My commute to my rehabilitation step-down unit for Covid patients in a community hospital takes me through my favourite part of London on foot. It’s a market street in West London where normally the shops are spilling over into the pavement, the cafes are bustling with locals and stallholders are bantering with their regular customers. People stop each other in the street to have a chat and there is a real sense of community here which is unusual for London with its transient population. I remember walking through it at the end of the first lockdown last June and just feeling the relief on the street as everyone came out of hibernation, blinking in the sunlight, believing that it was the end of the pandemic. Now, in our third lockdown, the street is quiet again. There is one market stall selling hot drinks that resiliently continues to serve the locals with a few resolute followers sipping coffee in the icy cold weather. All the shops selling vintage clothes and second-hand furniture have been boarded up and the cafe and restaurant staff stare into space with boredom waiting to serve take-aways. The only shop that continues to do well is the Portuguese pastry shop where they sell the best natas (Portuguese tarts) in London – a small oasis of joy.
Once I arrive at the ward and I have sanitised my hands, I take my temperature and change into my scrubs. We have 19 beds at the moment, eight more than last week, which were rushed into existence to meet the need. We have two doctors covering it with two occupational therapists and two physios. In the UK, we have highly trained nurses called advanced nurse practitioners (ANPs) who work independently like doctors in walk-in clinics. Many ANPs have been redeployed to work as ward nurses and as much as I love having them on the ward, they are far too overqualified for this role but they hide their frustrations well. Even with this redeployment, we simply don’t have enough nurses and they are spread thin across the 19 patients. We need to get everyone home as quickly as possible to free up the beds so that we can receive more from the main hospitals – a tiny cog in the giant NHS machine to process the constant flow of Covid patients. At times, I get called because someone’s respiratory rate has gone up or their oxygen saturations have dropped again and I start the work-up to get them back to the main hospital because we’re not designed, as a unit, to cater for sick patients. More often than not, I’m tying up loose ends – ensuring the blood results are getting better, rationalising their medications, getting them ready to be handed back to their GP – things that they don’t have time for at the main hospitals because they are just so busy.
The pressure is mounting but the one good news we have had this week is that numbers of new cases in London are slowing down although this will only be reflected in the hospital admissions from next week. We have just exceeded the highest number of excess deaths per capita since World War II and the hospitals are facing 70% more admissions than they did at the peak of in the first wave in March last year. The government blames the more transmissible Covid variant but they are ignoring the fact that we don’t have an effective track-and-trace programme in the UK. There is no requirement for negative Covid tests to enter our borders* and there is no enforcement of quarantine. Those who need to self-isolate only get a tiny support package (£500) which is insufficient to keep those living in poverty at home even if they had a positive test. The government messaging is unclear and the rules vague – so much so that even my highly-educated friends are unsure of how to follow the rules. Stories of politicians flagrantly breaking the rules are dismissed by the government whilst the person on the street is getting an ever-increasing fine. Essentially, what I am saying is that there are many simple public health measures that we have missed in order to prevent this virus from reaching our ITU doors. This is not just about transmissibility.
But judgement aside, my thoughts go out to our hospital colleagues who have been working hard over the last few weeks with the likelihood of this lasting a few more. The biggest worry is reaching that saturation point where we don’t have the resources to give the best care we can. As doctors, we are hard-wired to do the best we can and we have been trained to deal with death without emotion but that dreaded introspection occurs when we know that death occurred when we didn’t give our best. We all remember those patients in our lives that we feel guilty about killing, however hard everyone tells you that it wasn’t your fault. I can only imagine the mental health fallout after this pandemic especially amongst our nursing staff who get to know our patients better than the doctors do.
Our government game plan is vaccines and lockdowns – neither a replacement for a well-coordinated well-resourced public health strategy. At the moment, it’s just about pulling together as a nation to get through the surge but I just hope that, once we are through, we can see through the political narrative of blame. This is not just about transmissibility but about doing too little too late. With new variants arising from South Africa and Brazil, I can only hope that our government can be better prepared.
*This has now been implemented on the 15th January 2021
Bibliography
UK’s high Covid spending delivers worse outcomes than peers
In full: Boris Johnson faces grilling from MPs on Liaison Committee
global GP project 