts seems inevitable. At the moment, the Track-and -Trace service looks like it’s not very busy and Hareen may only pick up a call or two per session. However, there is potential for it to get busier if there is a second wave but now there is political braying about moving onto another strategy. Who knows what is next for our government.
We talk about the future of general practice and the impact of lockdown on our future work. We both suspect that the number of missed cancers, raised HbA1cs (from all the eating and not exercising) and all the chronic disease management will be through the roof. I personally have some hope though. I’ve seen more families cycling on the streets of London and most of my white collar worker friends have started exercising daily to counteract the boredom. I may have rose-tinted glasses on but I am always the glass-half-full person! Hareen has noticed on the ‘Tea and Empathy Facebook group’ that many GPs had enjoyed this time of less patient volume which has meant that we have been able to start delivering better patient care and we both worry about stepping back on the hamster wheel as patients start to come back. Hareen is also worried about the years of fallout we will have from COVID in terms of respiratory problems for those who had been admitted to ITU. The CT scans were terrifying and he worries about the amount of lung damage that his patients have sustained during their illness. What will their exercise tolerance be like? What about future management and complications? So much of the unknown.
Hareen’s parting words are about self-care. These are tough times for everyone with so much uncertainty and stagnation. Wellbeing takes different forms for different people and I feel that COVID has given us all an opportunity to pause and reflect. Looking after ourselves should not be a guilty pleasure and we can only deliver the best patient care if we are feeling fulfilled. The RCGP are running a campaign on GP wellbeing and I really feel that we owe it to ourselves to don our psychological PPE.
Thank you to Hareen for your insight into the British response to COVID-19. It’s always been a great pleasure bumping into you and I hope we can return to a new normal where we can bump into each other in person again!
Here is a link to an article that Hareen wrote for Pulse about his daily routine.
You can follow Hareen on Twitter at @drhareendesilva