Britain's NHS and the Covid-19 litmus test

London - The pandemic posed a challenge like no other but after initial mistakes the health system got its act together.

The front page of a newspaper is usually a good index of events and issues that matter the most to the people in a country. Several countries may have similar political systems but it does not follow that their news agenda would be the same. Some events may not be considered newsworthy in certain countries, while the same events may dominate the public sphere elsewhere.

For example, waiting lists for routine medical operations or shortage of nursing staff in some hospitals would rarely make it to the front page in many countries, but in Britain they hit the headlines often. One reporter’s beat that often makes it to the front pages is health, particularly the National Health Service (NHS).

The health system had a prominent status in the news agenda even before the Covid-19 pandemic hit, but it came under more intense focus since January 2020. Any discourse or analysis of pandemic-related coverage would identify some oft-quoted phrases, such as ‘protect the NHS’ and ‘prevent the NHS from being overwhelmed’.

The NHS is considered the closest thing the British have to a religion. Launched in Park Hospital, Manchester, on July 5, 1948, it was described by its founder, Aneurin Bevan, Minister for Health in the post-war Labour government, as “the most civilised thing in the world” due to its focus on the “welfare of the sick”. Academic Rudolf Klien estimated that it was ‘the first health system in any Western society to offer free medical care to the entire population”. Supported by almost all politicians and parties since its establishment, the NHS remains free at the point of use to all residents of the United Kingdom, irrespective of their ability to pay. It attracts medical professionals from across the world for training and employment, while many recount heroic tales of lives saved over generations. Such is the faith and concern about the NHS’s resilience that during the pandemic a large number of people with non-Covid issues stayed away to avoid adding to the workload of doctors and nurses, prompting senior health officials to publicly urge people to continue to approach hospitals as before, keep their appointments, and help clear the backlog of cases.

As Prime Minister Boris Johnson told the House of Commons recently: “Our National Health Service is the pride of our whole United Kingdom and all the more so after it has been there for us during the worst pandemic in a century. But the inevitable consequence of this necessary — and extraordinary — action is that Covid has placed massive pressures on our NHS. As we stayed at home to protect the NHS, thousands of people did not come forward for the treatment they needed. Like those who suffer from Covid, these are all people we know. Your aunt who needs a new hip. Your neighbour who has problems with their heart and needs a pacemaker. Your friends at work who thinks they should get that lump or cough checked out. So we must now help the NHS to recover, to be able to provide this much-needed care to our constituents and the people we love — and we must provide the funding to do so now.”

Funding the NHS has long been the subject of intense debate, now accounting for one-thirds of the annual public services budget. The UK’s health sector has a budget of over £210 billion, with NHS England alone allocated £147 billion (including Covid-related funding) for 2020-21 (its budget at launch in 1948 was £12.9 billion). To clear the waiting lists created during the pandemic, from next April a UK-wide 1.25 per cent Health and Social Care Levy on income will be introduced to raise almost £36 billion over the next three years.

Big achievements, big mistakes

After initially taking an almost cavalier approach to the challenge — reflected in Johnson joking and remarking about shaking hands with Covid patients in early 2020 — it took a while for the health infrastructure to come to grips with the pandemic, as deaths mounted and hospitals reached breaking point with a flood of patients. Big mistakes were made, but there were also major achievements. Large pop-up hospitals with thousands of extra beds (called Nightingale hospitals) were set up, while scientists devised new ways of countering the virus. NHS doctors, nurses and other health professionals went beyond the call of duty, grappling with severe staff shortage and colleagues being infected while treating patients, many dying. In June 2020, a trial revealed that the cheap and easily available steroid, dexamethasone, cuts death rates by a third in severely ill Covid patients. The game-changer was the development of vaccines in the University of Oxford and elsewhere, and implementing the largest vaccination programme in NHS history. Challenges remain, but the NHS is under less pressure than in mid-2020, though the forthcoming winter with its flu and related issues continue to pose new challenges to its exhausted staff.

As of October, much of Britain has opened up, including international travel to and from most countries, but new daily cases continue to register around the 40,000 mark — one of the highest in the world. On October 19, the UK recorded the highest number of daily deaths in seven months: 223. But the national mood now appears sanguine, likely for two reasons: the success of the mass vaccination programme means less number of those testing positive need to be admitted to NHS hospitals, and there is a sense of normalisation and desensitisation reflected in public pronouncements by leading figures. For example, health secretary Sajid Javid said last week: “Overall, things feel quite stable at this point. The numbers are a bit up, a bit down over the last few weeks. We don’t want to get to the position ever again where there’s unsustainable pressure on the NHS so it’s not able to see people in the usual way when it needs to, particularly emergency patients.”

The widely-watched daily Covid briefings from Downing Street by Johnson and top experts have stopped, with the focus mostly shifting to reviving the economy. Academic Linda Bauld, one of the leading experts in the British news media during the pandemic, told The Guardian: “We’re in a phase where we still have large numbers of people dying from this disease. But it has gone into the background. We’ve become used to something that has not gone away. I think there’s been a desensitisation to the mortality.” There are already calls that some of the earlier restrictions need to be re-imposed to avoid putting the NHS system under renewed stress.

Calls by the growing number of Covid-hit families to hold a public inquiry into the government’s handling of the pandemic have been resisted so far, but the first such inquiry by two parliamentary committees makes for sobering reading. Coronavirus: Lessons Learnt To Date, the 150-page report published earlier this month by the House of Commons’ Science and Technology Committee and Health and Social Care Committee, says that the vaccine programme has been “one of most effective initiatives in UK history” but delay to the first lockdown in 2020 was a “serious error” that should have been challenged. It concluded that some initiatives were examples of global best practice but others represented mistakes. In particular, it identified areas such as: the delays in establishing an adequate test, trace and isolate system hampered efforts to understand and contain the outbreak and it failed in its stated purpose to avoid lockdowns; the initial decision to delay a comprehensive lockdown — despite practice elsewhere in the world — reflected a fatalism about the spread of Covid that should have been robustly challenged at the time; social care was not given sufficient priority in the early stages of the pandemic; and the UK’s preparedness for a pandemic had been widely acclaimed in advance, but performed less well than many other countries in practice.

Says Jeremy Hunt, chair of the Health and Social Care Committee: “The UK response has combined some big achievements with some big mistakes. It is vital to learn from both to ensure that we perform as best as we possibly can during the remainder of the pandemic and in the future. Our vaccine programme was boldly planned and effectively executed. Our test and trace programme took too long to become effective. The Government took seriously scientific advice but there should have been more challenge from all to the early UK consensus that delayed a more comprehensive lockdown when countries like South Korea showed a different approach was possible. In responding to an emergency, when much is unknown, it is impossible to get everything right. We record our gratitude to all those — NHS and care workers, scientists, officials in national and local government, workers in our public services and in private businesses and millions of volunteers — who responded to the challenge with dedication, compassion and hard work to help the whole nation at one of our darkest times.”

Lessons learned — and the way forward

The committees concluded that the UK’s pandemic planning was too narrowly and inflexibly based on a flu model which failed to learn the lessons from SARS, MERS and Ebola. The result was that whilst pandemic planning had been globally acclaimed, it performed less well than other countries when it was needed the most. In the first three months, the strategy reflected official scientific advice which was accepted and implemented, but when the government moved from the ‘contain’ stage to the ‘delay’ stage, that approach involved trying to manage the spread of Covid through the population rather than to stop it spreading altogether. The report says: “This amounted in practice to accepting that herd immunity by infection was the inevitable outcome, given that the United Kingdom had no firm prospect of a vaccine, limited testing capacity and there was a widespread view that the public would not accept a lockdown for a significant period. The UK, along with many other countries in Europe and North America, made a serious early error in adopting this fatalistic approach and not considering a more emphatic and rigorous approach to stopping the spread of the virus as adopted by many East and South East Asian countries.”

Some exhausted health professionals left the NHS, while others have spoken of the challenges at many levels, including on their mental health. Kevin Fong, a London-based anaesthetist who was seconded as national clinical adviser to NHS England’s emergency preparedness resilience and response team, co-authored a study which found that nearly half of ICU staff are likely to meet the threshold for PTSD, severe anxiety or have a drinking problem during the pandemic. NHS staff, according to the study, had been ‘definitely injured’ to such a degree that their ability to deliver care has been impaired. He says: “Our duty of care extends to our colleagues not just patients because looking after colleagues is looking after patients. The end of the pandemic must not mark an immediate move to tackling waiting lists and diverting staff from one crisis to another. We need a huge programme of rest and recovery — if not reward too. I think the stress that the frontline workforce has been under is unlike anything — possibly unlike anything outside of war. We need to do some deep thinking because to get this wrong will be to risk further injury and to risk retention of staff. This has been horrific.”

Every decision on the NHS is invariably subjected to intense scrutiny by experts and think-tanks. The Johnson government has promised to correct years of under-funding the NHS with promises of new hospitals and recruitment to vacancies running into tens of thousands of doctors and nurses. Figures show that the UK’s investment in the health sector ranks between low to middle among comparable European countries.

There are demands for a fundamental change in how the NHS operates: from an NHS-primacy approach in which patients fit in with the schedules of doctors and systems, to a patient-centered culture such as the one in Sweden, which has some of the lowest hospitals admissions due to a better-funded primary care system that comprehensively caters to patient needs, in which only those needing advanced care are referred to hospitals. But few see such a change happening anytime soon in Britain.

(Prasun is a journalist based in London. He tweets @PrasunSonwalkar)

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“Doctors from the Indian subcontinent were not just contributing to the NHS; they were its very lifeblood. We should acknowledge they were among the architects of the NHS. The NHS evolved during its first four decades into a system based around general practice and primary care. By becoming family doctors, South Asian doctors prevented a GP recruitment crisis”

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Healthcare professionals from the subcontinent have been in the forefront of treating patients, taking on extended hours and dealing with situations when not much was known about the virus and ways of dealing with it

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Asian doctors, nurses on the frontline

Prasun Sonwalkar

GROUND REALITY

Several studies have concluded that people from non-white communities — termed BAME (black, Asian and minority ethnic) in official discourse — have been disproportionately impacted by the pandemic. BAME health professionals also comprise one-fifth of the NHS workforce and it is notable that the first 10 NHS staff to die from Covid-19 were from these backgrounds.

Doctors and nurses from South Asia have been in the forefront of treating patients, taking on extended hours and dealing with situations when not much was known about the virus and ways of dealing with it. A new parliamentary report says that there is some evidence that even within the frontline roles, BAME staff was more exposed to the virus than their white colleagues. For example, the Health and Social Care Committee was told that in the first wave of the pandemic, non-white NHS staff faced greater difficulty in accessing appropriate Personal Protective Equipment (PPE) that fitted correctly. According to the British Medical Association (BMA), 21 per cent of all staff is BAME — 63 per cent of healthcare workers who died were BAME; 20 per cent of nursing staff are BAME — 64 per cent of nurses who died were BAME; and 44 per cent of medical staff is BAME — 95 per cent of doctors who died were BAME.

Latest figures show that doctors who gained their medical qualifications in south Asia comprise the second largest group in the NHS, after those who qualified in the UK: currently there are 30,315 doctors in the NHS who qualified in India, 15,854 in Pakistan, 3,364 in Sri Lanka, 1,926 in Bangladesh and 394 in UAE. BMA surveys have consistently found disparities in doctor’s experiences by ethnicity, with doctors from BAME backgrounds reporting feeling less confident that appropriate adjustments have been made to mitigate risk; feeling less confident about PPE provision and feeling safe to report PPE shortages; and higher rates of bullying and harassment during the pandemic period.

Doctors from South Asia and elsewhere have long worked in the NHS, filling vacancies in deprived, inner-city areas where white British professionals were loath to serve, and elsewhere, achieving recognition for their expertise and work, but there are also continuing concerns over allegations of racism and unequal treatment. Such cases involving doctors from south Asia and elsewhere are often highlighted by the groups such as the British Association of Physicians of Indian Origin.

Doctors from south Asia have been often hailed not only for their contribution to the NHS over the last 73 years but also for their central role in its development as “architects” and “lifeblood”. Educated under medical syllabus influenced by the legacy of the British Empire, south Asian doctors came to the UK to train and settled to pursue careers in the NHS. They are also reflected in popular British culture, for example The Indian Doctor, BBC’s five-part television drama set in a south Wales mining village in the 1960s, which starred Sanjeev Bhaskar and Ayesha Dharker, telecast in 2010.

Julian M. Simpson, author of Migrant Architects of the NHS: South Asian Doctors and the Reinvention of British General Practice (1940s-1980s), says: “Doctors from the Indian subcontinent were not just contributing to the NHS; they were its very lifeblood. We should acknowledge they were among the architects of the NHS. The NHS evolved during its first four decades into a system based around general practice and primary care. By becoming family doctors, South Asian doctors prevented a GP recruitment crisis. It’s important to also remember that the NHS was established to make healthcare accessible to those who could not afford it. And for millions of people, particularly in working class communities across Britain, accessing that care meant going to see a GP from the Indian subcontinent.”

The Covid pandemic reinforced the key role of doctors and nurses from the subcontinent in the NHS. Adds Mayor Lachine, president of the Royal College of General Practitioners: “General practice in the UK would not be what it is today without the hard work, innovation, and courage of our predecessors...Indeed, without them, our profession and the NHS might not even exist at all. Not only were they doctors, but they became highly valued members of the communities in which they practiced. Whilst many faced incredible challenges, our exhibition also documents the overwhelmingly positive and lifelong relationships they forged with their patients.”

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