Beware the Old Normal

First published in the NASGP Newsletter in June 2020

What good has come from this unprecedented social experiment? And how do we preserve it?

Last Friday, on my way to the pharmacy, a young woman, mask-less, was walking straight towards me, her eyes glued to her phone. Fortunately, one of us was alert.
For me, she was a canary: the portent that the consensus over Covid was over. To impose lockdown was straightforward. It was – almost certainly – the right decision. Getting out of lockdown is anything but straightforward.

Sweden did lockdown-lite. It hasn’t been straightforward. Swedes are unsure what they can do and what they should do. People have made their own compromises. Their infection rates are higher than comparable countries.

The way out of lockdown is via the classic method of infection control – track and trace and isolate. That’s difficult in the UK, a country of 66 million at this stage in the pandemic and with a fragmentary – to be generous – test and trace capability. The government follows the (political) science, and we await a second wave. We will probably be living with Covid for years.

Meanwhile, what good has come from this unprecedented social experiment? And how do we preserve it?

Clapping doesn’t pay bills”

Some people hope that Covid will change societies for the better. They cite the Black Death and the First World War. But those lasted years and laid waste to a generation of young men. They transformed the social structure; deprived of their workforce, the elite couldn’t maintain the pre-disaster order. Six months of Covid, which has targeted the elderly and the disadvantaged, isn’t going to change society in such a fundamental way.

Back in March, there wasn’t time to wait for lumbering NHS bureaucracy to turn the ship around. So hospitals turned themselves inside out to meet the crisis. Staff found they could work across professional boundaries, co-operating to solve the problems presented by the unprecedented situation. Everyone, whatever their role, is accepting personal risk to serve patients. All staff share the rewards of meeting the challenges and seeing patients recover, supporting each other when patients and colleagues die. Doctors and patients have learned to accept that we live in an uncertain world.

Having rediscovered the strengths of teamwork, surely we don’t have to go back inside super-specialist silos. Like the phenomenon described by Dr Richard Asher in 1959: an ophthalmologist who suspected that a patient might have Laurence Moon Biedl syndrome referred him to a physician to check whether he had polydactyly. Do we have to resume rotas which left junior doctors floating around unanchored and unsupported, ticking off ‘competencies’ but missing out on acquiring from role models the wisdom and judgment that make a good doctor?

Politicians in power want to congratulate the NHS for its response to Covid and ‘move on’ to ‘get Brexit done’. But there’s a problem that won’t go away. The NHS now has to tackle the mountain of cases which couldn’t be dealt with during the crisis, in hospitals still stalked by Covid and staffed by people exhausted and bruised by what they have been through. With a second wave of infection impending. We haven’t enough doctors. We haven’t enough nurses. We didn’t have enough to support the model of service we had before Covid struck. The politicians say the NHS coped. It did what it could under the circumstances. But clapping doesn’t pay bills. Calling hospital workers heroes and giving them cereal box medals doesn’t staff the wards. Especially if politicians then pass laws to make them unable to work here.

They are poised to ‘take back control’. In April the Care Quality Commission tweeted that after Covid it would return to inspections “with a fierce ‘stink-eye’* and extreme regulatory prejudice”. They hastily withdrew the tweet, but I fear that behind the current emollient messages is an iron fist determined to cow the profession into submission.

It will be a fight to protect successful reconfigurations, worked out from the bottom up, against top-down attempts to reassert power through forcing the system back into failed channels.

Covid has changed general practice, too. It turns out that even GPs can work from home. Telephone and video consulting had to come, and sceptical GPs (mostly towards the end of their careers) and patients (mostly towards the end of theirs) have got used to it. We will be better able to decide which patients we should see face to face. Practice meetings via Zoom have proved effective and make it easier for part-timers to participate. But the big time-saver has been cutting red tape and pointless bureaucracy to concentrate on doing the real and important work GPs are meant to do.

Professor Martin Marshall, chair of the RCGP, told the House of Commons Health and Social Care Committee that 25% of GPs’ time is spent on meeting bureaucratic obligations of little value set by governments. And GP numbers continue to fall; this year there are fewer than last year. Will the government recognise that paring down these tasks could generate, perhaps, the equivalent of 20% more GPs? And persuade young doctors that our job is, once again, very rewarding?

For me, like many people, webinars are a more reliable source of information than the charade that is the daily press conference. If people in government were listening to the people who do the work, they might rethink and refrain from the refrain of ‘world-class’. We didn’t need to send planes to Turkey to bring back equipment, only to find that it wasn’t up to the job. Cheapest proved costly. Trusts gave up waiting for centralised supply chains to deliver. They contacted local businesses and found them delighted to help.

Result: flexible responses, short supply lines, rapid availability, the local economy boosted, businesses supported, livelihoods and health protected.

We are only part of the national health economy. Hands-on dentistry is to restart next week, but in the absence of on-the-spot testing and adequate PPE I’m not clear about the drill. Nor, I gather, are a lot of dentists.

The future of social care is a can that governments have kicked down the road for years, and the can is full of worms. I wonder if there will be any care homes this time next year: their problems were ignored by government, there’s no money in it and the sources of staff are being cut off.

And while all this goes on we have to work out how to live our daily lives, weighing up risks and uncertainties and hoping we have got it right. It will be a while before a walk in the park is a walk in the park.

* Definition (American): to make a facial expression of unreserved disgust, contempt, disapproval, distrust, or general ill-will towards someone.

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