Although distinctly unhappy, one-year-old Aidan turned out to have nothing more serious than a bad bout of hand, foot and mouth disease. I explained the diagnosis to his father, Alex, and assured him it would get better on its own. He appeared relieved, jiggling his grizzling son on his lap before getting up to leave.
“It’s a nightmare getting an appointment these days, though, isn’t it?” Alex’s tone was conversational rather than confrontational, as though expecting me to chime in with general agreement.
“What difficulty did you have?” I had spoken to his worried wife earlier that morning and had arranged to see Aidan within the hour. It was hard to imagine an easier or more responsive process.
“All that business about having to have someone call you back first,” Alex said. “I don’t know why you can’t just book in.”
We conducted a big patient survey in the summer and were delighted (and, if truth be told, slightly surprised) by the extremely positive feedback to our “phone first, come in if necessary” appointment system. It is only in the past couple of weeks that I have started to hear views like those Alex was expressing – entirely coincident with the vitriolic anti-GP campaign being waged by certain newspapers, which erroneously links difficulties in accessing GP care with the telephone-first approach the pandemic imposed on us in March last year.
“You know why we’re working like this, right?”
“No.” Alex looked blank for a moment. Then he shifted Aidan’s weight further up his hip. “You mean Covid?”
I nodded and briefly explained. Numbers remain relatively high. The “hot hubs” where we used to segregate suspected cases have been decommissioned; if someone with viral-type symptoms needs assessment, I’m back to seeing them in the car park, or spiriting them into the building through a side entrance. What I absolutely don’t want is them sitting in the waiting room alongside clinically vulnerable patients. The success of the vaccination programme notwithstanding, Covid still has the capacity to devastate. In my mind’s eye, I see the husband and wife on my list – in their late fifties, both double Pfizer-jabbed – who wound up on an intensive care unit (ICU) in late August. She’s at home now, though far from well. He remains ventilated and on kidney dialysis three weeks later.
I could understand the disconnect Alex was experiencing. Out there in wider society, it genuinely feels as though the pandemic is over. Yes, there are those figures being published daily: 30,000 new cases; approaching a thousand hospital admissions; a hundred-odd deaths. But they sound as though they apply to somewhere else, not to the UK where pubs, restaurants, cinemas, theatres, nightclubs and sporting events are all back in business and operating more or less normally. Not to a country where limits on gatherings have been rescinded, bubbles have been burst, and kids need to stay off school only if they themselves have contracted the virus.
Boris Johnson’s “Plan A, Plan B” press conference on 14 September reinforced this perception. The vaccination campaign has done the heavy lifting, we were told, and by extending it to younger teenagers and by giving boosters to the original, most vulnerable cohorts it should continue to keep the country safe. And if the few million eligible but unvaccinated adults would only come forward for their jabs, we’d be even less likely ever to need to enact Plan B – the reintroduction of a range of social restrictions should the NHS be deemed to be overwhelmed at any point this autumn and winter.
Chris Whitty, the chief medical adviser, defended this staged Plan A/Plan B approach by saying that no one can know what is going to happen in the coming months, so we have to wait and see and adjust our response accordingly. That is true, in the same way that no one can be absolutely certain that the sun will rise in the morning.
Aidan’s hand, foot and mouth disease is unusual for a viral infection: it is much more common in the warmer months. Most other viruses thrive in winter when crowded indoor spaces aid their transmission. There is only one thing that is going to happen to Covid rates – cases, hospitalisations and deaths – in the months ahead. They are going up. The reason our leaders are so sanguine about this is because of what the vaccination campaign has achieved, turning what was once an NHS-devastating disease into the equivalent of a bad seasonal flu – something they blithely assume the NHS will therefore cope with.
But alongside this we will see the return of all the usual suspects that invariably cause the annual NHS winter crisis by themselves – including influenza, parainfluenza, adenovirus, respiratory syncytial virus – which were essentially absent last year due to the lockdown in force at that time. As sure as the sun will rise tomorrow morning, the NHS will buckle under the combined strain.
The UK was an international outlier in March 2020. When most countries were seeking to drive down case numbers with rigorous infection-finding and quarantine, and were limiting importation with stringent border controls, we were confidently describing how we would instead be able to modulate infection rates through graded social measures so as to keep case numbers within NHS capacity. We know how that story ended: with one of the worst per capita death rates in the world.
We are demonstrating similar hubris now. Most other European countries have achieved comparable vaccination rates to the UK, yet most are continuing to use social measures as well in order to drive down case numbers ahead of autumn and winter. However bad rates get, the political opposition to lockdown in the UK is such that it seems unlikely we’ll ever go into one again. (This winter’s maelstrom will be caused by so much more than Covid alone that it will be described as a “severe winter crisis” that won’t be solved merely by heightened social distancing rules – though of course they would contribute to lowering all viral illness rates.) Moreover, I am no fan of burdensome restrictions: the last, long lockdown exacted a huge toll on people’s mental health, which was all too evident in the case mix I was dealing with throughout the first half of this year. But as the chief scientific adviser, Patrick Vallance, implied on 14 September, we do not need a lockdown now in order substantially to dampen case rates. In a highly vaccinated population like ours, light-touch measures produce very profound suppressions of transmission.
A Sage report published on 8 September highlighted the difference that home-working has made to overall infection control. Yet the Johnson government is so in thrall to its libertarian wing, it dare not recommend continuing this broadly popular measure. As for mandating masks again in a wider range of indoor settings, that is a political no-go area.
[See also: I had always resisted seeing patients “virtually” but the pandemic shows it works]
It has been reported the Scientific Pandemic Insights Group on Behaviours, the Sage subgroup responsible for advising government on behavioural aspects of managing the crisis, has effectively been disbanded, presumably because it was critical of the way Boris Johnson’s administration prizes the exercise of personal responsibility above all else. As a thought experiment, try applying this idea to government policy on speed limits – they become merely “advisory” and a matter for individual judgement – and consider how effective they might then be at preventing death and serious injury on our roads. Yet this is now the government’s approach to public health.
While such political gamesmanship plays out in Westminster, the NHS is in a state of crisis unlike any I have known in my 30-year career as a doctor. Every part of the system is disintegrating – and in late summer, too, when the workload should be at its lightest. I have never before had to wait in a call queue when arranging an emergency ambulance; now it is a constant. My record is 45 minutes, the ringing tone periodically interrupted by an automated announcement informing me that the ambulance service is experiencing unmanageable demand and imploring me to consider whether there could be any other possible way of getting my patient to hospital. Members of the public ringing 999 are similarly affected; despite the ambulance service correctly diagnosing my patient Bernie with a heart attack on the phone, it took two hours 40 minutes for a crew to attend. He survived, fortunately, but that was far from guaranteed.
The out-of-hours service I work for each week resembles a war zone. I cannot remember the last time all the shifts were filled by the requisite number of clinicians. Those that remain attempt valiantly to keep on top of the burgeoning workload, but it is a lost battle. Once it used to be a concern if a patient “breached” – ie, it took a clinician longer to call back than the maximum time deemed safe. Now breaching is essentially normal; people regularly wait for hours on end – the worst I personally witnessed on one recent weekend was 23 hours – for clinical help following their initial 111 call. These are eye-wateringly unsafe conditions, common throughout the country right now, and autumn has barely begun.
The difficulty so many patients are having in accessing daytime GP care has nothing to do with our ways of working, despite what the right-wing press would have its readers believe. Whether we were to conduct consultations face to face, by telephone, or using semaphore flags, there is simply insufficient capacity. In part this is due to the pandemic – both Covid cases and the ongoing vaccination campaign. It also reflects the huge backlog in non-Covid work. The symptoms – the pain, breathlessness, vomiting, collapses – being experienced by the five million people queuing for secondary care don’t get magically suspended once they join a waiting list. They continue to come back to their GPs, and we continue to try to help as best we can while they await definitive investigation or treatment. The waiting times for most specialties in my area is now around 48 weeks.
The hospital sector is similarly beleaguered, efforts to make headway with the pandemic backlog hampered by mayhem at both the front and back doors. A&E departments are being hit from all sides. With the lack of capacity in day-time and out-of-hours general practice, and in 111, patients head to A&E as a last resort. Within the hospital itself, Covid keeps coming: nearly a fifth of ICU capacity is now taken up by coronavirus patients again, limiting the amount of other work that can be undertaken. And discharges where social care is required are being delayed for weeks or even months by the lack of care staff in the community. A social worker with whom I was in discussion a fortnight ago told me she has no fewer than 60 people waiting for packages of care that there are no carers to deliver.
These myriad difficulties may seem to have their origins in Covid, but they are the consequence of more than a decade of underfunding of the NHS and social care by successive Conservative administrations. Just as the daily Covid figures feel virtually meaningless to most people, so do the vacancy rates in the health and social care sector. We are 50,000 nurses and 110,000 carers short. We were promised 5,000 more GPs by the Tories ahead of the 2015 election, a figure that increased to 6,000 in 2019. Instead, we’ve lost nearly 2,000 full-time equivalents compared with six years ago.
The workforce deficits across the sector pre-date the pandemic by years. Steadily eroding pay and conditions are significant reasons why staff quit. But survey evidence suggests these are less important than the demoralising inability to provide the standard of care they trained for, in a system that has been progressively starved of resources relative to need. And ill-health is compounding these retention problems. Official figures lag several months behind, but anecdotal reports speak of unprecedented rates of sickness absence in the NHS, around 30 per cent of which is due to stress, anxiety or depression. This picture would certainly resonate with Tom – exactly the kind of unflappable, highly capable paramedic you would want at your side if you’d been in an accident – whom I’m signing off work with emotional exhaustion.
[See also: Covid-19 hospitalisations in the UK are higher than last year and could hit record levels in October]
This is a crisis that has been developing since the onset of austerity, but it has taken the pandemic to unmask it. If you save money by repeatedly failing to service your car, you will get away with it for quite some time: the brakes may grind, the exhaust may look questionably sooty, but it will still run. If you then find yourself completing the Paris to Dakar rally in the same vehicle – and withstanding a global pandemic is just such a sustained, demanding effort – you cannot be surprised when temperature and pressure gauges go haywire, and parts start falling off in the road.
The hastily concocted National Insurance hike to fund a health and social care levy is the guilty, knee jerk response of a government whose serial neglect has been exposed. What is needed every bit as much as cash is a detailed and determined plan to restore staff numbers and morale. Raising money to fund waiting-list initiatives won’t achieve much when there are too few people left and with too little resilience to do the work.
Protect the NHS: that has been the mantra through the entirety of the UK’s pandemic response. As an exhausted, demoralised and understaffed service faces a winter I suspect will be like no other, a different subtext has been revealed. Protect the Johnson government from adverse headlines, it might better read. Those daily Covid figures will reflect just one aspect of the challenge facing the NHS in the coming six months. If they can be kept apparently manageable – without upsetting the Covid Recovery Group of lockdown-sceptic Tory MPs – then Johnson will consider it a result. As for the totality of the winter crisis the NHS will have to cope with? Well, we are, manifestly, on our own.
Phil Whitaker is the New Statesman’s medical editor
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This article appears in the 22 Sep 2021 issue of the New Statesman, Great Power Play