I am a practice manager in a large, semi-rural medical practice in Lincolnshire. We have just shy of 20,000 patients and a magnificent team of 60 dedicated individuals who provide clinical and administrative support in keeping the wheels of our little part of the NHS landscape turning. We all work exceptionally hard in normal times (although “normal” is a subjective assessment, depending on whether you actually work in primary care or “manage it” in depressingly increasing numbers from a distance…). I love my job, the people I work with and, ultimately, the people we provide our services to. Those people cover just about every part of the melting pot of humanity; they are ethnically diverse with a large proportion of eastern Europeans, significant numbers of the elderly and/or vulnerable, mixed with a goodly number of the young and healthy and, of course, those who fit no particular demographic – they are just people who occasionally need a bit of clinical assistance. They have passed the young and healthy point, and are not yet elderly or, heaven forbid, vulnerable or infirm. The majority are supported by family and friends and, in the most general of terms, would prefer to spend as little time as possible in any form of medical environment. We have our fair share of the worried well, the confused, potential psychopaths and sociopaths, and the occasional patient whose sole aim in life is to find fault, and share it with the world, before even mentioning it to us. We care diligently and professionally in every aspect of our working lives. We empathise and sympathise with our patients. We are a prop when they need it, a laugh and a joke when they need that, and yes, we occasionally get to the point where we share their sorrow or sadness and, no matter how professional and aloof we are supposed to be, will shed a tear with them – or for them, when they lose life’s battle. We are, in the basest form, the open face of tolerance and care that nearly every person in the country will encounter at some point in their lives, whether they like it or not. It’s what makes each and every one of us tick and come back, day after day, for more of the same. You too could have written this paragraph, and all you would need to have done is change the number of patients/staff. We are all cut from the same cloth, and we have met each other – maybe not in person, but as kindred spirits most definitely.
And then in early 2020, all hell broke loose. COVID-19 reared its stealthily ugly head, and all of a sudden everything that we hold dear in primary care was turned on its arse, except for one issue, which I will come back to. Since then we have been, for all the absolutely right reasons, disenfranchised from our patients. We have dealt with everything remotely, by telephone or video, we don’t let anyone into our building unless they are able to demonstrate that they are asymptomatic of the virus, and even then we insist that they take protective measures, as do we. Basically, anything and everything other than the coronavirus has been of absolutely no consequence for the past five months (and counting) although we are now, like most others, beginning to gather the data that will provide our income next year and – gradually – unlock the other services as soon as we possibly can. This is right and proper. But here’s the thing. We still have many, many patients that we care about – many of whom, for age or clinical reasons, are in some form of isolation. Many are on their own and are lonely at a time in their lives when they should have been able to rely on the warmth and care of their families, loved ones, friends or the societies that they have contributed so much to during their lives. Through no fault of their own, these families and friends have been unable to play a physical part in their well-being or support during this crisis. Whilst the situation is now beginning to ease – but by no means relent – we have set up a home-visiting service for those who are asymptomatic, to make sure they get their dressings done and their medications delivered; and we have also gone a step further. We phone them – for no reason. Just to let them know that we are thinking of them, and then spend a few minutes just making sure they are okay, reassuring them that we look forward to seeing them when it’s all over and just about anything else we can do to let them know that we care for their welfare. If we need to get others involved – from any sector, including the volunteers – then we will and we have. We couldn’t and wouldn’t do it any other way. Nor would you – did I mention, we know each other?
Within the process, we have moved heaven and earth even more quickly than a rat up a fetid drainpipe to get other ways of working on stream – from total triage, to e-consult to all sorts of other video consultations, remote meetings through Teams, and generally we have all done a fantastic job in getting to this point. And, with a will and a fair wind, we will be able to adopt many of these innovations for the future. We, at this practice, managed to adopt EPS – literally – in the space of two days, and we are already reaping the rewards of working in this way after so many years of lollygagging. Many patients who had been reluctant to believe in the notion of “self-limiting” conditions have discovered that they really do exist! Now there’s a surprise, and let’s hope they remember this when the doors are finally flung open again.
What did we actually learn in primary care as the pandemic evolved and grew to eventually (we all hope) dissipate? What can we take from the whole experience to make a better start for the new world order once we see what’s left of this one?
The most important thing that we (that’s me and my team) have finally learnt in a demonstrable way is that we are adaptable, proactive, team oriented, mutually supportive and inclusive – and bloody brilliant, collectively, in a crisis. The reticent have been brought out of their shells, the lazy (we, like all teams, have – or rather, had – a couple) have had nowhere to hide, and the disruptive, militant few have been brought to book through the “whole-team approach” and now realise that to be a part of any team, they have to engage fully with it from the inside, rather than try and destabilise it from the outside. Notwithstanding the tragedy that has so publicly unfolded around us all, we are better, stronger and more resilient than most of the team members ever thought they/we could be. Proud bloke doesn’t even begin to put my view into perspective and, as we are now firm friends in a kindred spirit type of way, I know that (gender aside) you will be equally proud of your own teams as well.
All very laudable and proactive and positive – but that’s not the point of this piece. It’s actually a rant, in case you thought otherwise at this point!
The NHS has long been feted as the best healthcare service in the world – and most of us actually involved in it, in some small way, will agree with the principle, but categorically not the process. Indeed, it might be argued that, notwithstanding the heroic efforts of the front-line NHS team over the past weeks and months, we are actually nowhere near the top of the pecking order for worldwide healthcare after all. The utopian dream, now that it has really been tested for the first time, is not quite as expected and we are going to be brought down to earth with a bit of a bump. Our system is so top heavy that few of us were surprised at how ill prepared for a disaster of this magnitude the system was. Nobody could possibly have prepared for it, or at least not the detail of it – but therein lies the problem because it has become all too obvious that nobody had planned for it at all. In its “normal” guise, the “health sector” is now awash with “inspectors”, “advocates”, “authorised bodies” and those with “regulatory powers”. Interestingly, as soon as it became obvious that the malodorous brown stuff was about to hit the fast-moving air-recirculation equipment, they beat a very hasty retreat. All of them! They suspended themselves from all formal involvement, lest their input detract from the task ahead. On the one hand, this is quite praiseworthy – a bit like the prospective political candidate caught with their fingers in the till, standing down from the race on the grounds that further involvement will detract from the task in hand for the party. Of course, on the other hand, it might not be a good time to be asking them what they have been doing in the run-up to such a cataclysmic disaster. And in this, I am not alluding to anything clinical. Heaven forefend! This pandemic is unprecedented in all respects and let’s face it, if these people were clinicians then they would all now be working on the front line instead of from their sofas.
No, my issue is simpler. Far simpler.
In the rush to find fault with all aspects of primary, secondary and social care (and I use those words advisedly) and to justify their existences, they have missed the simplest of areas that they should have been concentrating on. Instead of making sure that your local, friendly GP practice has suitable notices about “Smoking is illegal and we will kill you if you do it anywhere near this building, never mind anything else…” all over the place, why were they not deployed, as a major and ongoing part of their remit, to ensure that a robust, national disaster plan not only existed but was tested and refined continuously? And by this, I don’t mean monthly exercises across god-forsaken former airfields in the Highlands for a small number of interrelated emergency services, but making sure that the basic necessities for dealing with the type of event we are now all going through were catered for. How can it possibly have become a fact that PPE – so readily available when it’s not actually needed – wasn’t stockpiled at strategic repositories across the UK as a normal part of their day-to-day planning? How can we (that’s not us – that’s the NHS “we”), as the so-called guardians of the health of the nation, not have seen this coming? We all have Pandemic Plans – and they really can be rolled out at a moment’s notice – but they all hinge on the “system” being as well prepared as we are. The “system”, quite simply, was not. And none of the inspectors even thought to take a quick look, let alone do anything about it, other than to make sure that WE had a piece of paper in our systems, marked “Plan”.
So that is my first learning point for wider consideration: instead of concentrating on the many and various pieces of paper that the likes of the CQC deem to be necessary to make us “safe”, refocus their work (or abolish it altogether… next blog?) to concentrate on ensuring that contingency planning is not only very real, but physically possible based on a global meltdown rather than a localised solution. Yes, we need to have local solutions – but without the surety of a national plan, it is a box-ticking exercise at best, and another, in part avoidable, national disaster at worst.
The second point of learning revolves around the use and deployment of the ubiquitous “NHS manager” – never ever to be confused with practice managers. In the years since the NHS was formed, the single area that has seen constant and continual growth is that of “managers”. Every attempt to cull them results in abject failure and greater expense; stories of redundancy from one role to subsequent employment in another are legion, as are the steady influx of interim managers as they do not, as far as I am aware, actually appear on the staffing budget sheets whilst “interim”. This would, in itself, be a lousy business model in any environment, but with the NHS every one of them represents a reduction in the finances available for healthcare (the money is not coming from the back pockets of business owners, it is from the public purse). There is no natural incentive to hit any form of budget, as the biggest employer in the country simply cannot go bust – it will always be propped up by the exchequer.
If this pandemic has proved anything, then it is that most of these roles are not actually essential. My own CCG management team (and it is disproportionate to the number of patients in this neck of the woods already) started working from home the minute they could. Nothing wrong with that, of course, but what exactly was that work? Most of the roles which they exist in droves for were immediately suspended by NHSE once it was obvious that all of us in primary care would be focussing on the pandemic – and none of their roles were considered to be essential or desirable. However, what happened is that a subculture (what a surprise!) was very quickly developed amongst this particular cohort that meant that the majority of these individuals were able to simply regurgitate the same information that we all received direct from the NHS Hub anyway. Beyond that, it is difficult to understand exactly what they are doing, or what the point of it is. Examples of ineptitude are rapidly moving towards folklore status. How many weeks of “I am still seeking clarity on the issue of PPE” does it take for it to register that they are completely ineffectual in this situation? How many times did we hear that there would be “guaranteed weekly deliveries of PPE without request” before one (and only one!) actually arrived? How do we get to a situation, managerially, whereby all of the NHSE “teams” are automated fully to allow them to work from home – yet primary care has, generally, limited access to fully compliant laptops or other facilities that would have allowed a similar approach within this environment? Not that most of us would have taken it, but in most cases the option wasn’t even available to us. The majority of clinicians (bearing in mind that their workload became triage based immediately) could have and should have been able to opt for that approach and to “stay safe” accordingly in preparation for the long haul that was ahead. Nor do I have any issue with any of our own number that were able to work from home, with the appropriate technology, from day one either. The point is that all levels of the “NHS management team” decamped to their sofas before most of us had even seen the government directives with regard to locking down. I do make clear, though, that this is not a personal view of any individual – most are well meaning and sincere; they are doing what they are paid/required to do, and there are some fantastic people amongst them. But that’s my point; where is the definition of need and requirement for so many of the roles that now exist? As we are adapting and changing our own processes and procedures as a result of the pandemic (and rightly so), I have to ask how long will it be before the “managers” are all back to their pre-pandemic positions and recruiting even more of their ilk to concentrate on managing the “new GP service” that is emerging?
The second learning point is therefore the perennial: to try and find a way, finally and eternally, to reduce the number of unnecessary managers within the wider set-up. Unfortunately, this will always fall into the “hope over experience” category.
What really gripped me, however, was a combination of the above points. I live in a small, friendly market town in Lincolnshire. We have a great range of supermarkets, and their teams worked their proverbials off to deliver a service to everyone during the most awful times, whilst the uncertainty of the pandemic and its effects were still being felt at a cataclysmic level. Day after day, the infection and death rates were being reported with due deference by all concerned – it was a bloody scary few weeks for all of us – and these teams just cracked on and did the most incredible job in keeping us all fed and watered and safe whilst on their premises.
On one particular Saturday, after a necessary day at the practice keeping pace with change, I decided to stop at Tesco on the way home. About 16:00 or so, I joined a lengthy queue to try and get some basics, even though there was a massive sign at the front offering immediate access to the “heroes of the NHS”. Not my game – under any circumstances. No matter how many hours or days I put into running my practice, I have not been anywhere near a “front line” since 1991 when I was in the Services. After about 20 minutes or so, with the queue moving slowly but safely, a car pulled up and parked. Out popped – let’s call her Gemima (just because I would never admit to knowing anyone actually called Gemima). Gemima is a secretary to one of the low-hanging teams of CCG wallahs for my area, and – like the rest of her team – started working in their onesies and flip-flops in early March, from their sofas. I think you might have guessed what happened next… Out comes the NHS smartcard, straight to the front of the queue and, believe it or not, several of those in the queue not only stepped back and ushered her forward – they started clapping her! At this point (from about 30 metres away), I just stood totally bewildered and bemused and, yes, shocked at her nerve. To compound even this, she then turned to those who had started clapping, and she waved and bowed before strolling into the store! I wish I could say that I called her out – I didn’t. I wish I could say that this was a flight of fancy on my part – it wasn’t.
But it leads nicely to the final part of this rant… the aftermath.
It is quite probably an understatement to say that the great British public are a very generous bunch (ask Gemima….), and we are well aware of the great respect and admiration that has been shown by so many since this storm engulfed us. When it is all over though, and the rewards and recognition are being doled out from the political, commercial, entertainment and sporting fraternities, someone somewhere needs to set up a system to ensure that those awards/rewards/gifts and hospitality go to those who have genuinely earned them – not to those who simply have the ability to log into their NHS.net account with a smartcard. The military get around that particular concept by ensuring that those attending anything of this nature wear a uniform; if they weren’t actually involved in a particular issue, they most certainly could have been as it goes with the shiny buttons of the job. They are all signed up to it, and all liable to pay the ultimate price of their profession regardless of the non-wartime/conflict day job. It is recognition of the fallen and their families, and those who are willing to fall at some time in the future.
Something similar should apply post-pandemic. Even we in primary care have done comparatively little to earn any form of meritorious recognition, other than to keep the system running as smoothly as possible, with limited numbers of staff and even fewer patients to deal with. No, the true, really hard yards have been made by the front-line nurses and doctors – some of whom have made the final sacrifice for their endeavours – the cleaners and refuse collectors, delivery people, warehouse folk, posties and any number of others who have carried on regardless from a front-line position, but have largely been ignored (not by those of us who have played a key role, but not got that close to the real action and bravery). Let’s hope that they get the attention and respect of the nation when the rewards are being doled out.
And very few of them are from the “NHS management team”.