Echoing the views of Prof Adrian Banning, with whom The Leaders Council spoke earlier this week, consultant rheumatologist and associate medical director Dr Antoni Chan from the Royal Berkshire NHS Foundation Trust believes that the Covid-19 pandemic has acted as a reset button for the NHS and can be used as a catalyst for improvement.
Following the recent good news on vaccines and the emergence of real hope that there could now be a way out of the Covid-19 crisis, prime minister Boris Johnson has sought to inject some Christmas cheer as we lurch toward the festive season, by announcing an easing of restrictions agreed with all four nations to allow three households to mix together for several days during the holidays and enable people to have the family celebration they have craved.
As we finally look to be turning a corner in the fight against the virus, The Leaders Council of Great Britain & Northern Ireland has been reaching out to healthcare leaders and consultants from numerous departments to garner their thoughts on the latest developments, as well as having them divulge their experiences from the frontline.
Dr Antoni Chan of the Royal Berkshire NHS Foundation Trust is a consultant rheumatologist and physician based in Reading. He sees patients at Spire Dunedin Hospital and specialises in treating rheumatological conditions such as joint pain, swelling and stiffness. He is also the associate medical director of the Royal Berkshire Hospital, where he has worked since 2007.
Facing up to new challenges
Speaking exclusively to The Leaders Council of Great Britain & Northern Ireland, Dr Chan explained that when the Covid-19 pandemic initially broke out, rheumatology services were hit with immediate disruption, leaving his department having to rethink quickly about how it could adapt its services with patient safety, staff safety and location all factors of importance.
He said: “The pandemic came about very quickly around March time. It was a huge disruption to all our usual services. We could not see patients face-to-face, some patients were undergoing shielding, as were some of our workforce. Some had underlying medical conditions of their own while some others had to self-isolate under guidelines.
“Location also became a problem for us. In terms of location we couldn’t run our usual clinics due to the hospital being changed into a frontline Covid environment which rerouted to deal with patients who were suspected cases. When we think of disruption we think of people, location, and workforce as key factors, and these were all turned upside down by Covid.
“Firstly, we were required to identify which of our rheumatology patients could be higher risk and may have to shield, within a short space of time. A lot of our typical patients are on immunosuppressive or disease modifying drugs, or biological therapies, so Covid exposure could pose more of a risk. We didn’t know at the start what the impact would be in this sense, so we took a risk ratification process which was nationally guided by NHS England and the British Society for Rheumatology. What was key to being able to carry out a quick identification of at-risk patients was having a database so we could quickly form patient groups, rethink our strategy, and come up with solutions.”
In formulating solutions, effective engagement and communication was vital.
Dr Chan outlined: “We had to ensure effective communication and engage with our teams to gauge how to deliver care for patients if we can’t see them face-to-face because of shield, and we also considered how we could get around the forced reduction in our workforce.”
Working with a new team
Due to the forced halting of many routine services, many members of staff from various healthcare departments found themselves rerouted to the frontline and having to quickly get to grips with providing care for Covid-19 patients. Dr Chan and his staff were no exception to this, and so he was quickly forced to become accustomed to working with a new team and embracing a whole new set of challenges.
Dr Chan recalled: “A lot of us were called up to provide frontline care, so we contributed to the pool of general medical consultants and registrars looking after Covid patients. I was drafted onto a surgical ward during the pandemic which had been converted into a Covid-19 ward after elective surgery was stopped. So, I started working there and quickly had to get to grips with working with a new team of nurses and doctors who were more surgically trained.
“It is a challenge when you go onto wards when you have more medical problems to deal with. Many of the patients hospitalised with Covid were there because they suffered with other underlying conditions. The surgical team I was working with on the ward were more used to short line of stay process and procedure, where they would see patients, carry out the operation, deliver post-operation care and then discharge them. So, taking care of more medically dependent patients was a challenge for them. I quickly realised when I walked on to the ward in March that I had to spend time with my new team to help them understand how to manage these patients and get used to providing the type of care that they needed.”
The key to helping his new team become accustomed was introducing new communication procedures and protocols and encouraging every member of the team to share knowledge and experiences, particularly when new guidance emerged from NHS England or many of the various medical societies.
Dr Chan explained: “What we decided to do was introduce morning board rounds. I would sit with my team for five or ten minutes and then we would go to our patients. We would keep everyone updated with the latest protocols, because advice could change quickly with little notice, and there was a lot of information coming out of various different sources such as NHS England and the medical societies that our team members were involved with.
“It was extremely useful having such a pool of knowledge, so we encouraged everyone to maintain contact with their medical societies and share new information as a team. We could collect all this information and spend our morning meetings educating each other and it helped the ward run almost as a military-style operation at times. Within a few short weeks, we saw a huge transformation in how effective our procedures became in looking after Covid patients since we knew more about what to do and what to look for thanks to sharing our knowledge, and it proved to be a great learning experience.
Pressing the reset button and the need for compassion
Aligning himself with the views of the University of Oxford’s Prof Adrian Banning, with whom we spoke earlier this week, Dr Chan was insistent that the Covid-19 pandemic was not a disruption from which the NHS should merely seek to recover and return to normal, but urged healthcare leaders and providers to look at it as an opportunity to reset systems and pathways and look out how the system could be improved.
Further to this, Dr Chan also found that the pandemic had forced communication within the service to be enhanced in an unprecedented manner, which had brought about huge benefits.
Dr Chan elaborated: “One of the things we were concerned about at the start of the pandemic is that we were warned we’d all get burnout due to Covid. However, I have found the reverse. It has proved the most refreshing period. From my experience, everyone was working together in a way we’d never seen before, and Covid-19 proved to be the reset button to shakeup the system.
“At the start, Covid was a new condition that nobody really knew much about, so from junior doctors to consultants from senior nurses to junior nurses, everyone was equal as we all started from scratch and had to pitch in and learn about this new disease and draw from each other’s experience. We learned together and it was a nice environment. I felt that this is exactly what working in medicine should be like. If I ever needed to seek an expert opinion from another medical professional in another department, nobody would come and answer your call quicker than they would during Covid.
“Furthermore, what I learned from all this is that kindness is something we should take forward also. I know it is quite soft and we don’t really talk much about it, but kindness to each other and looking after each other, understanding we’re all in one team and all doing the same thing, this realisation amongst everyone was the greatest thing I saw unfolding before my eyes during this time. We have to think about compassionate leadership and how we can be compassionate when we provide care going forward, not only for patients but each other as medical professionals.”
Once again sharing the sentiment of Prof Banning, Dr Chan went on to highlight the importance of medical professionals having a period in the day to take a moment of rest and sit down and communicate with colleagues and discuss their shared experiences as a coping mechanism.
“The best time of day was when we could stop for a moment, take off our PPE and actually sit and have a cup of tea and discuss our experiences. This was energising and we all felt like a team at these points. Thanks to how we pulled together as a team, we were able to close the Covid ward earlier than expected and on the VE Bank Holiday Friday in May, we sent the last Covid patient home and all clapped as they walked out before we handed the ward back to the surgical directorate to recommence elective surgery.”
The experience of being abruptly thrust into a new environment and having to work with a new team and pull together to achieve positive outcomes is one that Dr Chan was determined to take forward and use as motivation in future.
“It was a great experience being thrown into a new area with a new team in a new environment and I will always hold it close to me. The key message is that despite all the disruption, we did it. When things get tough, we can adapt, this is the strength of the NHS. We are here to look after you and your family and we will adapt and change to make things happen. Kindness is at the heart of that approach.”
The role of digital in keeping rheumatology services running
Away from his newfound frontline duties, the rheumatology department at the Royal Berkshire NHS Trust was able to avoid the difficulty of a mounting backlog of work thanks to technology enabling routine services to continue even throughout the pandemic.
Dr Chan recalled: “Away from the frontline, we were able to continue delivering rheumatology services because we adapted. For the inpatients we had to make some changes but with our outpatients we moved to a digital programme.
“Before the pandemic we were about to start to push our virtual and telephone consultation service and at that point it had a five per cent use among the entirety of our patients. During the pandemic this became 50 per cent, so one in two of our patients switched to using the digital service and began having telephone and digital appointments. We had access to the NHS England digital platform, which was accelerated, and we could keep in touch with all our patients through video and telephone.”
However, where remote appointments and consultations were inappropriate, the problem of being able to see patients face-to-face due to restrictions remained, and so a decisive solution for where patients could be seen had to be found.
Dr Chan added: “We also had to consider where our patients could be seen and think about location solutions. Some of our patients in rheumatology need physical examination or injections which we cannot do over video or telephone, so we talked about hot and cold sites. Cold sites were where there are no inpatients, and we could potentially screen patients prior to going into the clinic and this would be low risk for Covid transmission. We identified a number of sites and rented a private hospital so we could see patients there. We also have community hospitals in Bracknell, Henley, Thatcham and Newbury, which are a part of our ‘hub and spoke’ model. The hub is the acute site where there are a lot of inpatients, and the spokes are on the periphery with none. We started to distribute our workforce to work in periphery sites and conduct face-to-face meetings with patients in these safer settings.”
Where there was the challenge of operating with a reduced workforce, owing mainly to healthcare staff being required to shield, technology was instrumental in ensuring that this setback would not impact capacity.
“When it came to dealing with issues around staff safety and availability, we realised that staff who were shielding could work from home and run virtual clinics from there. So, many were carrying out telephone and video clinics from home to make sure our capacity was not adversely affected. These members of staff were not unwell but isolating as a precaution and were still physically able to work. We increased our digital capability so staff could access medical records securely from home and feedback from patients was positive. We found that they appreciated this increased access via remote means and our telephone helpline which acted as a real lifeline for some. The telephone helpline gave patients access to a triage service, and they could then have a face-to-face appointment, another telephone call from a medical consultant, or a video follow-up depending on what we and the patient felt was mutually appropriate.”
As well as demonstrating just how effective the NHS can become by increasing its use of technology, Dr Chan believes that the pandemic has also made medical professionals and patients far more open minded about changes to the service.
“Thanks to technology and new procedures, we did not fall behind and kept on top of our workload so that when we reopened fully again in August, there was not a backlog. We were always seeing patients in some way during the pandemic and I think going forward we have to look at this as an opportunity to reset our service and use technology better.
“A lot of patients have now come to accept that remote consultations and appointments can be effective if we deem their conditions to be stable and therefore, they don’t need to physically come in as a matter of urgency. We have moved from a rigid face-to-face model to a hybrid model. The patient will always have the choice as to which form of contact they prefer and we can always switch from remote consultations to face-to-face if their condition worsens. I think this model works very well and it has brought other benefits. It has reduced travel for patients, it is more convenient for them, and we cut down on carbon emissions and parking congestion.
Digital is not suitable for everyone of course, because there is digital poverty and some may not have access to digital means of communication, and sometimes you may have a scenario where remote consultation isn’t appropriate due to the patient’s condition. Yet, some 30 per cent of our patients, we feel, are suitable for video or telephone follow-up. It takes time to get people to buy into change, but Covid was the circuit-breaker and shock we needed to positively disrupt the system. People are now more accepting of digital within the NHS.”
Research put on hold and reducing red tape
Within his role, Dr Chan is a primary investigator for clinical research studies and works towards finding newer and more effective treatments for his patients. One downside to Covid was that much medical research did initially have to be paused, but this did lead to other breakthroughs as research resources were redirected.
Dr Chan said: “Research did have to be put on hold during Covid. We were not able to recruit into existing trials because patients could not come in and research machinery had to be rerouted to the Covid effort. Research efforts were redirected toward Covid recovery studies, and we found that dexamethasone was a beneficial treatment which led to positive outcomes in critically ill patients in a short space of time.
“During this time, it also hit home how things could be approved much more quickly if we look at reducing red tape in terms of approval and governance. We have seen that with responses to Covid studies and also with the development of a vaccine. It is important that we have clinical standards and assurances, but we have to think about enabling our clinical team to do what they do best with the least hindrance.
“I think we could also use this as a chance to lighten the load of paperwork and unnecessary training. If we can use Covid as an opportunity to reduce red tape, we could also reduce the admin burden on our staff. This could be a good thing to take forward in the long-term and free personnel up more.”
Increased health awareness
It is undeniable that the pandemic has made us far more self-aware not solely with regards to our physical health, but also our mental wellbeing. The importance of mental health did not go ignored among medical professionals either over 2020, and Dr Chan keenly described some of the steps his department took for the benefit of both patients and staff.
“We are very conscious of the effects of mental health. We developed self-help guides and videos during Covid for patients, and issued helpful mental health questionnaires and we could then act upon outcomes where there were patients who were scoring quite high in the anxiety and depression scale, and give them access to various resources to help. With poor mental health, a lot of the medical conditions we deal with can worsen, because mental health is tied in with physical health, especially in our field.
“What Covid has done is help us help patients improve their self-management skills. We won’t lose sight of this positive development and next year we will be driving this agenda forward to give patients extra skills, which combined with our care, will improve outcomes and allow people to understand their conditions more. It also helps patients know better when to seek our expertise and help to make sure we can allocate our resources where they are needed most.”
The future of the NHS
While Dr Chan feels that the initial shock of Covid-19 has left the NHS braced for another scenario where most of its resources will need redirecting to the frontline, he is also optimistic that the medical profession is ready to take forward the lessons from this crisis and move toward a whole new model of service.
“Going forward, we are Covid ready. We have learnt from the first wave to be ready for another wave of Covid and with our digital infrastructure in place now, and we can keep things going. It doesn’t necessarily need more resources; it is more about making best use of our team. We must keep delivering care but in a different way to benefit all.
“The vaccine is a welcome boost to get healthcare and the economy going again, but I feel that rather than return to normal by this time in 2021, we will see a new normal which will inevitably include more hybrid clinics. The digital agenda has also reached out as far as affecting education, in terms of how we teach and organise meetings and seminars. We are now moving away from having large in-person conferences and looking more at a mixture of face-to-face and virtual platforms that all can access. Regarding education lectures, we actually found that attendance levels increased significantly when we shifted to virtual, compared to the face-to-face seminars of the pre-pandemic days.
“Of course, in the shorter-term, the vaccine should help us begin to see more people in person where we need to since the vulnerable will be protected. This will be hugely helpful in increasing our capacity a little further by reducing the amount of cleaning procedures and other time-consuming activities, particularly in-between elective surgery and cancer appointments.”
Leadership and valuing people
Dr Chan concluded by hailing NHS staff for their efforts during the crisis, and emphasising that the people within the health service are its greatest asset, he urged leaders in both the healthcare sector and within government to value people and their wellbeing and take that forward as an enduring lesson when Covid-19 is eventually left behind, and maintaining strong communication will once again be key to these hopes.
“What all of this has done is bring out the best in people. Everybody has stepped up to the plate and done the best for their patients and shown a willingness to learn from each other. It has been a rewarding experience sharing my knowledge and expertise, and knowledge is only useful if shared. Within the NHS, the people are our greatest asset, so what I want to see from leadership is that leaders in our profession are present on the ground and in regular dialogue with everyone involved in making the NHS work and actively engaging with us to help us with the support that we need.
“Throughout this pandemic, I have sought to do that by taking time every day to speak with everyone, from consultants, nurses and doctors to junior doctors and nurses, porters and cleaners. These are the unsung heroes and leadership is about being on a level with them. It is difficult to maintain communication effectively when we work in different departments as we saw pre-Covid, but the Covid reset has brought us all closer together as a team and shown us that it is possible. We have all had to pull together and make the best of this.”
Calling for leaders to put themselves on an equal footing with their colleagues, Dr Chan added: “Rather than our leadership sending us on resilience courses, I’d say to leadership that we need support around us. What we want is real time from them, people coming down to ground level to work with us and see what we are struggling with and facing on the frontline. We want you to spend more time with us. We do not ask for much. Even a voucher to go to Costa once a year just to sit and speak together about our challenges would be amazing to help us cope.
“Throughout the whole pandemic, it has taken togetherness, compassion, kindness and understanding from everyone. Everybody in the NHS who has been coming into work has put themselves at risk to contribute to the cause and it has not come without human cost. We have sadly lost one or two colleagues along the way, but it reminds us of why we do the job we do: to provide the best care possible. We mourn those we lose, but we use it as motivation. Patients are not numbers; they are real people. We are so often inundated with targets and mandates but what never changes, is the duty we have for and the interaction we have with our patients. It is all about what we can do to make things better for them and that core purpose has not changed throughout my time in this profession. If we can really harness what we have learned and keep to our ethos, that is the best thing that can come from Covid despite all the difficulties we have faced.”
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