David Oliver Q&A: a view from the Covid-19 coalface

With the ongoing Covid-19 crisis changing the way we live our lives and having a huge impact on the NHS, David Oliver describes what motivates him as a clinician at such a time, what the health service and the wider country need to learn from the past few months, and how pleased he is to be doing the job that he trained for.

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Published: 23/04/2020

You’ve mentioned recently that NHS staff are anxious and fearful, but they keep turning up regardless. What drives you and your colleagues at the moment?

I have devoted my whole working life to the NHS, but most of us have not before had to cope with the fear of becoming unwell or even dying for our work. Suddenly everyone is very aware that when they come to work they could get the virus and pass it on to their families.

So you don’t know how you’ll react until you’re there. But what’s been absolutely extraordinary is that people – because of really strong commitments to patients, commitments to professional values and loyalty to the people they work with – have kept coming into work anyway, despite that fear. They’ve sustained each other.

People are also coping because they’ve got a job to do – one that is valued and appreciated by the public.

Does that public appreciation feel new?

We know from British Social Attitudes surveys that the NHS is the institution the British people feel most proud of, and we know that nurses and doctors are top of the public’s ‘respect league’.

But we certainly feel extra appreciated right now. The public can see that frontline staff are putting their own health on the line. We’re telling everyone else to stay at home while we’re going to where the most severe Covid-19 cases are congregating.

What’s happening on Thursday nights is very noticeable, even if staff would rather feel that we have the right equipment and the right resources. But the support is definitely appreciated.

What do you feel has been the NHS’s biggest success over this period?

In each part of the UK, we have completely transformed the way we are working.

We have cleared loads of capacity, made remarkable strides in getting bed occupancy down, we’ve worked closely with local community partners to get more people out of hospital sooner. We’ve doubled, trebled and even quadrupled the capacity of intensive care units. We’ve doubled and trebled the numbers of doctors on our rotas, we’ve put so many people into completely new and unfamiliar roles – and they’ve embraced it willingly. It’s all been driven at real speed.

It shows that if you liberate clinicians, clinical leaders and frontline operational managers, they can innovate every bit as quickly as the private sector – free of the red tape and the bureaucracy.

What do you think the response to the coronavirus says about the position of older people in the UK and the NHS?

Although I’ve campaigned against ageism my whole career, you have to distinguish between age discrimination and actually age-differentiated decisions that are proportionate and based on evidence.

We know that if you’re over 70, particularly if you’re over 80, that you’re far more likely to be admitted to hospital or to die from the virus, even if you see yourself as fit and independent. So there’s sense behind the shielding of older people. We haven’t got the time for individual assessments of everyone. I don’t regard that as being ageist, even if some of how it’s been handled – blanket letters and making people complete a ‘do not resuscitate’ form – has been insensitive.

And then there’s social care. We’ve known for a long time that we need proper sustainable solutions to social care, but this has again really highlighted the lack of funding, staff and equipment in those key services. The social care worker who delivers those services in a fragmented provider sector, often on the living wage, is in a way even more heroic than those working in acute hospitals, who at least have better support and equipment.

So yes, it has said something. Even before the pandemic there were many older people with little human contact, so maybe this will make us think about how to address that, through wider solutions than just social care.

How do hospitals feel at the moment and is it good that admissions are going down?

Hospitals are in a strange place. Respiratory wards and intensive care units are very pressurised, but in other parts of the hospital system our bed occupancy rate is significantly down and our A&E attendance figures have gone back about 15 years. We’ve got more therapists and junior doctors on the wards as they’ve been redeployed from elsewhere, so it’s a bit uneven. I spend some of my time on an ordinary medical ward and some at the acute front door – and it’s only at that acute front door where it’s more stressful than usual.

For people coming through emergency departments on a general hospital size, I’ve written before that the best estimates are that around 15% of those attendances could be dealt with in a different way. So if A&E attendances have gone down by a lot more than that, you wonder what’s happening to all the other cases we used to see.

That is the talk among a lot of doctors. If every person we’re seeing has a respiratory problem and it’s likely to be coronavirus, what about the people with a chest pain, a cancer complication or stroke? In the final evaluation, we are going to have to see what happened to all those other people.

It’s been great to get people out into community settings a lot faster, but when they are back in their own homes I don’t have a sense yet of how they’re doing. Primary care will face similar issues with their telephone consultations. Are people with other serious problems going to do badly?

The battle with this virus is clearly still going on, but what are the lessons for the NHS and the UK more widely that are already clear to you from it?

I’m wary of saying how well we’ve done until it’s all over. If you look at many of the Asian countries, on the face of it their preparedness from SARS, their early aggressive contact tracing, testing the whole population and early lockdown does seem to have flattened the curve and worked.

The fact that Germany have tested lots of people – having already had four times the hospital bed base and ICU bed base of the UK – seems to have worked. It may be that by when we get to the autumn, our hospitals never did get overwhelmed, the lockdown did work and we didn’t have to make terrible decisions between two people who might have benefited from ICU.

We have certainly seen the incredible agility within the system if you let the right people crack on and lead change. Perhaps too that some of the things we’ve stopped doing during this time, and which probably add very little value, well maybe we should carry on doing less of those – things like appraisal, inspection and revalidation, or some of the actions of regulatory bodies.

In terms of what’s gone wrong, clearly we need to look at national-level preparedness and communications. I realise that every country’s government has had problems, but we know there was a pandemic preparedness report back in 2016. That highlighted a lack of ventilators, a lack of intensive care beds and pandemic preparedness, and we know that very little action was taken.

I realise we can’t have the inquest while the crisis is still going on, but it’s hard to escape the conclusion that, on the logistical supply lines for protective equipment and on ramping up testing, we’ve been a bit let down by central agencies and poorly coordinated actions. We could have been on things a month before we were. Those well-publicised delays in getting personal protective equipment, and the mixed messages about it, have caused anger among staff. That’s improving in acute health care but it’s clearly not yet improved in the community or in care homes.

There have been confusing lines of accountability and they were slow off the mark. There will be another novel virus, there will be another pandemic – we really have to learn.

When we come out of this crisis, some of the already well-highlighted problems in both the NHS and in social care also need to be addressed. The shortage of intensive care beds relative to other nations, the significant staffing gaps, a lack of social care funding, and cuts to public health.

I also can’t help but reflect, especially after what the Prime Minister said about his own care, that if about 13% of NHS staff are overseas trained, we really do need to stop any anti-immigration vibe that might prevent overseas professionals from coming here and staying here – we need them all.

How do the experiences of the past weeks make you feel about your career choice to be a clinician?

Despite the various national leadership roles that I’ve had, I would have really hated myself after this period if I’d not been at the coalface for it. I’m really pleased that I’m doing the job that I trained for.

I had got to a stage in my mid 50s where I felt myself starting to go through the motions on my clinical career, and I was getting most of my energy from my policy work or my writing. But this has actually really revived my interest in clinical medicine. Every day the international medical and research communities are learning new things about how to tackle the virus and how to organise services.

On the negative side, I’ve seen some pretty distressing situations. Patients dying when none of their family can visit them, and trying to communicate with them through a mask and protective gear when they’re awfully confused and distressed has been tough – it’s been hard to witness that degree of suffering.

And of course I've been a little bit fearful myself, because other clinicians in their 50s and 60s have died. As my wife is not a medic, she is worried every single day that I’m going to contract the virus and whether I’m going to stay safe enough. For the past six weeks, we’ve had to sleep in separate beds and use separate bathrooms. We distance from each other, and have minimised physical contact for weeks now. That can take its toll.

But I have gained a tremendous amount from being where it’s all happening – doing a valuable, worthwhile job that helps people. I feel I am where I ought to be.

David Oliver is an NHS consultant in geriatrics and acute general medicine and a trustee of the Nuffield Trust.