We must not let the horrors of Covid destroy our health service in the long term
Airless boxes, linoleum-lined and artificially lit, hospitals are not the beacons of health some may expect. Were it not for the familiar scent of fresh toast wafting through the wards at 7:10am every morning, it would be perfectly possible to exist within their walls yet outside of time, like one of Schrödinger’s subjects.
To stagger out into the daylight after a night shift is a disorienting, queasy experience.
But these crude, unchanging cocoons are vital threads in the fabric of our communal existence. As this rolling pandemic gathers pace and the fallout deepens, the human machinery within them can be heard turning, faster and faster, in a desperate attempt to help the victims of the pandemic.
The limit to healthcare workers’ capacity and appetite to care with such intensity is not far off. More urgently than ever before, Covid-19 has forced us to examine our society’s priorities, and ask ourselves what value we put on such work.
I was not alone in hoping that we had perhaps seen the back of the pandemic in the Summer. But while the virus only growled over the autumn months, the step-change in hospital admissions in December has been stark. In London, patients with COVID-19 requiring oxygen are now being wheeled through the doors of emergency departments in large numbers. That our nation is losing men and women before their time is in no doubt. When noting a patient’s date of birth, I find myself mentally noting whether they are older or younger than my parents— a yardstick that helps lend perspective, somehow. In recent weeks too many patients have been closer to my age than theirs.
Gargantuan operational efforts— to minimise infection, give the unwell the best chances, and look after our dependents— should rightly be the focus of our immediate attention. But just beneath the surface of our most pressing concerns lies the issue of the human cost to healthcare workers. Perspex screens can be installed at the counter of your local newsagent in hours, but unlike physical equipment, the human capital carrying us through the current crisis cannot be rapidly manufactured, yet will be needed as we recover and respond to challenges in the years to come.
Among the many privileges of being a clinician is the feeling that you can offer a patient something in a time of need that no-one else can provide. But any job, when looked at too closely, loses some of its glamour, and medical care is no exception. It is a fine thing to be able to save a life, but negotiating with an aggressive patient withdrawing from alcohol at 3am is not, the more so when your sleep patterns are in tatters and your food comes from vending machines.
In reality, providing acute medical care over prolonged periods of time inflicts a complex system of abuse on the human stress response. There is little time for chin-scratching over diagnostic dilemmas, and instead one juggles competing and evolving risks while trying to spot impending disasters early. It means taking responsibility for highly consequential decisions, despite imperfect information and in suboptimal circumstances. The role is necessarily, but profoundly, reactive.
In this fast-paced environment, which relies heavily on the nuances of communication, and often hurriedly so, the thick masks and visors we currently use make it difficult to hear what others are saying and compromise our ability to recognise facial expressions. Being able to speak to families only over the phone has only further depersonalised the relationships with our patients.
Lockdowns have been hard for huge swathes of the population, the emotional cost of which is yet to be fully realised. For healthcare workers in a chronic state of simultaneous sensory overload and sensory deprivation, constantly attending to acute clinical need seems to flatten the emotional toll. Perhaps this state of apparent equanimity helps us rapidly to channel our knowledge and experience into sensible clinical decisions for individual patients.
But organised chaos has been the reality of a hospital’s engine room for years, well before COVID. If I have painted a picture of a well-intentioned, but deeply flawed system, that is because that is exactly what it appears to be. That our hospitals are still ticking along is in no small part because they are home to a group of people who are, by and large, task-orientated ‘doers’, adaptable to change, able to see both comedy and sadness within the disorder, and ultimately willing to get stuck in.
This picture of hospital medical practice may surprise some; for others it will come as no surprise at all. Either way, many of the people who have been working at the sharp end of clinical medicine are constantly exhausted. So, while the pandemic has not fundamentally changed the nature of what we do, pressing down on the accelerator will necessarily sharpen priorities. Testing the system to breaking point will expose the neglected areas of our health service and those problems that we thought yet lay some years down the line.
Just as the heat of this pandemic has softened social norms we thought solid, so too could it recast the relationship between healthcare professionals and their work. And just as the economic cost of the pandemic may be paid for by our children, so too would the price for our heath service’s human capital be paid by those coming up behind us. For the wound inflicted by the pandemic on the healthcare sector may be neither immediate nor dramatic: the attrition of those with both the will and expertise to care may be far more gradual.
In our press healthcare professionals are often stereotyped at the extremes, as martyrs or egotists. We are of course neither, and have priorities and allegiances as complex as anyone else’s; but this misunderstanding of who we are, or what we want for our lives, makes planning the future for the health service after the pandemic all the more precarious. What will it take for individuals to expose themselves to occupational risk, be it chronic or episodic, when institutional trust is at such a low ebb?
I have no quick nor easy solutions to the complex challenge of sustaining the healthcare sector through a pandemic and beyond, but I do know that no plan will stand unless it takes account of human motivation. Because when things get sweaty, managerialism doesn’t seem to cut the mustard. The NHS will have to work harder to ensure it is an attractive prospect in a global job market, or risk the relationship with its workforce becoming more transactional or mercenary, even.
A crisis like this only makes sense if we embrace it as opportunity: an opportunity for policymakers to bravely realign their priorities and invest in making the health service a beacon of human service: one where staff who give of themselves can trust that at every turn, they will be looked after. The alternative – an institution that is self-seeking, cynical and lacking in courage – would be grim indeed.
Dr Robin Baddeley is a specialist registrar at a London teaching hospital.