If I were Minister of Health→

This essay won Distinction in the 2020 Doctors for the NHS Competition and was published in the December issue of the Journal of the Royal Society of Medicine: https://journals.sagepub.com/doi/10.1177/0141076820977839

Even before the coronavirus pandemic, other than being Prime Minister, the role of Minister of Health was probably the most daunting in Government. Considering the NHS regularly tops lists of most treasured British institutions, expectations of the Health Secretary may even be higher. Given the problems in the healthcare system over the last decade, it is an unenviable position to inherit, but vast improvement can occur; we need only look at the revolutionary 1948 foundation of the NHS itself.

Improvement is usually best identified and implemented by those in the system; thus, it makes sense to have a Health Minister with field experience. Having worked as an NHS doctor for the past eight years, and as an occasional patient for two decades before that, I offer qualified insights into developing the health service.

First off, let’s deal with the barrier to productive discussion: money. There is money to spend. The UK has one of the strongest economies in the world; if that doesn’t equate to public spending power, then I don’t know what use there is for a high GDP. Even if the piggy bank runs short after rainy day expenditures like the coronavirus furlough scheme, then the solution lies in making large multinational companies pay adequate taxes by reforming corporation tax law (for example, Amazon paid just £220m in tax on UK sales of £10.9bn in 2018). The point is, money is available; let’s not use that as an excuse to limit progress.

Now we’ve redressed our outlook, we can approach issues in the healthcare service uninhibited by a fiscal fallacy. So where to start? How do you begin trying to improve such a gargantuan system? For ease of discussion, I have focused on three key areas. Handily titled ‘People, Places and Public Health’ (forgive the alliteration but it’s the hallmark of any fledgling manifesto), I shall address these sequentially but consider all three to be of profound importance in improving the health service.

People

When asked to consider the biggest limitation of the health service, a plethora of headlines crowd for attention. Are the longer wait times in A&E more pressing or are the notoriously large waiting lists for elective operations the biggest issue? In actual fact, these are all facets of the same problem, namely that of insufficiency. There are not enough resources to meet demand and that translates to longer waits, compromised care and poorer health outcomes. And out of all the resources needed for a functional healthcare system, the most important is staff.

When we talk of a ‘lack of beds’, we actually mean a ‘lack of staff’. A hospital can bulk buy beds enough to fill every empty room in the building, but without a concomitant reinforcement of staffing (and that means all healthcare professionals, from cleaner to consultant) expanding numbers of medical equipment is essentially futile. Patients need computed tomography scans and antibiotics, yes, but all these interventions are facilitated by staff, for example, the porter to transfer a patient to radiology and the nurse to set up an IV.

Unfortunately for the NHS, staff are leaving in droves. From Brexit to burnout, the causes for people leaving are myriad. Each reason should be addressed individually; however, an easier way to summarise the problem is that of balance: for many, the pros of the job no longer outweigh the cons.

Over the past few years, austerity-driven cutbacks have made conditions in the NHS extremely difficult. Experiencing insufficiency as a daily reality wears people down. Not only that, but healthcare workers are regularly denigrated in the press and undermined by the Government, with both entities scapegoating healthcare workers (or Moet Medics as some of us are known) for deficiencies in the system.

But let bygones be bygones. How do we stop the attrition of the workforce? No, let’s go one better – how to actively recruit people to the health service? Coronavirus has shown that by increasing the standing of the healthcare worker, more people are attracted to the field. Since the pandemic hit, applications to study nursing at university have increased by 15%, which is no doubt fuelled by the heroic portrayal of nurses in the news. However, it is not just through the media that standing improves, the whole healthcare profession must be made more attractive.

For this we look at Google. Why do so many people want to work there? The lucrative salary plays a part but NHS workers would likely settle for more conservative wages. An inflation-matching pay rise is a good starting point, but if the Department of Health were to go one better and make salaried positions handsomely paid it might draw workers away from more costly locum work. Recruiting a regular workforce would make for reliable staffing levels and thus, safer care.

We can aspire to even more than that. The NHS could become a truly tempting employer by rewarding its employees benefits like free meals, free parking and free gym membership as swanky private companies do. And why not provide heavily subsidised childcare at Trusts for all employees? A large clientele already exists; the only thing needed now is to develop the infrastructure. The NHS could then truly practise what it preaches by improving the well being of staff as well as patients.

Finally, the system should place great emphasis on nurturing staff potential. Study budget and study days should be easier to access and professional development should be encouraged and facilitated. This ties in with the second prong of my plan as Health Secretary: structural organisational change in the places we work.

Places

Healthcare is demanding. It is labour-intensive and can be emotionally draining, but it needn’t be hard. By that, I mean the essence of healthcare can be deconstructed to a fairly simple model (Figure 1).

Figure 1. Flow diagram showing simplified healthcare process.

But as many of us working in the system know, it can feel incredibly hard. The process in Figure 1 is sludged up by lack of flow through the system, which is down to the aforementioned insufficiencies. These insufficiencies are partly due to Trusts trying to reduce budget deficits by cutting costs and, in so doing, reducing services, where they can. The other tactic employed is to erect boundaries (often prodigious bureaucracy) to stall people when applying for services. Paperwork also burdens clinical staff, who often have to produce exhaustive written evidence of the work they have done.

So what I propose is an overhaul in the approach. First, we stop penalising Trusts. Anyone who has been in debt knows that you cannot make good decisions when you are financially stressed and this is backed up by psychological research. The ‘scarcity mentality’ has been well documented in Mullainathan and Shafir’s key psychological experiments, which show poverty can lead to a drop in IQ, ergo poorer decision-making skills.1 To ameliorate this effect in healthcare, we must eradicate deficits (remember, Amazon could make up the shortfall) and instead of fining poorly performing Trusts, provide more money to tackle problems.

Improvement initiatives should heavily involve care workers themselves as their intimate knowledge of the system means they often know how best to solve a problem. Hands-off management has been shown to provide better services; for example, in the Netherlands, the Buurtzog care initiative allows individual teams to decide how to deliver care rather than by having far-removed managers dictate the approach. Analysis reveals that Buurtzog boasts higher quality social care for less cost than the average.2

Also important in the approach is eliminating redundant layers of bureaucracy. Do Trusts really need a stratum of admin staff to double-check that every worker has done their e-learning? If that is necessary, could these staff not be redeployed to offer on-the-job training, thereby increasing administrators’ experience of the system they are managing and minimising the paperwork burden on healthcare workers. Caregivers should spend as many hours actually caregiving rather than completing documentation to ‘prove’ themselves. We must trust that healthcare workers, who for the large part went into this profession to help people, are doing their job. An errant employee usually becomes apparent in a team and can be reformed individually.

With more effective internal processes, Trusts can broaden their vision to upgrading their physical places of work as well. That means bringing healthcare facilities into the 21st century by switching to renewable energy, rejigging waste disposal schemes to incorporate as much recycling as possible and buying local foods for the canteen. A healthcare system should embody the best values and always be on the right side of history.

Public health

The final part of my plan involves public health. The current health system has mastered the process in Figure 1 with a tiered approach (primary, secondary care, etc.), albeit hindered by the problems listed above. The NHS knows exactly how to investigate chest pain; however, processes for keeping people well enough to stay out of the healthcare system are less refined. Public health is a relatively virgin field and has great potential.

First off, we need all hands on deck and that means incorporating with social services. So much of healthcare is determined by effective social care and vice versa, the two organisations are really two heads of the same Hydra. That means the social workers and healthcare professionals should be working in the same team as par for the course rather than by occasional referral to each other.

A key limiting factor in hospital discharge of the ageing population is community care provision. We need a wholescale expansion of care, multiplying the number of facilities from nursing homes to rehab/respite centres to hospices. Concomitantly more care staff should be employed and, similar to NHS workers, the profile of carers should be raised. As the coronavirus pandemic shows, this is truly essential work and should be esteemed as such.

With robust care infrastructure in place we can concentrate on promoting public health. This starts with adequate provision of the known basics, e.g. addiction and smoking services, which over recent years have actually been reduced by a third among councils. Of course, keep existing programs in place, we should keep promoting good diabetic control and immunising babies, but I also propose a stronger focus on wellbeing.

Hear me out, I know the idea of wellbeing has become a cliché but I am talking about more than superfood smoothies. Wellbeing forms the first tenet in the World Health Organization’s Constitution and is pivotal to the concept of health. It informs personal perspectives and can be the deciding factor on whether a disease becomes an illness. Thus, we should be doing all we can to promote wellbeing in every citizen.

This starts with combatting impediments to wellbeing, e.g. loneliness, inactivity, mental health and, of course, poverty. These are huge topics and would need specific targeting; however, key strategies for the former rely on strengthening communities. Alongside housing the homeless, multigenerational initiatives, e.g. beautiful community centres and providing free NHS gyms, would improve our communities immensely. I also propose heavily subsidised health holidays for all families, thereby fostering an interest in outdoor exercise in the next generation.

Mental health is a huge topic and in addition to its improvement through the ‘People’ and ‘Places’ part of this plan, additional attention should be given to psychology services. In my opinion, counselling centres should become as commonplace as the high street optician, recognising the fact that a lot of health issues are worsened by past trauma and underdeveloped coping mechanisms.

As to poverty, I need another 2000 words for that.

Summary

So there you have it, my proto-vision as Minister of Health. The ideas may sound simplistic, especially when condensed into a three-point plan, but sometimes problems have to be simplified in order to deal with them. The health service is undoubtedly complex but the aspirations are easy enough to visualise and strive for: to optimise the health of every citizen in the most effective way possible. We must not let imagined impediments limit our vision. We can do better so let’s begin.

The second round of Corona is here, and I’m ready for it→

I still get chills when I think back to March. Within the space of a few weeks, my life was no longer recognisable. A month which started with my final bridal gown fitting, sobered rapidly when 10 days later my partner and I found ourselves notifying the guestlist that our June wedding was postponed. The cancellation barely registered with me: my attention was entirely taken up by the worsening pandemic.

The hospital where I worked felt the full impact of the exponential curve of coronavirus infections. Within three weeks of the first case of COVID-19, the Intensive Care Unit was scrambling for more beds and I, newly seconded, turned up for my first shift in full PPE.

What followed is still too difficult to articulate. Looking after a hospital’s sickest patients is challenging at the best of times. However, the situation during the height of the pandemic was unparalleled. Every shift saw that many more gasping patients, that many more deaths. With so much to do, staff powered through in survival mode, only registering their ordeal when the situation eased in late summer.

That is why this new surge in coronavirus cases, mere months later, strikes fear into healthcare staff across the country. Going through that again? Please, please no.  

But the dreaded second wave needn’t be like the first. One of the most astounding features of human character is the ability to learn, quickly, if needed. Ten months since the UK’s first confirmed coronavirus case is plenty of time to have learnt what does and does not work in managing a pandemic. As such, the public should have faith that when it comes to enduring this next wave; people have had training for it and know what to do.

By now, we know that social distancing works in reducing the spread of the virus. If that is news to you, let me bring you up to date. A recent Lancet meta-analysis, investigating strategies to limit virus spread, shows that at greater distances, eg above 1 metre, there was significantly lower virus transmission. Most of us probably knew this already, standing back, as we always have, from the sneezing colleague at work.

In fact, most of the coronavirus management strategies, such as hand-washing, were commonsense methods we already used for colds, so in the case of corona, these measures could be emphasised with billboards and even street graffiti reminding us about hygiene. As we find ourselves in the mother of all cold and flu seasons, we should remember that this behaviour is not uncommon to us. It is something we would normally do but, this time, with life-saving benefits. And unlike in summer, wearing a mask brings the added bonus of warming the face in the cold autumn/winter air.

With the practicalities down pat, that leaves psychology. For many of us, last year took an incredible toll, and the question is, how do we survive more? The answer to this isn’t as easy as reaching for the Imperial Leather. As social restrictions have escalated, we find ourselves back in our homes, alone or perhaps confined with (not so) loved ones. Many will dread this prospect but a moment’s reflection may help manage the negative feelings. All of us have faced losses as a result of the pandemic, but we should take pride that we have borne it. Some have flourished, whereas some of us have weathered less gracefully, crying every step of the way.

My wedding celebration is scheduled for summer 2021, but even now I receive emails from my hospital calling me back for extra ITU shifts. Of course, I am hoping the vaccine will be our saviour, but knowing the practicalities of rolling out mass immunisation schemes, it may be some time before everyone is vaccinated. With new infections rising exponentially, the second wave is here and I may face an exact replay of last year with another cancelled wedding and stint in ICU. Surprisingly, I don’t dread it as much as I thought I would.

In the past year, I have learnt so much about this disease and myself in the process. I know what it is to work weekly night shifts looking after the sickest of the sick and to cry at a lack of loo roll in the supermarket. But those trying circumstances ended (albeit temporarily) and they will do again. Similarly, for you, I don’t know what your corona story is, but I know there are hardships. Take heart from how much you have already endured, and know that you too are ready for the second round of corona.

Health workers, not ventilators, are our most precious resource→

Read at https://sussexbylines.co.uk/

As the UK braces itself for round two of the coronavirus pandemic, the conversation has reverted back to subjects from earlier in the year. Perhaps to reassure the public that the second wave may not be as bad, the media touts the gains in hospital beds (or hospitals for that matter), and the amount of new equipment boosting the effort this time around.

During the first wave of the pandemic, ventilators were quickly heralded as the number one life-saving solution for the sickest coronavirus patients. The global rush for ventilators was so extreme that, despite quadrupling production, Dräger, one of the world’s leading manufacturers of the machine, could not begin to meet the demand. Subsequent development efforts involving big names like NASA and Dyson, as well as numerous smaller 3D printing companies, bolstered the world’s hope: by building and distributing enough ventilators, the ravages of this disease could be mitigated.

Unfortunately, it turned out that ventilators alone were not the solution.

As the Intensive Care National Audit and Research Centre (ICNARC) data from the first wave of the pandemic showed, the percentage of Covid-19 patients dying in UK Intensive Care Units (ICUs) after receiving mechanical ventilation was high – of the 10,812 patients admitted to British ICUs with coronavirus up to August 31, almost 40 per cent had died. And even before the onset of the coronavirus pandemic, mechanical ventilation was well known to cause complications, which led to clinicians being cautious about placing patients ‘on the vent.’ Add to this the virulence of Covid-19, and it was soon clear that ventilators were not the cure-all that the initial hype led us to believe.

What did improve outcomes, however, was good nursing.

Ventilators are complicated machines and require expert knowledge to be used effectively. Without a trained operator they are at best an inanimate object and, at worst, a potentially lethal device. Most of the time, the trained ventilator operator in an ICU is not the patient’s doctor, but their nurse. During the initial peak in the pandemic, junior doctors, newly seconded to ICU from other training posts, encountered a steep learning curve and did best when taking instruction from the nursing staff. Not only do these specialist nurses routinely adjust complicated ventilator settings, but they do so while managing myriad infusions, as well as attending to the various other care needs of their patients. Superheroes indeed. Which is why expanding the number of ventilators is to ignore the real limiting factor – adequate nursing numbers.

Healthcare workers are the most precious resource in the NHS. The oft-used phrase ‘lack of beds’ actually means ‘lack of staff’. A hospital can easily bulk buy enough beds to fill every empty room in the building, but without a concomitant reinforcement of staffing (and that means all healthcare professionals, from cleaner to consultant), expanding the quantity of medical equipment, be that beds or ventilators, is essentially futile.

Health systems only function when there are enough qualified workers to provide comprehensive, high-quality care. Every job, from sanitising the floor to emptying a catheter bag, is vital, so there should be as much focus on investing in healthcare workers as there is on procuring equipment, especially during a pandemic. Of course, there is much ground to be made up now, as years of NHS cuts and general dereliction by successive Conservative governments has led to an exodus of healthcare workers at every level.

The first and most pressing step in supporting the medical workforce during the current situation is ensuring its safety. Only with healthy teams can ongoing robust care be provided to the thousands of patients with coronavirus. The national shortage of personal protective equipment (PPE) and coronavirus testing for health workers at the start of the pandemic (with the latter still an ongoing issue) spoke to extreme deficiencies in policy and planning. The pleas for PPE from Drs Tun and Chowdhury, who later went on to die from coronavirus, were not only heart-rending, but showed the relative inertia of a government which only expanded testing for healthcare workers eight weeks after the first UK case.

In the longer term (unless there’s a deus ex pharmacia, COVID-19 will be on the agenda for months, if not years), healthcare staff will need ongoing nurturing. Before progress can be made, however, regressive actions must be reversed and that includes valuing nursing students enough to waive their tuition fees (abolishing student nurse bursaries was a punitive step taken by the government in 2017). Inflation-matching pay rises for public sector workers should also be on the agenda. Given that MPs have already led the way by voting for their own supra-inflation pay rise for 2020, why not (at long last) extend that to public sector workers? Money is not the only way to show appreciation, but it is one of the most fundamental, and when nurses have to turn to food banks, gross pay scale reform is critical. 

Remember, when breath becomes short, a coronavirus patient won’t turn to the politician, nor even the ventilator, for salvation, but to the healthcare worker. Pray that they are there.

2020 Vision: An NHS Doctor Looks Back In Disbelief→

It seems strange looking back on the first half of 2020 now. As the January 1st fireworks popped, the atmosphere for most of us was one of celebration. Yes, there were undoubted obstacles to face, not least the definitive date for Brexit a month later, but a new year, let alone a new decade, symbolised a fresh start. At that point the coronavirus pandemic that would come to define 2020 was a mere Chinese whisper, barely touching the headlines in the UK and then only with the cursory dismissal of previous contained outbreaks like SARS.

That nonchalance seeped through the NHS hospital, where I was working as a doctor in general medicine. Despite burgeoning worries from abroad, for example the increasingly tragic reports from Italy and the WHO's pandemic declaration on March 11th, most UK healthcare workers remained calm, protected by a veil of ignorance and hubris. That was the rest of the world, it couldn't happen here.

Two weeks later and that veil was ripped away as the number of coronavirus infections and the ensuing death toll exponentiated.

It was unlike anything I had ever experienced before. The daily intake of patients, usually a diverse list including chest pains and stomach upsets, narrowed down to one ailment alone: shortness of breath. This in itself was frightening. In the history of the NHS, seismic shifts like this have only been seen in the context of devastating but short-lived phenomena like terrorist attacks. COVID-19, however, caused such a sustained influx of disease that an apocalyptic shift in perspective occurred. The situation was more in line with wartime medicine; a relative plague had descended and people were dying in droves.

Suddenly questions were asked, which no medic of recent generations has had to contemplate. Would we run out of ITU beds? Probably. Would we run out of oxygen? Possibly. Would we run out of masks? Definitely.

As the NHS plunged into disaster mode, healthcare workers looked to the helm for guidance. They, the big bosses in the government and Department of Health must have been prepared for this, if not from decades of Public Health research then from the beacon signals of other countries that had fallen to coronavirus beforehand. The UK had fair warning and those who were privy to all the international briefings, would surely have been making plans and provisions for when the virus came to the country.

It soon became apparent that this was not the case. Suspicions arose with the Government’s vacillating approach to the pandemic. Herd immunity was initially touted by key advisory figures like Sir Patrick Vallance only to be backtracked upon when the consequences of exposing the general population to a virus that caused a 7.8% mortality rate in the over 80 age group became devastatingly clear. When lockdown finally came, the prime-ministerial address was difficult to stomach not due to the restrictive measures but because of the hypocrisy of it coming after weeks of laissez-faire. The final, physical proof that the Government had not prepared for the pandemic was in the lack of PPE, which became all too evident as healthcare workers penned letters and then subsequently died protesting its shortage.

At that point, with all trust in senior leadership gone, NHS workers hunkered down to do what they always do – their best work in the most challenging of conditions. Endeavours like the Nightingale Hospital were dismissed as mere show and some even went as far as to say Boris Johnson’s hospital admission with coronavirus was a propaganda stunt, meant to engage sympathy after negligent handling of the pandemic.

When I mentioned these viewpoints to my partner, a Swiss National, he was amazed that public sector employees could be so cynical about the authorities they work under. However, after more than a decade of NHS cutbacks and attrition under a Conservative regime, jaded attitudes amongst healthcare workers are common. Such mistrust in the political body is only reinforced by scandals like Dominic Cummings’ lockdown-breaching “Vision Quest” and the misrepresentational counting of PPE.

So what next? As the UK claws its way out of lockdown, healthcare workers take stock of what has happened whilst simultaneously fearing and bracing for a “second wave”. The most difficult to deal with is, of course, the horrendous death toll. Not only does it personally touch each worker who cared for a coronavirus patient, the figure is an acknowledgment of the failings of the system and the government that allowed this to happen. With the world’s second highest coronavirus death rate per capita amongst major countries, the UK, the land where vaccination was first formalized, can no longer claim to be at the forefront of Public Health. Despite our extraordinary efforts during this pandemic, it is another sore loss healthcare workers have had to bear.

Coronavirus: The UK’s Steep Learning Curve to Social Discipline→

As lockdown measures start to ease in parts of the world, countries are taking stock and reviewing their performance in the COVID-19 pandemic. Things are not looking good for the UK. As the death toll approaches 40 000, the UK has a global ranking of having the 5th highest coronavirus death rate per 1 million population. This coming from a country that has the 6th highest nominal GDP in the world. Something has gone wrong such that one of the world’s richest countries has fared so badly in keeping its population safe.

With ever-stronger calls for a public enquiry into the UK Government’s handling of the pandemic in the UK, journalists and citizens alike are performing their own analyses, trying to understand how such a ghastly toll could happen. What is apparent is that the global West has had worse outcomes than the East and now begins the careful deconstruction as to why.

Whilst the reasons behind this difference are multifactorial, a key issue is how quickly and effectively lockdown measures were adopted in respective nations. The UK has become notorious for its lackadaisical approach in the initial weeks of the pandemic, whereas Sri Lanka, like many other Southeast Asian countries, took coronavirus more seriously from the start. On March 20th the Sri Lankan Government enforced a national curfew, which remained in place for at least seven weeks. The UK too went into lockdown on March 23rd, however, with less success in containing the spread of coronavirus when compared to Sri Lanka.

Part of the reason for this may have been the enforcement of the lockdown. The latest political scandal involving Dominic Cummings shows that even top government figures have broken public health rules with impunity. Such transgressions were compounded by a lack of police authority to enforce social distancing guidelines in England and unclear advice, such that the Chairman of the Police Federation, John Apter, bewailed the government's lack of clarie as to what the population were and were not allowed to do as part of the lockdown.

Sri Lanka, on the other hand, was better prepared to regulate the lockdown arguably because this is not the first time the country has faced an urgent national situation. Having endured a civil war that lasted over a quarter century, Sri Lanka is well schooled in exercising social discipline. Curfews are not new to a country that within the spell of twenty years has faced terrorist bombings, armed conflict and a devastating tsunami. Thus, when the government, backed by the military, mandated a lockdown to prevent the spread of corona, Sri Lankans generally knew to obey.

During the civil war years it was not uncommon to be stopped on roads by armed police or the military performing checks on the credentials and purpose of a traveller’s visit. Whilst this decreased over recent years, since the 2019 Easter bombings a significant security presence is felt at Colombo’s international hotspots e.g. airports, hotels and shopping malls. Sri Lankans are familiar with such a presence, whereas in the UK it is the stuff of exception, usually only seen at large public gatherings.

In the case of policing during the pandemic, some UK citizens, unused to having civil liberties infringed upon (even if it is in the name of public health and safety), took issue. This was seen in the Hyde Park demonstrations of May 17th where 70 people gathered to protest the coronavirus lockdown. When confronted by Police, some protestors reacted strongly, shouting abuse and tussling with officers.

Although such a level of opposition is in the minority it is clear that Britons are chafing at the social restrictions and even a mild lightening of lockdown measures has seen a rebound of unsafe behaviour. The ongoing warm weather has seen a nationwide surge of people descending on parks and green spaces in such numbers that social distancing is almost impossible. Unused to following real-time governmental orders, UK citizens risk spreading infection for the sake of sunbathing. 

Time will tell whether this means the dreaded “second surge” of coronavirus cases for the UK but the death toll as it stands is shocking enough. Meanwhile the UK government continues its tradition of confusing its population with obscure advice, recently downgrading the pandemic slogan from “stay home" to the ambiguous “stay alert.” With little practice in the latter, the UK should be looking to countries like Sri Lanka as to what this actually means. 

Why Sri Lanka may be Spared the UK's Care Home Cull→

Many raised an eyebrow when the UK Government outlined herd immunity as its initial approach to the coronavirus pandemic. Exposing a significant proportion of the population to COVID-19 in order to gain a theoretical immunity seemed risky especially considering BMJ analysis of the data from China, which revealed a 7.8% mortality in the over 80s at that time. As the virus spread through the UK in those frightful weeks the first stage of the government's ill-thought strategy seemed to be working, more of the population was indeed exposed to the virus and infection rates began to climb.

 So did the death rate.

 Two months after the UK government belatedly adopted the lockdown strategies favoured by the rest of the world, the toll of that initial complacency is evident and this is none more so than in the elderly population. Coronavirus has rampaged through UK care homes and the death toll during these past few weeks has been well above the past five year average. The figures make for shocking reading with at least a quarter of all coronavirus deaths from care home residents in England and Wales. Bearing in mind the UK has the unenviable title of having the second highest corona death toll in the world, the numbers of care home residents that have died is in the many thousands with at least 12 526 care home residents having the virus listed as a cause on death certificates. In all likelihood that number is far higher given the indirect effects of corona on health in vulnerable people.

As the UK struggles to save face and more importantly, its population, comparison with other countries occurs in order to analyse how the UK got it so wrong. Although cases of coronavirus are beginning to spread in Sri Lanka the death toll cannot compare to the UK and this will hopefully remain that way given the social structures in place. The Asian subcontinent is famous for its close-knit, multigenerational family units and care homes are the exception rather than the rule. Rightly or wrongly social taboos still exist preventing families enlisting help outside the home in caring for their elderly relatives and as such, institutions grouping large numbers of elderly people do not exist in Sri Lanka to the same extent as they do in the UK. This could be to the country's benefit in the coronavirus pandemic.

Even before COVID-19, infectious diseases were the dread of care homes. By their definition nursing homes house congregations of vulnerable and frail people and infections can rip through with devastating effect in this "sitting duck" population. Outbreaks of diarrhoeal illnesses like norovirus have been known to cause devastation in such groups and now the highly transmissible coronavirus is causing deaths on an unprecedented scale. In the UK this has unfortunately been aided by national shortages of PPE and hospital discharges of corona positive patients to care facilities in the early weeks of the pandemic. Sri Lanka will hopefully be spared this tragedy as family units remain self-contained and the elderly stay in small, protected social "bubbles" not dissimilar to the successful New Zealand policy of containment.

With care being conducted exclusively within the family the Sri Lankan elderly population will also be spared cross-infection from generic agency carers, who work in different sites with different citizens, as is the case in the UK. Narrowing down exposure to the virus seems to be the preferred global strategy for tackling the spread of coronavirus, which is part of the justification of lockdown measures. Luckily for many of the older Sri Lankan population their risk of exposure is restricted to family alone and thus cross-contamination from other infected patients remains unlikely as long as the family observes isolation protocols.

 As the world analyses what strategies work in minimising the impact of coronavirus, countries that lead the way show that they have prioritised the safety of their most vulnerable citizens. In Sri Lanka this is aided by a pre-existing system that allows for care to be provided in small, self-contained settings and a culture that holds a deep reverence for the elderly. If only the UK Government held its senior citizens in such high regard.

Source: http://www.island.lk/index.php?page_cat=article-details&page=article-details&code_title=222952

The Guilt of Good Things

It takes something extraordinary to make a hospital stand still. Usually places of unremitting activity, forget New York, the NHS is the entity that never sleeps nor stops.

Today was the exception.

This morning the UK observed a minute’s silence in remembrance of those NHS workers who have died during the coronavirus pandemic. It was a strange moment for those of us working in the hospital. At 11 a.m. the bell usually used to signify the end of visiting hours, rang out through the wards and everyone who could, stopped. Save for the beeping of electronic monitors or the puff of a ventilator, silence reigned. In a stillness incongruent with the surroundings, patients and staff alike reflected on a tragedy that affects everyone in healthcare at the moment.

More than 100 NHS staff have died from COVID-19, their exposure to the virus undoubtedly higher as a result of their occupation. They form a special group amongst the 21000+ UK corona deaths, each tally actually a person, much loved and much missed. The toll is disastrous and worthy of not just minutes but months of ongoing silence and mourning.

The sixty seconds ran through and then normal service was resumed, that is if anything can be called normal during this pandemic. The fact stays with us, however, fellow workers have died and we must honour them. We remember it as we apply an oxygen mask to a patient’s face or as we open an email from the Chief Executive, notifying us of another colleague bereavement. These are hard times and there is little relief when we look to our leaders or the media.

During such sorrowful periods the feeling of happiness seems insensitive and yet, for many of us, including those in the healthcare service, lighter moments do prevail. What I have been struggling with though is the accompanying sense of guilt.

I cannot recall a more spectacular run of April weather, nor a more beautiful collection of spring foliage than have occurred this year but every venture outside my home has felt wrong, bordering on criminal. Even if I am walking to work or on a health-boosting 20 minute jog around the block, I still feel guilty to be challenging the public health message even if I am technically within the boundaries of its advice.

And then there is the sheer intensity of emotion that comes with life at the moment. Working daily in such extreme circumstances, the simplest of pleasures takes on disproportionate dimensions. A toddler’s clunky descent down the stairs yesterday almost brought me to tears and I relish my morning croissant to a level bordering on obscene. But then just as I savour the enjoyable instant, my rush of dopamine is curbed as I recall the many things there are to be sad about.

Even tucking into the bolstering free meals sent to the hospital from local restaurants and organisations like Fuel Our Frontline is not without its ethical considerations. I, as a healthcare worker with an adequate pay cheque, can well afford to buy my own lunch. Would the free meals not be better sent to those whose income has been threatened by the lockdown? Instead of naan my delicious curry lunch comes with a side serving of guilt.   

So what are we to do, us healthcare workers, who have lost colleagues, loved ones and too many patients? Is it right to feel happiness when the circumstances are so sad?

It is imperative.

Much has been made of maintaining mental health during the pandemic and this is especially true of those working in the healthcare service. It is because the circumstances are so sad that we must celebrate happiness, even as we remember those who have died. If healthcare workers are to continue working and not crack with the strain of working during this pandemic then we must bolster our own mental and emotional reserves.

Guilt runs co-existent to work in the NHS. Even before coronavirus dropped the bottom out of the health service, clinicians were frustrated at the expanding waiting lists and the inability to deliver quality care due to the limitations of the system. Now with such a severe illness health workers must face another level of desperation altogether, watching as their patients die before their eyes. There is no sense in compounding grief with guilt.

There will be more moments of remembrance, no doubt, over the coming months. Even as we reflect on our loss, the world edges back in. The bell rings, bringing us back to the present and we are faced with life’s ongoing demands. If we are to meet them then we must have a counter-weight to our sorrow, therefore, we must celebrate joy where we can. That means smiling when there is cause to smile, letting go of the guilt and if possible, carrying on.

Love in the Time of Corona

These are unusual times indeed.

A global pandemic has reached the shores of the UK, traveling through every echelon of society, from pleb to prince. Its spread has put paid to mathematical predictions, after all, modelling is exactly that - a best guess given the circumstances. What Nobel Prize winner would be able to interpolate the perversities of human nature like the compulsion to hoard when there is enough for all or the the need to mingle despite the significant health risk?

So here we are, reacting to a situation familiar in history but novel in our lifetime. This has happened before as dusty schoolbooks could tell us. Plague, flu, smallpox: somehow miniscule organisms have always had the ability to decimate a population but our ever increasing medical arsenal of drugs and machines have made us feel if not invincible, at least secure. Coronavirus, the common cold in certain forms, has reoriented our perspective, reminding us of a number of things including that we, as ever, are vulnerable.

A reminder of death is not necessarily a bad thing unless you or a loved one are sick. A brush with mortality has a crucible-like effect, burning away the superfluous to leave the most enduring parts of the spirit. That, in most cases, is love. The world boils away to just your connection to those you hold dearest. The daily grind and petty grievances evaporate in the immediacy of now and life shrinks down to a few bodily functions - the beat of a heart and the breaths taken from a hospital bed.

Breath.

What an undervalued sensation it is. The simple act of drawing air into one’s lungs, in and out, in and out, in a rhythmic cycle since those first gasps dispelling the amniotic fluid, if lucky, we hardly notice the process until it ceases altogether. But for those of us who have struggled for breath or seen someone struggling, normal breathing is the stuff of miracles. If you have the good fortune to be free from any lung condition right now, take a deep breath and marvel. Air is a tonic; drink deeply and freely.

Maybe it is a bit much to ask those who have been isolated for weeks at a time to take pleasure in such rudimentary activities as breathing but bear with me. There is something to be said for this simplification of the daily routine. How long have we now decried the frenetic pace of modern living? Now when life is stripped down to Boris’s “essentials” (ahem, eating, banking and building it seems), our threshold for enjoyment resets. Before corona, many of us looked to the latest immersive experience to make the heart thrill. Now there is pleasure to be had in even the smallest walk to the shops. What a treat to be out in the sunshine (and what sunshine it has been!) enjoying the budding leaves and the sweet, thirst-slaking air.

And what of those in the most restricted form of living, self-isolation? Even if we cannot go outside for walks, hopefully we have access to a window and can see that “little tent of blue” canopying our view. As the sun sets a return to the window will reveal a theatre of colours - hot pink, neon yellow and cyan, sunset shades that printer ink could never hope to recreate.

Within the space of two weeks these simple things have come to mean so much to me as corona has upturned my pre-existing life. As I walk towards the hospital each morning the dread of the upcoming shift is transduced by these small pleasures into something more productive, more heightened. I feel love. I think of my family, I see an unblemished blue sky and I breathe. That is enough.

I breathe.

I breathe.

I breathe.