Medical Practice and Women’s healthcare under Covid-19

Pandemic Perspectives has looked at the impact of Covid-19 from myriad different angles and debated its effect on politics, economics, culture and society from both national and global perspectives. Prior to our July 22^nd session, however, we hadn’t had an opportunity to get a close view from those working at the frontline – the doctors and medical staff who have been dealing with the direct consequences of the disease.

That was rectified by our guest speaker, Dr Michael Rimmer a specialist registrar in Obstetrics and Gynaecology, who was recalled from his academic sabbatical (he is undertaking a PhD in paediatric onco-fertility preservation at the MRC Centre for Reproductive Health), to return to practice for NHS Scotland in Edinburgh. Dr Rimmer has previously studied at Liverpool, St Andrews and Warwick universities and has until recently lead the UK Audit and Research Collaborative in Obstetrics and Gynaecology, the largest trainee research collaboration of its type in the UK. He is active within the Royal College of Obstetricians and Gynaecologists, sitting on the scientific advisory committee and centre for quality improvement, tasked with driving up standards within the UK for women’s healthcare.

Dr Rimmer talked eloquently about how he put his studies on hold during the pandemic to return to frontline NHS work for 5 months, which he combined with leading the first and largest evaluation of the provision of women’s healthcare across the NHS during the first wave of the pandemic, which is  available via open access at https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.16313

Dr Rimmer explained how he was recalled from his academic studies by a series of emails that expressed gradually increasing urgency at the start of the pandemic, the final one confirming his deployment within NHS Scotland where he had never previously worked. Unsure whether he would be returning as an obstetrician or as an emergency stopgap in A & E, he noted, without rancour, that in face of the unfolding emergency the NHS initially considered his redeployment to the midlands where he has previously worked, and that with thousands of doctors to potentially deploy he ‘was simply a number’ in the institution’s planning process.  Thankfully he was allowed to be deployed in Edinburgh, much to his relief. As an aside he noted that NHS Scotland differs from its English counterpart in being wholly centrally funded, compared to the internal market driven model of NHS England, a difference he was keen to see made a recognisable impact on his day-to-day work.

Returning as an obstetrician, he felt he was slotted back in with few difficulties, other than the usual issues with IT when starting in a new department. Later in his talk he pointed out that the much-maligned IT infrastructure in the NHS was actually quite remarkable in the amount of complex data it could reliably transmit from one part of the country to another, but in this instance his lack of access to that data would have severely impeded his work if he had not been creative in getting around his lack of a log-in ID.

The first major problem that all medical staff faced was the issue of appropriate PPE. Unsure of the manner of transmission of Covid-19 the PPE provided seemed largely inadequate, consisting of a surgical face mask, gloves and a body covering he described as a ‘pinny’, leaving large parts of his body exposed to airborne viral particles. He noted that the surgical face masks provided did not offer the protection of FFP (filtering facepieces) masks, that at their higher grades can effectively filter out virus particles. He is unconvinced that the PPE initially supplied provided adequate protection. He noted that practices common to much of medical practice, such as CPR, were now fraught with difficulty, as ‘aerosol generating procedures’ they put medical staff at risk in a way that could not easily be countered. In addition, in order to prevent droplet-spread, all fans in the hospital were confiscated to reduce the possible spread of the virus, leaving often poorly ventilated areas hot and uncomfortable to work in. In the early days of the pandemic it also took several days for test results to come through meaning that transmission within the hospital from infected patients was difficult to prevent. 

Dr Rimmer pointed out that one of the key consequences of epidemics was that they generated fear, and that people therefore stayed away from contact with medical services and hospitals for fear of contagion. In obstetrics this can mean women would not attend hospital as they would routinely for concerns which could have a direct effect on health outcomes. This justifiable fear of contagion, he noted, had a particularly significant deleterious effect on cancer patients, either those undergoing treatment who would be immunosuppressed and therefore highly vulnerable to infection, or who would miss out on early diagnosis and therefore face the possibility of the disease progressing to more advanced stages when they finally underwent investigations. 

Concerned for the preparedness of obstetrics and gynaecology services during the pandemic, Dr Rimmer instituted a survey of junior doctors in 148 maternity units nationwide. Although the report concluded that the vast majority had completed specific training drills, implemented Covid-19 specific protocols, operated dedicated Covid-19 emergency theatres and felt they had adequate PPE, it noted that half reported a planned reduction in oncology surgery and that strategic planning was required to restore routine gynaecology services. Specific issues arose within obstetrics and gynaecology that could not easily be resolved. The inflation of the body cavity to undertake keyhole surgery, for example, leads to the expulsion of potentially contaminated air on deflation, therefore guidance briefly suggested returning to traditional surgical methods that are both more invasive and lead to great post-operative scarring. In addition, the curtailment or standard family planning services would inevitably result in more unplanned pregnancies. There had been, he noted sadly, a significant increase in still births. He also noted that recent published literature identified that isolated mothers under lockdown were more prone to depression and less likely to sustain breast-feeding, and that social-interaction was a key correlate with happy and healthy mothers and children in general. He noted that home visits by health visitors had been reduced with attendant risks and that it had been a highly anxious time for pregnant women, as although the safety of the vaccines for adults had been broadly established there was no available evidence for the effect of vaccines on the unborn child in the early stages of the pandemic.

In the subsequent discussion David Christie referred to a cardiologist friend who felt that the PPE he was provided with was farcical, and constituted little more than pretending he was protected – he asked if the standards of PPE improved over the course of the pandemic? Dr Rimmer also felt that at the beginning it had seemed almost tokenistic and had not really improved.

Christopher Griffin expressed concern about the future of the NHS. He noted the government’s rejection of the call for a 15% pay rise and its desultory offer of 3% and asked whether this would lead to a ‘mass exodus of exhausted workers’ from the NHS. He also noted the massive backlog of operations engendered by the pandemic and sited the instance of a twenty-three-year-old who had been offered an appointment in January 2023. He suggested that it was private industry that was the main beneficiary of the pandemic and wondered whether public health services would be marginalised so much that the NHS might be completely eclipsed. Dr Rimmer was much more confident in the long-term resilience of the NHS. He pointed out that the unnerving number awaiting operations and procedures, now almost 5 million, had been up to 4 million prior to covid-19, and argued that in many ways this could be seen as ‘a bump in the road’. However, he was less sanguine about how the shortfalls could be made up, and outlined a number of profound difficulties. Firstly, he noted that without substantial increases in finance the NHS simply lacked the money to put on the extra shifts required to catch up, and that even if the money was available there were insufficient trained staff to do the work. The solution to staff shortages was no easy fix either, he argued, nursing training taking three years, for a nurse capable of running an ICU several further years training was required and the training of doctors from intake to consultant was significantly longer still. He noted that although Jeremy Hunt had instituted seven new medical schools during his tenure as health secretary, such was the time lag, that not a single doctor had yet to qualify and commence practice. Moreover, he expressed concern over the attractiveness of medicine in the NHS, noting that doctors’ normal weekly hours were 48/week, and can rise to as high as 56 hours, and that 12 hour shifts without a break were not uncommon in many specialities. Although the pay was reasonable it did not compare with the remuneration in other nation’s health services and many doctors would migrate for better pay and conditions elsewhere. Many doctors were due for retirement and the tax arrangements for consultants meant that any increase in working hours could result in a raised tax burden that actually reduced their net income.

David Christie asked about the impact of Brexit on recruitment to the health service and wondered whether the upsurge in appreciation for medical staff seen in early in the pandemic with ‘clap for the NHS’ displays would both be sustained and aid future recruitment. Dr Rimmer noted that there had never been much recruitment from the EU of doctors (pay and conditions being generally less favourable in the UK) although the UK has a diverse global workforce with may valuable contributions coming from outside the EU.  He also doubted that, faced with long waiting lists for routine treatment, the ongoing perceptions GP practices are still ‘shut’ and the oncoming yearly winter NHS crisis, public appreciation would be long-sustained.

Richard Kendall queried the impact of the pandemic on training, and questioned whether virtually delivered training could possibly be of the same quality. Dr Rimmer echoed his concerns, noting that the practice of medicine was inherently physical, from applying a stethoscope to the chest to listen to breathing, taking blood or inserting a canula – all were physical skills that required practice. In addition, he noted that the soft skills of interacting with patients and building productive relationships with colleagues required a physical presence and could not be developed virtually. He expanded on his earlier concerns about training to meet the backlog, noting that thanks to the collapse of assessment at A-level, university medical schools were so overwhelmed with successful applicants that Exeter University was offering £10,000 and free accommodation for students to defer. The whole issue of who was going to do the training and who would pay for it needed to be urgently addressed. With more patients to see and less time, on-the-job training of new staff, which was currently unpaid and time-consuming would be difficult to maintain. He expressed concern that the high standards of British medical practice and its international reputation would be hard to maintain in the future, however this is an issue faced globally as opposed to the UK alone.