Never forget – COVID and its legacy

When Simon Tavabie moved on from the role where he had worked at a London hospital during the height of the COVID pandemic his colleagues gave him two leaving gifts.

The first was a Kintsugi kit – the Japanese art form of repairing broken crockery with a golden lacquer. The second was a photo album depicting the scenes of England’s capital city during lockdown – famous landmarks and iconic streets overnight turned into a striking ghost-town. 

The Kintsugi kit would prove to be a useful mindfulness exercise during a period of burnout after brutal experiences working in palliative care amid relentless fatality. But it was also a ‘metaphor for where we were at as a team’.

Dr Tavabie, who has recently accepted a consultant post in palliative medicine, has not got past the first page of the photo album yet. On that first page Dr Tavabie’s supervisor – a colleague whose support he will never forget – wrote: ‘This is probably too raw to look at right now but in the future I hope you can look back at this and know that you made a significant impact for the lives of people going through this.’ 

It has been hugely poignant during a period of massive reflection. Of coming to terms with what he saw. Of trying to understand his role at the forefront of the response to so much tragedy. And of none of those things going away while the world moved on. 

For Dr Tavabie, the pandemic meant seeing an extraordinary amount of death.

His team sometimes looked after as many patients in their most vulnerable moments in a week as they would normally do over two months.

They went from having four or five new referrals a day to sometimes 40 or 50. The pandemic claimed endless amounts of compassion from Dr Tavabie and colleagues as they tried to look after both patients and families who could often not comprehend what was happening to them and how quickly they deteriorated.

Some patients had oxygen levels of 50 or 60 per cent – normally incompatible with life – but would be awake and talking before dying in the coming hours. 

Some of those memories – those stories of individual trauma for families and for Dr Tavabie – come surging back when a current patient is struggling with breathlessness. Flashes of daydreams of finding a colleague in tears in a cupboard or the sound of oxygen alarms going off constantly are still common.

But Dr Tavabie also remembers the good parts too – the incredible support of his supervisors and colleagues. Sometimes all these emotions overwhelm. Sometimes they drive an optimism about how ‘amazing’ people can be toward each other, or how they can rally. 

The Doctor spoke to Dr Tavabie a year on from the first wave of the pandemic – now four years ago – and he spoke of having a ‘significant amount of emotions’ he would have to deal with as a result of those relentless, gruelling, painful days in the hospital. 

He has done a huge amount of work to process those emotions. Therapy has been helpful and productive. But some memories of that time, some of those emotions, remain in a box. The pages of that photo album may not be flicked through for 10 or 20 years, if they ever are.

There have been positive legacies too.

Dr Tavabie’s former workplaces now offer psychologists or counsellors to talk through work-related psychological distress for free. That is ‘massively helpful’, says Dr Tavabie.

And, perhaps most crucially, doctors like Dr Tavabie who have the tools from their experiences of going through the pandemic and of processing what they went through are now the driving forces in a compassionate leadership that some new consultants see as crucial.

Dr Tavabie says: ‘I think it has helped me have a bit of insight into what people go through and I can help direct them.

‘My experience has certainly shown me that there are lots of good people in the NHS. Lots of people who really want to do the best for their patients and for their colleagues.’

Peter Blackburn

On 6 March 2020, Rosie Baruah was presenting at a BMA conference on women in medicine at Murrayfield in Edinburgh – and she had to leave early.

The consultant in intensive care medicine and anaesthesia at Edinburgh’s Western General Hospital had to attend a meeting to make preparations for what at that stage was looking likely to be a pandemic.

‘We decided as an ICU that we should sit down and put pen to paper and put together a contingency plan in case it was necessary to execute it – so we all packed into a tiny room, breathing each other’s air, thinking about what we would do if this “Covid” actually became a thing.’

At the time, leaving the conference felt ‘a bit OTT’, she says. But of course, it turned out that they were actually preparing for a situation that would go on for a very long time – and still have ramifications today.

‘I guess every ICU has always had escalation policies for major incidents,’ says Dr Baruah.

‘But the feeling was always that it would be for something like a major pile-up on the bypass, or a huge industrial accident. The kind of thing that would be challenging for a week or two then it goes back to normal. But this time it didn’t go back to normal.

‘At the time, I don’t think any of us were thinking that society and the experience of living in our social groups would change so profoundly. That was probably the last time I saw so many people face-to-face for years.’

As a single mum with a daughter who was aged 13 at the time, Dr Baruah also had to consider her home circumstances, as well as the risks to her personally as a health professional.

‘I remember my daughter asking me, “What happens if you get sick?”. I said that she and Petal, our dog, would go to her dad’s. She said, “But who’ll take care of you?” and I just told her I’d be fine.

‘But she was old enough to look at news websites and see that a lot of healthcare workers who were dying were of ethnic minority heritage – so she was seeing all those brown doctors and nurses dying and her mum [who is of Indian heritage] could only really tell her she’d be fine – and of course I might not have been.’

Although it was an intense time at work, there were occasions when Dr Baruah felt almost lucky.

‘Working in ICU we had the best quality PPE compared to anyone else in the hospital. I almost felt guilty going to the wards wearing my fancy FFP3 mask and seeing all those doctors and nurses managing without when they were more exposed than I was.’

But emotionally it was hugely difficult, especially in April when patients started to die. ‘Their families couldn’t visit. For me, that will always be the hardest thing about COVID, the way that patients had to be separated from their families at that time of intense distress was very difficult.’

She does believe that some lessons have been learned – by health professionals, if not necessarily by governments.

‘As a specialty, I think we’re better now at looking after patients with severe respiratory failure. And we know we can set up a second ICU, whereas before it was just a theoretical table-top plan.’

She has seen colleagues – particularly nursing staff, but also doctors – leave healthcare or take time off with burn out since the pandemic, as well as those left with long COVID.

She also wonders about the long-term impact on other healthcare staff and society in general. And she’s not sure what would happen in the event of another pandemic.

‘I don’t know if I could manage it psychologically again – trying to keep the family going, plus working at that level at work.

‘If it was a major incident that required an extra week or two of increased clinical activity, yep, roll your sleeves up, get on with it. But to have another two years would be very tough, and I don’t think I could be so resilient a second time around.’

Jennifer Trueland

Four years ago when The Doctor spoke to Justin Varney-Bennett, then the director of public health for Birmingham, he spoke of looking across the Birmingham skyline from his apartment balcony and seeing 1.2 million people whose lives were in his hands. 

The burden of responsibility was overwhelming. The moments of peace never came.

Now, Dr Varney-Bennett, looks out across that same skyline and remembers what he did, the impact he and his colleagues had, and the lives that were saved.

It hasn’t been an easy journey. There has been huge amounts of emotion and experience to process. And there has been no little sense of resentment that his team, like those around the country, were left out of the awards and the kind words for NHS staff – sitting in a less seen space between the health service and local authorities.

‘It took a bit of learning to let that go,’ Dr Varney-Bennett says.

‘But at the end of the day while a hospital doctor can remember the individual names or patients I still look out at the city and know that if we hadn’t done what we did the city just would not look like it does today.’

The relentlessness of the pandemic never really gave way to something much less all-consuming.

While the long tail of COVID continued, Birmingham hosted the Commonwealth Games with Dr Varney-Bennett’s team playing a huge role before another crisis hit England’s second city with the council effectively declaring itself bankrupt and being forced to make massive cuts to services amid the spiralling cost of social care amid other difficulties.

Dr Varney-Bennett just got on with it. But it is hard to fathom how – despite his commitment to regular psychological support for himself and his team – given he didn’t even have a deputy during most of that period, and that he himself suffered multiple diffuse bilateral pulmonary emboli across both lungs, likely as a result of asymptomatic COVID infection. 

Dr Varney-Bennett has since moved roles and is now settling into his new position as director of public health for the Department of Health and Social Care in the south-west of England, albeit still living in the city he loves. It was a necessary move, he says.

‘I needed to have space from that whole legacy and history. I’m phenomenally proud of what we did but… it’s very hard to be a wartime leader and a peacetime leader. I think I can do both but probably not in the same organisation because the cognitive switch that is required of myself and others is a hard one.’

For Dr Varney-Bennett there is some disappointment at how quickly some of the more positive aspects of the pandemic have been forgotten – the togetherness and instant integration between health system and local authorities, the sense of togetherness rather than tribalism between all staff. He hopes that after this period of recriminations and inquiries that long-term lessons can be learned.

He says: ‘The [UK COVID-19] inquiry will draw conclusions about decision making and that’s why we’ve got it, but I hope the medical profession learns the lessons around self-compassion and compassion for each other. And I hope the borders between the NHS and local government that came down but ultimately went back up quite fast can be moved again.

He adds: ‘I hope that in five years’ time medical training and education also looks radically different because through the journey of reflection we have got to think radically about how to train people to be able to respond and adapt. I did have a few lectures about outbreak response, or scenario planning, but training for war and experiencing war are two different things.

‘Personally, I feel I now carry a weight of experience in my voice and in my soul through what I experienced. You can’t teach that but you can expose people to it and try to help them learn the lessons of the past.’

Peter Blackburn

As a former army medic, Dave Triska uses military language selectively. So the way he describes general practice’s feeling of abandonment is striking: ‘There’s no help coming.’ The sense that general practice was the centre of a ‘connected web’ is long gone.

‘It feels like all those threads have been cut now, and as a GP, you're floating on your own,’ he says.

‘The rest of the NHS has collapsed around us. You think: How can it get worse? But it does, week on week, year on year.’

He still has good, rewarding days as a partner at his surgery in Milford, Surrey, among some awful ones. The role of the GP is more protected now, ‘probably the job it should be’. Technologies they’ve embraced as a team have reduced the admin burden.

Yet, the bigger picture – the backlog of ‘patients that need ongoing support, care that I often know is not coming’ – swamps these small satisfactions.

Unprocessed trauma from the pandemic is rife. The impact on patients has never been debriefed: the ‘really significant shift in the rate of mental health problems post-COVID and the lowering of the bar for seeking access to medical care’ are symptoms of this, Dr Triska believes.

Health workers too have been denied time and space to work things through. Worse still, they ‘ran towards the danger’ in COVID on the expectation that their ‘covenant of trust’ would be paid back, that ‘we would be supported and protected going forward’.

Instead, they have felt betrayed, says Dr Triska. 

GPs, for example, were ‘thrown under the bus’ as politicians blamed them for rocketing A&E attendance and referral rates. ‘There’s been nothing, not even good will or good thanks.’ Exhausted, many in the NHS are choosing not to go the extra mile anymore – or leaving. 

Adding to this moral injury is the sense that lessons have not been learnt. Perhaps it’s politically expedient to ignore them. For one, lack of infection control fuels the regular waves of virus that engulf his surgery.

He’s also deeply frustrated at the lack of NHS directive to kickstart the kind of tech transformation in secondary care that helped boost productivity in primary care during and since COVID. 

‘Why are we still getting the letters saying you've got a telephone appointment in three months to discuss your result which is already here?

GPs would still want to help patients with things outside their remit, such as ‘navigating the vagaries of outpatients and referrals and follow-ups’.

‘But now the number of people who need that help is so high, it's just not feasible.’

Meanwhile, patients are suffering ‘a kind of existential despair’: they don’t know if help is coming either. And their ‘anger at the whole system’ is often directed at the most accessible part of healthcare, general practice.

Reluctantly, Dr Triska has reduced his hours, taken on some consultancy work outside the partnership.

‘I'm much more aware that this is a job that can take everything from you, in the most literal sense for some people. That’s almost like an abusive relationship: you have to have your barriers and boundaries. 

‘Has it made me a worse doctor? Don't think so. Do I see it as a calling anymore? No, which is a very sad thing.’

Seren Boyd

Five years ago, Amy Small was working flat out as a GP partner in a practice in East Lothian, near Edinburgh. She loved her job – in fact, she admits that she probably put it ahead of her family, including two children, then aged five and three.

In April she caught COVID, and assumed – being young, fit and energetic – that she’d soon get over it, and be back to normal. She waited, and waited, and waited, but she didn’t get better.

Dr Small was one of the first doctors in the UK to develop what was to become known as long COVID. She tried to go back to work, but found the simplest of admin tasks or the slightest exertion left her exhausted for days. She had brain fog, couldn’t find the words she needed.

Then she lost her job – her GP colleagues invoked a clause in the partnership agreement that said that any partner who had not been ‘fulfilling their partnership duties’ over a six-month period could be ‘expulsed’ – and she was. It was extraordinarily difficult – but meant a new beginning for her.

‘I loved that job and I was very committed to it. We built that practice from nothing into something amazing, but at what cost? We were so dedicated to it, and it came first, before family, before everything. I was completely, 100 per cent dedicated to it.

‘So when COVID happened, there was the devastating partnership loss, and the illness, and all the trauma that came from that time. But that then opened the opportunity for a completely different switch in career.’

Dr Small used her platform as a BMA activist and a doctor with a large social media following to document her experience with long COVID, and to call for action.

Her story featured in The Doctor magazine – and the cover, featuring her image, was used in the House of Commons in a debate to highlight the issue.
Partly as a result of this, she now works three days a week as clinical advisor for a charity, Chest, Heart and Stroke Scotland.

‘I get to use all the skills that I’ve developed over many years of BMA work and other things that I’ve done to help advocate for people living with long covid and other chronic diseases, and also at a national level, influencing the Scottish Government, and highlighting the plight of people living with these diseases.

‘All the work I’d done previously gave me a platform to be able to do this work.’

There have been other changes too. Dr Small now lives in Sheffield, where she works as a sessional GP. She has maintained her BMA activism and appreciates the better work-life balance she now enjoys.

‘When you’re a GP partner it’s all-consuming, because even when you’re not at work, it’s still your business and you’re still running it. But now I go to parents’ evenings, I go to the school plays and concerts.’

She has largely recovered from long COVID, she says, but she is determined to ensure that the many doctors still living with it are not forgotten. ‘We have to learn from this. We can’t let it happen again.’

Jennifer Trueland

For Sethina Watson, the fear and uncertainty in the early months of 2020 were all the more acute as the parent of a clinically vulnerable child.

Then an anaesthetics registrar, Dr Watson was forced to ‘shield’, relocating from hospital wards to working remotely to support colleagues.

Although she returned to the wards after the first lockdown, Dr Watson still finds that first year of the pandemic almost surreal.  

‘Like many people when you look back [on those years] it seems a bit unreal, like it never happened. At the time you never imagined getting back to normal. [COVID] feels both very much in the distance but very much recent at the same time.’

Being able to shield along with her husband, a fellow consultant anaesthetist, proved invaluable in protecting their daughter, whose health has ‘improved significantly’ since the pandemic.

But Dr Watson worries that the physical and psychological toll of those years, especially for health workers, has not been addressed, despite the greater focus on wellbeing.

‘I think as a nation, we haven't been given a collective chance to pause and reflect, we've all just carried on,’ she says.

‘I still think there is a level of burnout and exhaustion that undoubtedly stems from that time that we are still dealing with.

‘[For NHS staff] there was no recuperation phase: we went straight back into dealing with the elective care backlog and dealing with complex patients who may have had a more negative impact from the results of the pandemic.’

She adds: ‘If anything, [COVID] strengthened my commitment to the specialty [and] it’s actually been a great privilege to have been able to help people.’

Ultimately, Dr Watson hopes doctors and their allied healthcare colleagues will be given the time, space and support needed to come to terms with those pandemic years.  

‘We did lose colleagues, and that’s devastating and also unbelievable and terribly sad,’ she says. ‘Certainly, lots of our profession and other health professionals still suffer from some trauma from that time.

‘Having to say goodbye to your relatives over an iPad, not having the resources to look after people, means we’ve all got to deal with some level of moral injury.’

Tim Tonkin