As the UK edges toward the festive season and the traditional winter months draw ever closer, Dr Andrew Stradling, Clinical Director of Urgent Care Medway & Swale ICP and Emergency Medicine Consultant at the Medway NHS Foundation Trust, has called on healthcare sector leaders to closely engage with staff on the ground and ensure that they have the support that they need to cope with impending pressures.
Dr Stradling’s professional expertise covers a range of disciplines including Paediatric Emergency Medicine, Resuscitation, Trauma, Simulation and Education. Speaking exclusively to The Leaders Council of Great Britain & Northern Ireland, he reflected on how the pandemic had affected emergency medicine across the two waves of the virus seen in the UK to date, and how the health crisis had taken its toll on medical research and the NHS workforce.
Covid ready, hospitals empty
Reflecting first and foremost on the first wave of Covid-19, Dr Stradling identified that there were two main phenomena seen within the Medway NHS Foundation Trust’s patient population, those being the proliferation of patients suffering from Covid itself, and secondly a drop-off in the number of patients presenting themselves to A&E facilities with other conditions.
Dr Stradling recalled: “During the first wave, firstly we had a whole new set of patients with a fairly poorly understood disease, and there was disappointment within the medical community that it appeared each country was finding out about Covid for itself. We were learning lessons about how patients presented, how their clinical condition varied and deteriorated, and about when they needed critical care. It felt like we did this in isolation globally, rather than learning from other nations that had had their peaks before we did. So, there was that cohort of patients that were attending emergency care with significant illness from Covid, and also with that fear of the unknown.
“Secondly, there was our other group of patients who would normally come to emergency facilities with more everyday injuries and conditions. These numbers of patients that we’d normally see daily completely fell away and there was a real concern both locally and nationally that we didn’t know where these patients were. They weren’t presenting themselves to primary care, and clearly one would expect that significant illnesses like heart attacks, strokes, internal haemorrhages, etc would still continue to occur, yet we were not seeing these patients coming into emergency departments.”
Even as the first wave began to subside, Dr Stradling and his colleagues continued to find that the numbers of emergency patients did not begin to level out to pre-pandemic levels, although this did change as the second wave of the virus began to appear.
“Interestingly, after the first wave and easing of lockdown we never saw a surge in numbers for these types of patients. I am fortunate in my department that we have a very effective front door model with primary care on-site. The emergency department only really see those patients that need emergency specialist care and those numbers entirely dropped away. Normally in my department pre-pandemic, we would expect to see between 450 and 500 attendances daily. During the first wave we saw between 100 and 120. On reflection, we had perhaps wrongly assumed where the workload would be and had changed how our junior doctors were allocated around the hospital. For periods of time in my department, we had more doctors in than patients, which is something I have never experienced before.
“The second wave I feel has been more insidious. It has been slower to build up in terms of patient levels and there has been an increase in the patients coming in again, because I do not feel there is the same level of fear around Covid within the population. We are now seeing more significant numbers of patients coming to us with non-Covid-related illnesses and injuries. Our injury numbers were right down before because people were staying at home. But in the second wave, the lockdown is less stringent and people, it seems, are less compliant because there is less of an element of fear and so other illness and injuries are still happening and care is needed.
“We are also getting to grips with a different type of patient in this second wave too, in the first wave we saw our critical Covid care wards becoming overwhelmed and we were exploring the possibility of using Nightingale hospitals. Within this second wave cohort of patients we are seeing many hospitalised patients with Covid again but not as many of them require critical care, so it seems as if the first wave could have effectively wiped out those more vulnerable patients.”
However, despite the lack of emergency patients presenting themselves at hospital with non-Covid related issues during the first wave, Dr Stradling revealed that this has not correlated with an increase of sudden death in the community as has been seen elsewhere, perhaps helped by the fact that people were remaining at home.
He said: “We were not actually seeing or hearing about an increase in sudden death in the community in Medway during that first wave, even though one may expect that to happen. It is, however, an area of consideration and research because we do not yet know what has happened to those patients that would normally be coming into hospital.”
Research and education hindered
Elsewhere within the NHS, there is the opinion that the acceleration of the digital agenda brought about by Covid-19 has been largely beneficial for education and the sharing of ideas and knowledge, yet this is not a view that Dr Stradling aligns himself with.
He elaborated: “A lot of research has been forcibly put on hold by the pandemic and many things including education have also been affected in a number of ways. Soft things such as conferences and academic meetings were entirely halted and then resumed online, but I feel that meetings and seminars with more than a couple of people attending lose much of that free interaction and free sharing of ideas. Those kinds of interactions where we gather people together which inevitably produces ideas and new perspectives have been lost.
“On the plus side, there has been much research clearly carried out on Covid itself, not just on vaccines but on what the treatment modalities are and what is effective in suppressing the virus and what isn’t.”
Physical health to improve and mental health to suffer amid winter burden
What has become clear as the pandemic has wore on in the UK is that the population is becoming far more health conscious, and while Dr Stradling acknowledged that this could have a positive effect for the physical health of Britons in future, he was concerned that the same benefits post-Covid would not be seen in mental health, with the strain on providers of such services only set to increase along with the typical NHS winter pressures.
Dr Stradling explained: “I do not feel that as a population we were very good at practising hygiene as a whole compared to some countries, and we are very free and easy with antibiotics. Many clinicians have been warning for a long time about antibiotic resistance as a future threat and the dangers of superbugs, and the general public at large having now lived through this may now have some appreciation for that because of the global impact a novel virus has had on health and the global economy.
“However, I am not convinced that we will see many future positives coming out of this for people’s mental health. I appreciate that people are talking more openly about it, but from my experience just in the healthcare industry we have a workforce that is exhausted and there are people in this sector and other key service industries that so often go underappreciated. There is a whole group of people who logistically kept the country running who maybe do not get the credit they deserve.”
Dr Stradling added: “In healthcare more directly, it is sometimes easy to view staff as separate to the general population and simply assume we are more thick-skinned. Yet, our healthcare workers are parents, children, and carers at home, and they have all the same worries and interrelationships as anyone else. They are not immune to mental health crises. One of my worries is that we are moving into what I think will be a long winter with an exhausted workforce which will have trouble coping with the strain.”
Supporting staff
To enable healthcare staff to be better prepared for the challenges of the winter and the post-Covid impact on mental wellbeing, Dr Stradling insisted that more consistent and targeted engagement from healthcare leaders was needed, in line with the views of Leeds and York Partnership NHS Foundation Trust mental health expert, Alison Kenyon.
He said: “Early on in the pandemic, we were faced with a rapidly changing situation and people do not necessarily understand you need nuanced advice. People can easily perceive leadership as being inconsistent and unclear, especially when you feel that you are being asked to do one thing on one day and something different the next when carrying out the same task. But in reality, the instructions change because of new knowledge and because the situation has changed. It is all about proper communication, and how we communicate with people in such rapidly changing situations is hugely important and is something we need to look at.
“I also think we have seen a lessening of the faith in national leadership from those early days in the pandemic when advice was changing rapidly and other inconsistencies such as in PPE provision and logistics. I do think that we are better at all of that now and we have had conversations about staffing difficulties and how we can improve that. Yet, one thing that our chief-executive suggested was a double pay rise and this is an example of where I think leadership and those on the ground do not quite align. Many of my colleagues agreed with me that if staff are disenfranchised or exhausted, then paying them more just to come in is not the answer. The solution is to engage more closely with them, make them feel wanted and loved and understand their needs better to gauge what support can be given. Leadership has to understand better the patterns in which staff work and give them the authority to arrange things themselves.”
To this end, Dr Stradling believes that a future framework of having decisions affecting staff on the ground being made at a local level, in consultation with national bodies, could be the way forward.
“I think that national communication and local decision-making is probably the way to go and I think more places have now started to get that right, and my place is also starting to find that balance. We are being allowed a bit more local autonomy and I think if people are able to own their own problems and destiny, then they will have more to give in the game.”
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