‘Laid-off cabin crew with resuscitation skills’ – what is the answer to the NHS staffing crisis?

Faced with an NHS and social care system ill prepared for the coronavirus pandemic, a call went out for 250,000 volunteer community support workers to help up to 1.5 million people who have been asked to shield themselves from infection because of underlying health conditions.

The response has been staggering, with more than 400,000 coming forward. The recruitment target has now been raised to 750,000. They will deliver medicines from pharmacies, drive patients to appointments and bring them home from hospital, and make regular phone calls to check on people isolating at home.

Quite how vetting, safeguarding, training and safety issues will be addressed is unclear, but that this is tapping into a strong desire on the part of many people to be helpful to their fellow humans cannot be doubted. There have also been large numbers of retired NHS workers offering to return to work and help their struggling colleagues. 

The Tories have been obsessed with getting unpaid labour to support the failing health and care systems, now wrecked by years of their austerity and underinvestment. In the process, they have also given volunteering a bad name. After Cameron’s ‘big society’ initiative sank without trace, 2018 saw the launch of a charity called helpforce. This planned to massively boost the numbers of NHS volunteers from 74,000 to “millions” and was the (as yet unrealised) ambition of merchant banker Sir Thomas Hughes-Hallet, better known to his friends as ‘Huge-Wallet’. The aim appeared to be for volunteers to do the work that hard-pressed doctors and nurses (through staff vacancies) did not have the time for. With 40,000 empty nurse posts, and bursaries that had been axed, NHS England managed to find £2.3m for helpforce in the Long Term Plan.

Currently, the NHS Nightingale nursing workforce is to be supplemented by recently laid-off air cabin crew with resuscitation skills, and first aiders from St John’s Ambulance. This unit has more than 80 wards each with 42 beds; around 16,000 members of staff could be needed should it reach full capacity. 

An unresolved question is just where the trained NHS medical and nursing staff will come from to add to the small numbers of military personnel and staff promised from the private sector. Chief nurses around the country have been asked to state their numbers of spare critical care staff – the replies are not difficult to imagine. One suggestion has been to send staff from distant parts of the country relatively behind London in the course of the pandemic and give them crucial experience before sending them back to their own hospitals. One of the objections to this is that the average length of stay for a critically ill patient is two weeks, and the surge in patient numbers likely to be maintained much longer than this. Staff sent to London would probably be kept there, greatly reducing NHS capacity in the regions just as the caseload rocketed. However, if we had a properly coordinated national response to the crisis, the possibility of NHS workers moving temporarily to hot spots might be a valuable strategy.

Of course many people still have a sense of social solidarity and want to find ways to help others. Such altruism should be both lauded and facilitated. It stands in stark contrast to the neoliberal ideology of Conservative governments – it appears there is such a thing as society after all. 

In response to the pandemic support for medical and care staff, as well as vulnerable neighbours, has been provided by members of the public all over the world, independently of the state.  This is indeed evidence of the thrilling and transformative force of mutual aid. In this context there is plenty of room for volunteers, and an energy that needs to be harnessed in the fight for universal health care in the post-covid era.

However, volunteers recruited by the government or their agencies should never be used as a substitute for trained staff. They should only ever be in supporting roles. Look to supermarkets: now in urgent need of extra hands, they have created new jobs and hired people to work. In the first instance community support staff could be recruited from those workers who have lost their jobs and livelihoods. They could be given a contract, a wage and some training. While I would prefer an experienced ICU nurse to look after me if I become ill in hospital with COVID-19, since they will be at a premium and caring for six patients rather than the usual one, I will not object to them being assisted by redeployed cabin crew with some medical skills and experience of keeping cool in emergencies. There may well also need to be willing volunteers in non-clinical support roles to keep the show on the road. 

Volunteers are not the solution to the crisis in staffing that existed pre-pandemic, and is now exacerbated by illness. But together with additional paid redeployed staff recruited with some level of skills, given basic training and afforded the usual protections of employees, they will be part of the solution until the crisis is over. Some of them may then even join the fight for restoration of a truly public, universal NHS.

Dr John Puntis is a consultant paediatric gastroenterologist, the co-chair of Keep Our NHS Public, and a member of Doctors In Unite.

COVID-19: A GP’s Perspective

As I write we are at the beginning of the pandemic in the UK. We still have relatively small numbers of cases but they are steadily increasing along with, tragically, associated deaths.

There is a very fine line between not fuelling mass panic, which is unhelpful, but also in taking sensible precautions.

Public health messages such as thorough hand washing and minimising touching our faces and each other are very important. This will have some effect in slowing the spread of the virus. However, we only have to look across to Italy to see how it has quickly overwhelmed their health care system, even when they have twice the number of critical care beds per person than we do in the UK.

In my view, our responsibility is to try to slow the spread of the virus, to minimise the pressure on critical care (though of course the pressure is still likely to be huge), and also to demand that the government increases the number of critical care beds as a matter of urgency by requisitioning private hospitals, upgrading existing beds in NHS hospitals and if necessary setting up field hospitals.

This will also require immediate training of NHS staff to look after critically ill patients as there are not enough at present. The last 10 years of systematic underfunding and dismantling of our NHS, along with massive cuts to social care, is now having devastating consequences.

Primary care is where 90% of NHS encounters take place, so it seems obvious that most cases of COVID-19 will be dealt with here. It is important that health workers remain well as far as possible and so are able to continue to treat patients. Unfortunately, personal protection equipment (PPE) that has been issued to GP practices is more or less useless – simple paper surgical masks which do not stop infection.

Many GP surgeries are moving towards a system called Doctor First, where patients are not allowed access to the premises without first speaking to a doctor over the phone. This is to protect staff and other patients from people who may be infectious with COVID-19.

Patients are being advised by the government to self-isolate and sweat it out at home if they become unwell, and to contact NHS 111 if they cannot manage self-isolation. NHS 111 has rapidly become overwhelmed, and there are reports of 12 hour waits for a response.

Understandably patients are not all going to meekly wait at home. Some will either come to our surgeries and demand to be seen or go to A&E, spreading the virus.

There is a debate about self-isolation, closing schools and universities and whether these are the correct strategies. I think it is not possible to say with any certainty yet whether we should or should not adopt these measures. If we do, are we just pushing another peak further down the road? What happens to, for example, children who live in poverty and rely on free school meals, or families where parents have to work to pay their rent? Will such strategies push the burden of childcare for school age children to vulnerable grandparents?

What we can say with certainty is that years of austerity have decimated our NHS, and that despite this NHS staff are, as always, rising to a very difficult challenge. While we wait for a vaccine and more critical care beds, we need to try to slow the spread down.

We should demand:

Immediate requisitioning of private hospitals to increase the pool of critical care beds.

Immediate training of NHS staff who are willing, to help look after critical care patients.

Adequate supplies of proper PPE for all staff on the front line.

Suspension of all non-essential work, for example CQC inspections, appraisals and enforcement of key performance indicators such as QOF and enhanced services. No practice should be financially penalised for dealing with this unprecedented crisis.

Adequate IT and internet connectivity to cope with the rise in remote working.

That sick pay is paid from day one. Staff should not suffer economic hardship for self-isolating or being off sick. Anyone who comes to work who is potentially infected is a danger to everyone else.

Sick pay be extended to those on regressive employment contracts, such as zero hours contracts.

No penalty for those people missing DWP assessments as result of self-isolation.

Provision of centralised primary care type services in each borough for those patients who are too sick just to sweat it out at home, but not ill enough to go to hospital.

Much more testing. We can learn from South Korea, where mass testing is being performed via drive through test stations.

Dr Jackie Applebee is a GP and the chair of Doctors in Unite.

The private sector needs radical reform for patients to be kept safe

Michael Walsh, a shoulder surgeon, has been sacked by Spire Healthcare and accused of subjecting scores of patients to unnecessary operations that left many in pain, traumatised and unable to work. This is a depressingly familiar story, with echoes of the case of Ian Paterson, the rogue breast surgeon who also worked for Spire. Paterson subjected more than 1,000 patients to unnecessary and damaging operations over 14 years in both private and NHS hospitals. He is serving a 20-year jail sentence imposed in 2017 for wounding with intent and unlawfully wounding nine women and one man whom he treated between 1997 and 2011.

Walsh is the latest PR disaster for Spire and has exposed it to accusations of systemic shortcomings in its 39 private UK hospitals with 7,000 doctors and surgeons on their books. Most of Walsh’s patients were in the private sector with fees paid by insurers or out of their own pocket, but others were NHS patients under the choose and book scheme which diverts patients to the independent sector for speedier operations. Given pressure on the NHS and delay or cancellation of surgery, such diversions are becoming ever more common. While the NHS Long Term Plan promotes a consumer choice agenda, it is unlikely that patients of Paterson and Walsh would agree this leads to improved patient care as claimed:

“The ability of patients to choose where they have their treatment remains a powerful tool for delivering improved waiting times and patient experiences of care. The NHS will continue to provide patients with a wide choice of options for quick elective care, including making use of available independent sector capacity… Patients will continue to have choice at point of referral and anyone who has been waiting for six months will be reviewed and given the option of faster treatment at an alternative provider, with money following the patient to fund their care.”

The recent Paterson Inquiry, lead by Bishop Graham James, should have been an opportunity to highlight failings in the private sector that consistently put patients at risk. There was however an obvious omission – a failure to tackle the hugely problematic nature of the relationship between the private sector and the NHS. This includes the sharing of consultants, the need to make profit, and the inevitable conflicts of interest that these create. As pointed out by David Rowlands (director of the Centre for Health in the Public Interest), investors in UK private hospitals must have breathed a huge sigh of relief on reading the bishop’s recommendations:

“At stake for the investors was the possibility that the Right Reverend Graham James would deem their business model so incompatible with the safety of patients that it would require fundamental reform. Yet rather than tackle the private hospital industry head-on, the bishop put forward a series of low-impact recommendations which will do nothing to prevent another Paterson, but instead leaves intact the archaic and dangerous form of medical practice that abetted him.”

And lo and behold, we now have Walsh to demonstrate the prescience of this observation.

The independent sector is lavish with payments aimed at bringing in consultant work. Just seven private hospital firms paid about £1.5 million in gifts and hospitality to consultants who referred patients to them in 2017/18. Rowlands points out that consultants, by bringing in patients, are the main source of income to a private hospital and sometimes each worth millions of pounds. There is not only a financial disincentive to challenge their practises (killing the golden goose), but more operations mean more money, and since consultants are not employees of the private hospital it can deny responsibility when things go wrong. This is even more worrying when an increasing volume of NHS work is being sent to the private sector (including one third of hip operations) under the NHS England banner of “improved patient experiences of care”.

By November 2019, over a ten year period the number of NHS patients having surgery in private hospitals nearly trebled:

“NHS figures obtained by the Guardian showed that it paid for 214,967 people in England to have an operation in a private hospital in 2009-10, Labour’s last year in power. The figure soared to 613,833 last year, a 185% rise in nine years.”

It should now be obvious that the care model in private hospitals can have long term and even tragic consequences for NHS patients, such as Peter O’Donnell who tragically died after hip replacement. The Department of Health and Social Care should also come clean, and rather than disguising it on their balance sheets as NHS spending, accept that the cost of all these operations constitutes a form of privatisation. Rowlands demands logically that:

“private hospitals should take on full legal liability for what happens in private hospitals by employing the consultants directly… and private hospitals should fundamentally reform their post-operative care arrangements and bear the full cost of any transfers to NHS hospitals.”

An analysis of Care Quality Commission reports from private providers has identified a plethora of risks. These include consultant surgeons without indemnity insurance, clinical outcomes not being monitored by the hospital, not all clinical incidents being properly reported, and inadequate pre-operative assessments (important for excluding high risk patients, since most private hospitals do not have intensive care facilities or back-up specialist teams).

It is time for the independent sector to focus on patient care rather than profit, and for its parasitic relationship with the NHS to be brought to an end. The government must realise that so-called ‘patient choice’ has its limitations, and commit to proper investment in our public health services so that there is no need for patients to take the risk of going elsewhere.

Dr John Puntis is a consultant paediatric gastroenterologist, the co-chair of Keep Our NHS Public, and a member of Doctors In Unite.