WHILE during lockdown, many people have been struggling with enforced inactivity at home, others have been working hard to keep critical services functioning. The clapping on a Thursday night started for the NHS, but it quickly expanded to recognise social care workers and then all those who keep us safe and supplied with what we need. One thing this crisis has brought home is a recognition of who the REAL key workers are.

When I returned to the NHS at the start of the lockdown, I wasn’t needed in the breast cancer service, as routine clinics had been cancelled and the team were focusing on the diagnosis and treatment of patients with cancer. I therefore took on a more administrative role regarding the Covid response.

While it was lovely to be back, I was struck by how the hospital had been reorganised to accommodate the many Covid patients who might require critical care and ventilation. The number of critical care beds had been quadrupled, albeit on a temporary basis, and the emergency departments and wards divided into red and green zones to reduce the risk of cross contamination between patients. GPs and hospital specialists were carrying out consultations by phone or video link, so patients could discuss their symptoms from home, and often they didn’t need to be seen physically but could get a prescription or be referred for investigations. While there were already patients being treated for Covid, the hospital felt calm: staff had worked hard to get ready, and there was a sense of the breath before the dive or the quiet before the storm.

There is, as yet, still no cure for Covid and, even with full ventilation, it has not always been possible to change the outlook for some of the sickest patients. Having been involved in the support and palliative care of breast cancer patients for more than 30 years, I was invited to become part of a project group which was working to develop simple guidance on the management of Covid symptoms to reduce distress and ensure patients were comfortable. With the images we had seen from Italy, we were preparing for the worst but did not want the principles of good palliative care to be lost in the middle of the pandemic crisis. Rather, we wanted to ensure that all patients, whether with Covid or not, would be made comfortable and treated with care, gentleness and dignity.

On top of providing guidance and practical solutions, there was recognition of the need for emotional support for staff who might be facing the traumatic situation of losing a patient, for the first time, or on a scale they had never experienced before.

It was clear this would be especially important for any young nursing and medical students, who had stepped up to help with the Covid response, but even those with years of experience can struggle when dealing with the loss of a patient. Wellbeing centres were established in our acute hospitals where staff could simply take a break, share their experience with colleagues or seek more formal support from the psychology team.

Thankfully, with the impact of lockdown, the acute surge has flattened out, the pressure on hospitals has stabilised and all the preparation and hard work of staff has meant that the hospitals have never been overwhelmed. But Covid-19 will be with us for quite some time and, while the initial focus has been on hospital capacity, the real frontline is now in the community among frail elderly people relying on home care or living in care homes.

As most care homes stopped allowing visitors in early March, it had been hoped this would help to protect them from the spread of Covid. However, it quickly became apparent that, as the elderly and frail are most at risk from the virus, care homes were the most vulnerable and, once an outbreak began, it spread easily within such a closed environment.

Achieving integration of health and social care has been Scottish Government policy for many years, but this crisis has shown just how far we still have to go. However, the epidemic is now breaking down barriers that would normally take years to climb over. All three local health and social care partnerships are working together to provide whatever support is required to those caring for elderly residents. Public health teams are providing additional infection control advice and have begun testing both staff and residents. NHS National Services is providing additional PPE and health boards have offered to provide nurses and healthcare assistants to ensure sufficient staffing. Thankfully this determined effort has begun to reduce the deaths in care homes but, with the frailest people in our society living there, they will remain vulnerable.

As the focus of the palliative care group changed, from hospital to community, it brought together hospital specialists, in emergency medicine and geriatrics, palliative care doctors and pharmacists from the hospice, as well as GPs, community nurses and social care staff. This multidisciplinary approach has broken down barriers and brought real drive and creativity to tackling difficulties and coming up with solutions. The aim was to ensure that staff in all settings, from the acute hospital to someone’s home, could be provided with guidance, teaching and practical solutions to control symptoms and keep patients comfortable at the end of their lives.

Over the course of my career, it was always important to me that patients felt cared for and loved at the end of their lives and that the focus was on squeezing every ounce of pleasure or joy out of the days they had left. “End of life” does not just means the days or hours before someone dies, but is about providing quality of life during the entire last phase of someone’s life. This has been totally disrupted for care homes as one of the most painful aspects of infection control has meant isolating residents and excluding visitors, leaving hospital patients lonely and care home residents feeling lost.

ONE of the first decisions agreed by the group was that patients’ closest relatives should be allowed to visit at the end of life, whether the patient has coronavirus or not, and this is the policy right across Scotland. It is critical that patients do not feel isolated from loved ones at such a time and that relatives get the chance to express their love and say goodbye, even if it is limited to the very closest family members and through the layers of a mask and gloves.

While we have, of course, had to hold all of our meetings online, progress has been swift as members of the group have worked at speed to pull together guidance, develop teaching materials and set up workshops on palliative care available to all staff, regardless of where they work.

Most importantly, it has established totally new relationships and grown into a network that will, hopefully, provide support to colleagues working in all sectors, from the acute hospitals and community services to social care staff, as well as voluntary groups who support family carers and bereaved relatives. Its strength is that it cuts right across all the normal silos that have existed within the NHS, and between the NHS and social care.

Like many parts of society, the NHS has had to change itself in a matter of weeks to prepare for the coronavirus outbreak. The challenge now is how to deliver more routine healthcare services while the virus is still circulating.

However, we mustn’t lose the innovations or forget the lessons we have learned and, most importantly, we must maintain the new relationships that have been formed. For all the difficulties ahead, the prize we could finally achieve is the real integration of health and social care.