COVID: It never went away

‘We’re hanging on by our fingernails.’

Dan Goyal, a consultant in internal medicine in NHS Highland, has been pushed to the limit and left reconsidering his career choices.

‘The demands on the service, both COVID and non-COVID, are exceptional. In the past we’ve had time to gather our thoughts, but we haven’t had that for a year or so. It’s worse than it’s ever been.’

A new Omicron variant – labelled BA.2 – drove a fresh surge in cases and gave frontline staff like Dr Goyal no respite, even after two years. Despite vaccination success, ONS data shows a significant recent spike.

And the effect on doctors and other healthcare workers is severe. In Scotland, according to estimates from the Office for National Statistics, 5.35 per cent of the population had COVID in the week ending 16 April, falling to 3.01 per cent in the week ending 7 May. 

In England, the comparable figures were 5.90 and 2.21 per cent. The percentages may be falling but the overall number of cases are still higher than at many points when tight public health restrictions applied.

The hidden wave quietly ripping through the country has led to fewer deaths than previous spikes, but healthcare services remain on their knees as they battle through 94 per cent bed occupancy levels and ambulance wait times of up to 22 hours amid unprecedented staff absences driven by COVID and stress.

‘In terms of COVID itself, we are much better at dealing with it, and we can handle it, but in terms of accumulated stress, it’s much worse,’ Dr Goyal says.

He explains: ‘Each wave has seen the virus get progressively less severe. Now, we expect patients to recover, even the more vulnerable. Prior to this we have been putting in the effort to get them to recover but knowing the odds are against them.

‘That’s a relief, but we have been overworked, colleagues are psychologically stressed – and now we’re getting pressure from Government to clear waiting lists.’

South-west England has been one of the worst affected areas in the country by this latest wave.

The Northern Devon Healthcare NHS Trust had, at the time of writing, six full-time COVID wards in operation, including one at a community hospital. In January 2021 there were four wards, but the trust had the option to send patients to the 116-bed Exeter NHS Nightingale.

‘COVID numbers are almost at the same as the January 2021 peak,’ said David Strain, when he spoke to The Doctor on 6 April. He is the regional NHS lead on COVID who has also played a major role in the BMA’s response.

‘The rhetoric is that COVID is all over. But the numbers I have seen suggest we would have the same number of people in hospital with COVID as the previous peaks.’

Patients in UK hospitals with confirmed COVID were at slightly higher numbers on seven days in early April – around 20,000 – than they had been at the year’s previous peak on 10 January, the figure for 6 May being 10,270.

Deaths where COVID was listed as one of the causes were also at similar levels in early April as they were in January.

The level of deaths is ‘still more than heart attacks, strokes, pneumonia’, Dr Strain adds. ‘We always have to put the caveat in that the patients we see in hospital are at the narrow end of the wedge. We are seeing that same narrow end of the wedge but not as many people are going to ICU. In the last wave, there were five or six times as many patients in ICU support.

‘We are doing amazing things to keep the vulnerable out of hospital. As soon as they test positive we are getting them in within 48 hours and giving them pre-treatment. That didn’t exist in the first and second waves. We have effectively kept one entire ward’s worth of people out of hospital.

‘A lot more patients are presenting with symptoms that are not specific. For older adults, delirium is the most common but lots of patients are coming in with chest pains, or abdominal pain. It fits with the new symptoms of COVID. We’ve become incredibly cautious with anybody coming in.’

Yorkshire-based consultant in pain medicine and anaesthesia, Ian Wilson, says his hospital is encountering many triple vaccinated COVID patients.

‘So many people are coming into emergency departments that we have trolleys in waiting areas.’

Helen Wall is a GP partner and clinical director at Bolton Clinical Commissioning Group.

She says: ‘It doesn’t really matter whether patients go in with COVID or not. As soon as they test positive they have to be isolated in a COVID ward. It has an impact on patient flow. Then no one can get through the front door in [emergency departments], and people are on trolleys for lengthy periods of time.’

The level of staff absence has made things exponentially worse. There were 74,082 staff off in England on 31 March. You’d have to go back to 20 January for a higher daily total.

Dr Goyal’s 15-strong medical team, which includes five consultants, has trudged through with three to five doctors off at any given time.

It is a vicious cycle with COVID causing stress, stress causing absence and absence piling on the pressure. Often even doctors signed off by their GP don’t want to take time off ‘because of the impact it has on their team’.

‘People are very much at the limit of what they are able to do,’ adds Dr Wilson. ‘It’s still a challenge to absorb that clinical workload and find the right places for people to be safely cared for.’

And with NHS waiting lists at record levels – 6.4 million in England alone – Dr Wilson makes the point that Government does not seem to have grasped – that more staff off with COVID equals ‘fewer people to do the catch-up work we need doing’.

Dr Strain says staff tend to be off for longer in the current wave.

‘Before, people had minor symptoms and were champing at the bit for that negative test to come through after five or six days,’ he adds. ‘Now, more staff are unwell for longer, 10 or 11 days – or they have long COVID so can only come back for half days.’

As well as COVID absences, he notes: ‘A fair number of people are facing burnout. The recovery that was supposed to begin at the start of this year has been set back.’

For many staff it is simply too much to go back to work.

Erica Favero was clinical nurse manager on a COVID ward in a south-west community hospital for the first and second waves and has since been diagnosed with PTSD.

‘When I tried to go into COVID [wards] again [in the current wave] it hit me completely,’ she says. ‘I couldn’t walk into the ward, and I had palpitations. About a week before being asked to go back into COVID, I started a shift trying to overcome this feeling, but it got worse. I was talking to a patient but wasn’t really concentrating on what they were saying. I burst into tears.’

Ms Favero says she now has to live with the guilt that she is not able to care for COVID patients and support her colleagues. Staff absence also remains ‘an ongoing nightmare’ in primary care, says Dr Wall.

‘In December and January, every single practice in the area had most staff off. We scraped by and got through that – now, months down the line, we feel like we’re about to lose all our staff again – and I know hospitals are struggling too. People say we are living with COVID, but it doesn’t feel like it.’

Having to self-isolate with COVID himself recently, conducting clinics online, Dr Wilson believes staff are more likely to pick up the virus outside of hospital than in it due to public apathy, the end of free tests and Government messaging.

Dr Strain agrees. He says: ‘People have decided it’s gone. While I appreciate why, wanting it to be gone and it going are two different things. It hasn’t gone.’

ONS data shows just 40 per cent of adults said they had taken a lateral flow test between 16 and 27 March, down from 61 per cent between 6 and 16 January. And only 68 per cent of adults reported wearing a face covering outside their home, dropping from 95 per cent between 19 and 30 January.

The BMA has lobbied for the Government to reconsider its move to scrap free COVID testing for the public, which it says ‘risks creating a two-tier society between those who can afford to pay for tests and those who can’t’.

Dr Strain adds: ‘The big demoraliser is when staff wear their FFP3 masks and goggles, and shower before leaving the building, then go to the park and ride or get on the bus and are surrounded by people who are oblivious to it. The rhetoric that COVID is all over makes the work they have been doing every day seem pointless.’

Among those driving that rhetoric is former health secretary Matt Hancock, who recently declared ‘the pandemic is over’.

The prime minister’s office said in April that COVID should be ‘managed like any other respiratory illness’ – although this was rebuffed by the BMA, which said the Government was ‘burying its head in the sand to the immediate threat of the virus to our healthcare services’.

The effects of COVID-19 are being keenly felt in primary care.

Dr Wall says cases of long COVID where patients didn’t know they were infected are a common occurrence and the mountain of unmet need which built during the pandemic is now showing, too.

She estimates 40 per cent of her patients are presenting with issues the patients ignored or are related to secondary care delays.

That unmet need – that mounting backlog – is the elephant in the room.

And the biggest question is whether there will be enough staff left to deal with the backlog if pressures continue as they are?

‘Resignations are high,’ says Dr Goyal. ‘Every third person I speak to is looking for the exit – to New Zealand, Australia, to go and work on a cruise ship. Everybody is on edge. I’m questioning my career choice, to be honest.

‘We are passing the work around because we don’t have the capacity. That brings on a spiral.

‘We don’t have enough capacity to treat people well enough to prevent them from becoming more severely unwell – and we end up having to put NHS resources into recovering them. And that continues.’

These issues threaten to become existential for an underfunded NHS with too few staff and appearing to lack the full support it needs from ministers.

‘The big question is how many post-COVID issues we’re dealing with,’ Dr Goyal adds. ‘We know if someone gets discharged with COVID they will have a very significant healthcare usage for at least two years. And we have had a lot of COVID patients.’

NHS leaders and the Government will have to find the will to address some of these very significant questions – and the answers to those questions must include addressing pay and terms and conditions, wellbeing of staff and, perhaps most fundamentally, the future shape of the workforce.

Dr Goyal says: ‘Everybody does more hours than they should, and they’re not being paid overtime. If the organisation was like that for the first or second wave of a pandemic, fine, but we are two years down the line now and have ended up with an inefficient service and more resignations. It’s not sustainable.’

Dr Wall agrees ‘morale is shocking’.

‘In any crisis people go through that stage of ‘we’re all in this together’, or ‘we are going to beat this’ when you have that adrenaline,’ she says. ‘Then people get fed up.

‘Throughout the pandemic we’ve seen patients get really disgruntled, then we’ve had another wave. Some patients are actively choosing to be abusive to us because they perceive we are using COVID as an excuse not to see people when really we are working harder than we ever have. We are busier than we have ever been, dealing with more patients day by day.’

Dr Wall adds: ‘Because of the amount of demand versus the capacity, versus having staff off with COVID or stress or anxiety we are in a really difficult position – and it’s been worsened because nobody [in politics] is coming out and saying it.

‘COVID is crippling us, then I go into the normal world and it feels like COVID doesn’t exist anymore. This wave that we all know is really happening, and is bad, is hidden from the public.

‘There are more challenging times ahead.’