Introduction

If, just two years ago, all healthcare staff were polled to predict what would be the greatest threat to human health in a century, I suspect few would have bet on a respiratory virus causing a brutal, lasting pandemic. Covid-19 proved to be just that, of course. Despite the lack of preparedness for what was never in the script, the NHS coped admirably.

Images of doctors, nurses and other healthcare staff attending critically ill patients in hospital remain indelibly etched from the first wave. Meanwhile, primary care, whilst not enjoying such a high profile initially, adapted quickly, introducing triage, and largely, though by no means entirely, replacing face-to-face appointments with phone, video and email consultations. If my specialty was waiting for its moment, it came with the vaccination rollout, the standout success in the UK's battle against Covid-19, and largely delivered by primary care to much admiration at home and abroad.1

However, I am not alone in being extremely worried about the massive backlog of non-Covid health problems, which by November 2020 hit a staggering 4.46 million.2 I fear that a perfect storm comprising over-cautious attitudes, bureaucracy, silo working and manpower shortages mean that we are poorly placed to move out of ‘medical lockdown’.

We appear to have reached a plateau, no longer galvanised by the adrenergic fight-or-flight of the first pandemic, and now in a soporific twilight zone. Yet this will worsen public health and risks compromising our profession’s standing as well as its morale.

In this paper I will argue that many of the causes of the current problems have their origins in poor planning well before the pandemic, and that the situation can only be salvaged by robust leadership in both primary and secondary care, and a much more open and honest discourse within society on where Covid-19 lies within the wider context of overall risk, and use historical data to illustrate how we may move on constructively.  

Primary care and medical lockdown

A potentially pivotal event in gauging professional attitudes within primary care was the massive upset voiced after the receipt of the recent letter from NHS England, written by Nikki Kanani and Ed Waller, ostensibly reminding GPs of our duty to offer face-to-face appointments.3

Personally, I was not initially offended; my practice has maintained a reasonable level of such contact, including unrestricted wound care and phlebotomy, throughout the pandemic, and has steadily increased standard consultations as rates of serious infection declined. But I also know from conversations with friends, colleagues and patients that until recently many practices took the route of extreme caution, offering no personal contact. That is, of course, untenable, and reflects a long-standing elephant in the room, that of significant variation in practice.

That variance, in turn, has its origins in the foundation of the NHS in 1948, which was initially bitterly opposed by the medical profession. As a result, the then-health secretary and founder of the NHS, Aneurin Bevan, shrewdly and against his purist socialist principles, devised a compromise, the sweeteners being allowing consultants to continue private practice outside their NHS time, and GPs becoming independent contractors within the NHS.

Despite the seemingly perpetual problem of low morale, in reality we as a professional cadre enjoy considerable autonomy. As a result, primary care reflects some of the best aspect of business including entrepreneurialism, creativity and responsiveness to local need. It can also reflect some of its worst vices, such as unhelpful hierarchies and an elastic interpretation of what constitutes work. It behoves us to help our patients as best we can, applying due caution whilst not falling victims to an exaggerated view of risk.

Covid-19 has again demonstrated that primary care can adapt quickly, and whilst traditionalists will yearn for the face-to-face consultation to re-emerge as the default, tech enthusiasts will view matters differently, and I suspect that the pendulum will settle somewhere in between. Certainly a good deal of clinical work can be done remotely, and video consulting appears safe and effective.4

Primary care should use its autonomy to flexibly apportion methods of consulting, for in a population as diverse as the UK there will be significant variation an acceptability of different methods dependent on socio-economic and cultural factors. We must also look to upgrade existing practice premises with regard to human movement, infection control and airflow, and optimise these in health centres built in the future, as well as being robust on matters such as limiting patient entourages within the premises.

The pandemic has also shown that one can trim needless bureaucracy in primary care. My practice colleague Sukaina Hirji and I have used the example of the simplification of death certification and cremation as something that should sensibly be made permanent.5

We would also benefit by paring down bloated CCGs, where numerous overlapping roles dilute responsibility and accountability. If an outsider were invited to a CCG meeting, they would be forgiven for thinking that the dominance of nurse managers in the middle tiers of the hierarchy means that there is a vast oversupply of nursing graduates relative to clinical job vacancies. Of course the opposite is true, and with a paucity of boots on the ground, it is time for clinicians and government to confront the perverse incentive for nurses to leave clinical care for cushier, better paid and less accountable roles as functionaries in the bureaucracy.

Secondary care and medical lockdown

I must start with the declaration that it is exactly 25 years since I stepped into a hospital to work a shift, so my observations are indirectly derived. I will also acknowledge that during the peak of the pandemic, excellent care has continued in many settings: for emergency departments, obstetric care and 2-week wait for suspected cancer, business has continued as usual, though there is reasonable concern that patient-driven factors has led to unmet need with respect to cancer referrals.6

As mentioned earlier, there was also the not inconsiderable challenge of treating thousands of patients admitted with Covid-19. Admittedly, those domains are urgent services, but it begs the question why other specialties appear static even now?

I believe that at least some of the answer lies in the separate cultures of primary and secondary care, which must show more willingness to work together gainfully, and the concern must be that enforced professional isolation caused by the pandemic has reinforced the silo thinking, and the silo working that inevitably ensues.

As a GP, the most galling aspect of the Kanani and Waller letter3 was the feeling that secondary care avoids the scrutiny and opprobrium applied to primary care. My predecessor as Senior Partner at Chorleywood Health Centre Russell Wynn Jones, and I, were both enthusiasts for primary-secondary collaboration, setting up numerous clinical services and research projects at the interface. But we also articulated our concern about the extent to which unhelpfully conservative attitudes within secondary care often prevail, to their own detriment.7

Hospitals should be free to do what they do best, which is high-tech diagnostics and treatments, but are needlessly hampered by a recalcitrant desire to hang onto mid-technology areas that could reasonably be handed over to primary care, which, when properly supported, has an excellent track record of absorbing such workload. After all, almost all hypertension and asthma, and the majority of diabetic care, is conducted within primary care. Three therapeutic areas I would cite where the secondary care monopoly is needlessly obstructive are the initiation of donepezil for dementia, isotretinoin for acne and methotrexate for psoriasis or inflammatory arthritis.

These are precisely the conditions that, whilst not immediately life-threatening, are associated with a massive reduction in quality of life and functioning, yet referrals often take months to see or are rejected, leading primary care to act as a spokesperson for secondary care. This in turn erodes professional goodwill, as well as our collective public image.

Mental health is another case in point. Over 90% of mental health issues are managed within primary care,8 which should be supported in the development of facilities,9 whilst secondary care must be more responsive to serious and growing problems such as eating disorders in adolescents and young adults, with which it clearly has profound difficulties coping.10

Another area of concern has been orthopaedic surgery, dealing as it does with generally non-life-threatening problems which, nonetheless, are invariably painful and disabling, particularly hip and knee osteoarthritis. In my area, the vestiges of service are still being conducted, overwhelmingly, by fairly junior physiotherapists and GPs with a special interest, but that can only get people so far, and the surgical backlog must be tackled. There is also the very real problem of junior surgeons becoming deskilled and lagging behind in their training.11

It is quite possible to operate now in Covid-free environments, and it behoves consultants and their managers to show leadership in pulling together and support this. Thousands of extra hours of manpower will need to be bought, comprising combinations of recruitment of locums, using the capacity of the private sector and possibly the under-used Nightingale hospitals, and paying existing staff to work extra shifts.12

The cost will be gargantuan, yet healthcare workers can reasonably ask the government to show a statement of intent. Morally as well as practically, it is surely better value to pay someone 100% of their hourly rate for 100% of effort, than to keep millions of workers on furlough at 80% for no yield.

Risk evaluation and the public discourse

With 128,000 deaths to date, it is clear that the UK has been hit exceptionally hard by Covid-19. But its direct risk to health and the related risks including a reduced focus on non-Covid healthcare should be framed within a wider public discourse on risk.

I am concerned about much of the reporting in the media, for example, still referring to the pandemic, but rarely acknowledging that the virus is now endemic, and will clearly be with us for a while yet, if not in perpetuity. It was also clear, from the moment the genie was out of the bottle that the virus mutates, so the hysteria surrounding each variant – currently the delta (Indian) one - is unjustified.

Journalists in both print and screen – some occupy both camps – seem disproportionately of the over-cautious type. Press previews invariably feature Zoom calls with a middle-aged millionaire in front of a bookshelf, baying for just another month / quarter / year of restrictions, which is what we invariably get though this is proving economically devastating, especially to young people.

I agree with Michael O’Leary, CEO of Ryanair, who reacted to Portugal’s relegation from the travel green list with incredulity that doubly-vaccinated UK citizens, testing negative, have to tolerate another summer season with effectively no chance of a holiday abroad. Within a fortnight of this, the Sword of Damocles also fell on the proposed final easing of restrictions on 21st June 2021. It is clear that Covid-19 will be with us for some time, and we must manage its risk without paralysing the rest of life.

Healthcare must learn from its own history. Tuberculosis has been a scourge for millennia, identified in Egyptian mummies. Yet the tubercle bacillus was only isolated in 1882 by Robert Koch, and it was not until the invention of streptomycin by Albert Schatz in 1943 that there was an effective antidote, though the first BCG vaccine developed in 1921 was an important step in the fight against the disease. But the world did not go into lockdown in the six decades between those two momentous discoveries. Nor did medical life: indeed, the late-Victorian era to the mid-point of the 20th century was something of a golden age, encompassing the pioneering /  discovery of wound care by Florence Nightingale, radiology by Wilhelm Rontgen, birth control by Marie Stopes, thyroid disease by Hakaru Hashimoto, insulin by Frederick Banting and Charles Best, and penicillin by Alexander Fleming, Howard Florey and Ernest Chain, amongst others.

Did those remarkable men and women have their practices and research projects curtailed whilst waiting for an unattainably low risk? Yet modern healthcare is uniquely convulsed by the idea that the only acceptable risk is zero, which is bizarre when set against the risk inherent in most human activity.

At the time of writing, the average daily deaths from Covid-19 roughly equate to the number killed, no less tragically, in road accidents, but there is no clamour to reduce the speed limit to 5 mph. People happy to go rock climbing, parachuting or skiing recreationally are deeply discomforted by any risks attached to illness, and indeed illness prevention measures, in this case vaccination.

In his 1974 book ‘Medical nemesis’,13 the late Croatian-Austrian philosopher Ivan Illich opined that despite admirable scientific progress, medicine’s reputation was being damaged by using health as a controlling tool, and by a lack of honesty about its limitations, including the inevitability of death. I fear that we are part of the collusion, and that an open and honest discourse with the public, beginning in our consulting rooms, would be a far better strategy. It would at least give us a chance to counter the Christina Patterson and Chris Whitty view of the world, which I aver is unduly influencing public and government opinion.

Summary 

The Covid-19 pandemic has hit the world, including the UK, brutally. The NHS has responded magnificently both in managing those unwell with Covid infection, and other acute health problems, as well as carrying out a mass vaccination programme, the success of which has reduced the proportion of infected people presenting with serious clinical disease or dying. Despite this, lockdown and prolonged restrictions remain the government default when cases of infection rise.

Given that the virus is now endemic, it is a folly to persist with lockdown, a failing strategy with which the law of diminishing returns has caught up, and whose deleterious consequences of impeding attention to the backlog of non-Covid health problems, as well as exacerbating regional, generational, gender and ethnic inequalities far outweighs its influence in case transmission and fatality.

The successes in coping with the peak of the pandemic have enhanced the standing of healthcare professionals amongst the public, yet we risk undoing the hard-earned gains and suffering reputational damage unless we show proactive, concerted leadership in opening up both primary and secondary healthcare and attend to the backlog of non-Covid health problems.

We should also engage actively with each other, and our patients, on the heterogeneous and multi-dimensional issue of risk. Ultimately, there is a selfish motive to be selfless, for our working lives are far more satisfying when helping people rather than parroting excuses for why things cannot be done.   

For more news and articles on lockdown go to our Covid-19 section

 


Edin Lakasing, GP, trainer and tutor, Chorleywood Health Centre, 15 Lower Road, Chorleywood, Hertfordshire WD3 5EA

Email: edin.lakasing@nhs.net

Competing interests: none.


References

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