President of the Royal College of Physicians Professor Andrew Goddard reflects on the year since the UK went into lockdown, and what vital lessons we must learn from COVID-19.
Most people will always remember where they were on March 23 2020 when the prime minister issued his life-altering ‘stay at home’ message. For physicians, the gravity of the situation had hit home much earlier.
By 23 March we had already seen the change in our day to day care; the change to having to wear additional personal protective equipment more often (and often not able to get it); the change from working in our usual specialties to working fulltime on general medical wards treating COVID-19 patients. In our April 2020 surveys, many members reported being impressed at how quickly and efficiently their trusts re-organised hospitals to manage the outbreak. Intensive care units were rapidly expanded; specialty staff were redeployed to acute and general, research staff returned to clinical practice and some senior consultants took charge of wards and patients they would never usually manage to support and protect junior colleagues.
The physical and emotional toll on staff
It has been incredibly tough, bringing healthcare staff at many points to their absolute limit – but we have kept going, united by a drive to give the best care to our patients and a sense of ‘this is what we trained for’. Much of the public focus has been on Intensive Therapy Units, but of course the vast majority of patients have been under the care of a physician, up to 94% in some hospitals. In the first wave, final year medical students stepped up to give much-needed support, and throughout the year trainees have put on hold their learning, potentially impacting career progression, to play an invaluable part in treating the ever-growing volume of patients with COVID-19.
We have lost friends, colleagues, and family members. The College has suffered many losses, with the death of our Registrar Donal O’Donoghue the hardest of blows. As the worst of this wave passes, the priority must be rest and recuperation for all healthcare staff who have been involved in the response to coronavirus. This is especially true for trainees, who have given up a great deal personally to play their part and on whom the whole effort relied so heavily. Getting their training and progress back on track is a key priority and the RCP is making that clear in every meeting we have with decision makers.
I remain concerned that in January, 29% of physicians said they had sought either informal or formal mental health support and a third of trainees said the pandemic had made them question medicine as a career. I want to personally thank members for everything they have done throughout the pandemic. I know it has been difficult – an understatement in the context of what we’ve all seen and been through.
The good and the bad – learning the immediate lessons
The NHS has done all it can to rise and respond to the challenge of managing the outbreak of coronavirus and as Chris Whitty said in Commentary, every one of us should be proud of our role in that. The NHS’ rollout of the vaccine is nothing short of remarkable, and I hope that the development of an effective, safe vaccine in Oxford for a virus that brought the world to a standstill will boost perceptions of and interest in medical research in this country and encourage more physicians to get involved. Our genomic sequencing, too, has been world-leading – we identified new strains, and opened up our platform with other countries.
The challenges over PPE, and other decisions taken in our pandemic response will surely be considered in the public inquiries that we anticipate will take place when this is all finally ‘over’ and the pressure on the NHS has eased. The primary aim of any and all inquiries must be to identify and recommend changes so we’re better prepared for next time. Were we prepared? Preparedness, I think, will need to be defined very widely.
We absolutely need to look at preparedness and decision-making in very practical terms, such as stocks of PPE, our approach to testing and how many critical care beds we have. I appreciated Chris’ honesty that we were ‘flying blind’ in the early days because we didn’t appreciate the importance of asymptomatic testing and that we did not have the capacity to test early on. That is the sort of frankness we will need if we are to learn lessons.
Time to face our underlying weaknesses
But preparedness should also include looking at how we came into this pandemic – our workforce, the state of public health and health inequalities. We were carrying a huge number of vacancies as a health service pre-pandemic with close to half (43%) of advertised consultant posts in England and Wales in 2019 going unfilled due to a lack of suitable applicants. An inquiry will need to look at whether we had enough doctors to use the additional ventilators that were produced, and to staff the Nightingale hospitals that were rapidly built.
There is no doubt that the underlying state of public health in the UK has affected the way we have coped with the impact of COVID-19. High levels of obesity exacerbated the negative impact of the virus, so lowering levels of obesity in the population must be seen as part of preparing for future pandemics and similar crises. The disconnect with social care, too, makes the promised reform this year even more urgent.
Preparedness will need to extend to a wider examination of all the protected characteristics plus socioeconomic status. The government’s own research shows that it was ‘a range of socioeconomic and geographical factors such as occupational exposure, population density and household composition, coupled with pre-existing health conditions’ that was behind the virus hitting some ethnic groups harder than others. NHS Chief Executive Sir Simon Stevens told the health and social care select committee in February that ‘a combination of occupational exposures, crowded housing, prior health risk, including obesity…and broader inequality’ resulted in differing levels of exposure and deaths.
We are determined that these underlying causes of health inequalities are no longer ignored, and that is why we established the Health Inequalities Alliance last year. Our long-standing work to expand the NHS workforce and support a more research-active NHS have also been shown to be more important than ever as we turn towards building a better health system after the pandemic. This pandemic has only underlined how important progress on these issues is to delivering the best care for our patients, and giving physicians a fulfilling career. We will keep going.