The volume of patients, the complexity of illnesses, and the unrelenting nature of the covid pandemic are having a huge impact on morale among our junior doctors, many of whom are experiencing their first winter in the NHS, write Nikki Nabavi and Clara Munro

A winter surge in hospital admissions is not unfamiliar. However, Public Health England’s annual flu and covid reports1 show that the current pressure on hospitals is not comparable to the usual winter influx. The difference in healthcare staff’s morale between the start of the pandemic and now is palpable, not least among those who are experiencing their first winter in post.

The nervous energy that characterised last spring has been replaced by chronic exhaustion. Natalie Ashburner, vice chair of the Doctors’ Association UK, says that doctors feel “battered by the unrelenting experience of caring for those with the virus.” And the idea of “just a bad day on call” is replayed without any opportunity for recovery.

Pushpo Hossain, a junior doctor in London, says, “When you are doing everything you can and you reach the ceiling day after day, morale falters.”

Alone

One major difference is that, during the first wave, doctors weren’t also providing routine care. This has now changed, and in addition there are long backlogs of patients, some of whom have had their treatment delayed for over eight months. It’s created an additional pressure on the NHS that wasn’t there during the first wave.

The Faculty of Intensive Care Medicine surveyed its members in November 2020, before the peak of the second wave, and reported that only 18% of respondents agreed that staffing levels in intensive care units were adequate.2At the peak of the second wave in January, junior doctors and medical students were being asked to volunteer in intensive care, sometimes through call-outs on social media.3

The BMJ heard concerns about staffing levels from several junior doctors around the country. “Staff are constantly having to isolate, which leaves us so understaffed,” says Amelia Seifalian, a foundation doctor in Watford. “Often at 9 pm we are asked on our hospital’s foundation year 1s’ WhatsApp group if anyone can go in and cover a night shift, as they are short of around four doctors.

“These shortages mean that juniors are left with more responsibility than usual, and things that you would usually ask your senior house officer for support on or double check with them, you are unable to, which makes us feel less confident.”

In a 2019 study published in the Journal of the Royal College of Physicians, 66.4% of doctors reported “feeling part of a team” as being the most important factor affecting their morale.4 Bethan Markall, a junior doctor based in Birmingham, told The BMJ that rota gaps also affected doctors’ sense of team support and camaraderie: “Juniors no longer have a team—it’s not unusual to work four different shifts, each with completely different teams.” This leads to a lack of team identity and reduced support.

Markall adds, “First year foundation programme teaching has only been online, meaning we have had less of a chance to meet our cohort or socialise with them, which can be quite isolating.”

This trend of isolation is highlighted by the stark contrast between the culture of free team meals and social support, as seen during the first wave of the pandemic, and the new socially distanced canteen booths that Seifalian describes, allowing for little to no mealtime debriefs with colleagues after difficult days. She emphasises the importance of reflections with colleagues. “I don’t want to talk about it to my family or housemates,” she says. “I don’t want to share the burden.”

Infantilised and ignored

Morale may be further eroded by feeling “infantilised” by colleagues. Freddie Stourton, a foundation doctor in the south of England, says that it can feel frustrating and exhausting to be thrown in at the deep end and then be “told off” for things that are out of your control. Senior staff can expect juniors to be familiar with their surroundings or a ward’s logistical practices, even though they are sometimes working with completely different teams on different shifts. Some reported being shouted at for “standing in the wrong place” five minutes after arriving at a new ward and while trying to help a patient.

While all doctors will be familiar with the “bad shift,” those who spoke to The BMJ said that the covid pandemic had brought an increasing frequency of these shifts among junior staff who lack the experience to contextualise these encounters.

The Doctors’ Association UK is among those who have called for greater provision of accessible mental health services for doctors. A spokesperson told The BMJ, “We have grave concerns about the effect that this pandemic is having on the mental health of NHS workers. We urgently need more specialist mental health services that are well funded, adequately resourced, and accessible to those who need them.”

The BMA, meanwhile, has called for medical staff to be prioritised for covid-19 vaccination to help reduce the absences that are leaving rotas short5 and subsequently affecting junior doctors’ ability to attend vaccination appointments themselves, while changes to shift patterns and night shifts6 make this challenging.

Stourton says that, in some ways, the shunting of junior doctors reflects an attitude that’s persisted throughout the recruitment process: doctors who have undergone years of training being “treated like numbers on a page, with patchy communication and changes in the process with little or no notice.”

Partha Kar, consultant in diabetes and endocrinology and a BMJ columnist, says that “what junior doctors have taken on in this pandemic has been nothing short of astonishing. Stepping into areas way outside their comfort zone, with specialties not being a barrier or given a second thought—their desire and determination to help without any hesitation has been fabulous to see and be part of, as well as inspiring.”

He concludes, “The least as seniors we can do is to find some time, if possible, to have a kind or caring word, or even a simple thank you, for their efforts in these extraordinary times.”

Read the article in the bmj

DAUK’s Dr Natalie Ashburner & Dr Richard Gilpin in Health Europa Quarterly discussing the impact of COVID-19 pandemic on the welfare of healthcare staff.

April 2020, DAUK conducted a survey of 350 healthcare workers which found that 57% felt so stressed they have bene overwhelmed or unable to cope because of pressure at work during the last month. 
11% had felt suicidal and 3% had self-harmed in the past month because of stress from increased pressure at work. 

October 2020, DAUK surveyed >800 GPs:
– 78% working during the Pandemic had impacted negatively on their mental health
– ‘My mental health has reached the stage where I have even thought about crashing my car on the way to work’ 

Despite all the evidence of the mental health impact of COVID-19 in health and social care, little will change while the same mismanagement, slowness to react and lack of communication continues to dominate the decisions taken by those in charge.

Access the full article here

Visiting a north London hospital as some of the first patients received doses of the Oxford/Astra Zeneca vaccine, prime minister Boris Johnson said tougher restrictions were inevitable.

‘If you look at the numbers there is no question that we are going to have to take tougher measures and we will be announcing those in due course,’ Mr Johnson said.

Scottish first minister Nicola Sturgeon, meanwhile, has announced a lockdown from midnight – with schools across Scotland to remain closed until February at the earliest.

Labour leader Sir Keir Starmer on Sunday called for a full national lockdown in England within 24 hours, and groups including the Doctors Association UK have joined calls for an emergency national lockdown.

COVID-19 lockdown

Former health secretary Jeremy Hunt – now chair of the influential House of Commons health select committee – warned that although during his record tenure in the role the NHS had faced four ‘serious winter crises’, soaring rates of COVID-19 infection in the second wave of the pandemic meant pressure on the health service was now ‘off-the-scale worse than any of those’.

Mr Hunt called for immediate closure of schools, borders and a ban on all household mixing.

Calls for rapid action to contain the COVID-19 pandemic came after the UK recorded more than 50,000 new infections per day for six days in a row.

COVID-19 cases rising

More than 75,000 people in the UK have died within 28 days of a positive COVID-19 test, and on 28 December 23,823 were in hospital with the virus – more than the number at the peak of the first wave.

DAUK vice chair Dr Natalie Ashburner said: ‘We acknowledge that these decisions are far from easy to make but the rapid of acceleration of the virus is deeply concerning and the current measures don’t appear to be containing transmission of the virus.

‘For the sixth day in a row over 50,000 transmissions have been recorded and the death toll is climbing inexorably. DAUK is particularly worried that things will get even worse as the effects of Christmas and New Year are fully realised.’

Dr Zainab Najim of the DAUK GP committee said: ‘We are in the midst of the toughest winter the NHS has ever seen, exacerbated by the new highly transmissible strain of COVID-19.

‘Sickness rates among NHS staff have doubled to trebled compared to last winter and there are real worries that safe patient care could be compromised by the sheer number of patients needing care and staffing ratios not seen in peacetime.’

Read the full article here: https://www.gponline.com/tougher-measures-imminent-hunt-warns-covid-19-crisis-off-scale/article/1703589

Batches of the Oxford/AstraZeneca coronavirus vaccine have started arriving at UK hospitals ahead of the jab’s nationwide roll-out.

Some 530,000 doses of the treatment will be available for roll-out across the UK from Monday, with vulnerable groups already identified as the priority for immunisation.

The vaccine has been developed in the UK by Oxford University and the pharmaceutical giant AstraZeneca.

The roll-out will begin after England’s chief medical officer Chris Whitty warned vaccine shortages are likely to cause problems for “several months”.Advertisement

He said the UK urgently needs to maximise the number of people who are vaccinated, but added a lack of global supplies will likely hamper efforts to protect the nation in the first part of 2021.

Public Health England (PHE) has said it does not recommend mixing coronavirus vaccines from different suppliers amid fears over the possible shortages.

Both the Oxford/AstraZeneca vaccine and the Pfizer/BioNTech vaccine, which has been rolled out from December, require two doses.

The UK government had issued guidance telling NHS medics that if a person who has received their first coronavirus jab goes back for their second but the same type is not available, or the first vaccine type is unknown, then it is “reasonable” to offer a dose of another vaccine.

Dr Mary Ramsay, head of immunisations at PHE, has since told Sky News that mixing is not recommended and should only happen on “rare occasions”.

The Princess Royal Hospital in Haywards Heath, which is part of Brighton and Sussex University Hospitals NHS Trust, was one of the first hospitals to take delivery of a batch of the Oxford/AstraZeneca vaccine on Saturday morning.

First doses of the vaccine will be administered next week after the UK recorded another 57,725 coronavirus cases on Saturday – its highest ever daily total. Another 445 deaths were reported.

Dr George Findlay, chief medical officer and deputy chief executive at the trust, said the vaccination programme gives NHS staff “more confidence” coming into work.

He added hundreds of people are expected to be vaccinated per day at the Princess Royal Hospital site, with efficiency expected to increase after the first few days of the programme.

Dr Findlay said the Oxford/AstraZeneca vaccine, which can be kept at normal fridge temperature, is “much easier” to administer when compared with the jab from Pfizer and BioNTech, which needs cold storage of around minus 70C.

More than a million people have already received the first of two jabs of the Pfizer/BioNTech vaccine.

Second doses of either vaccine will now take place within 12 weeks rather than the 21 days that was initially planned with the Pfizer/BioNTech jab, following a change in guidance which aims to accelerate immunisation.

Doctors’ Association UK (DAUK) has raised concerns over the spacing of the second dose of the Pfizer vaccine and what it calls “the lack of a coherent strategy for the current crisis”.

Dr Natalie Ashburner, vice-chair of DAUK, said: “Poor communication and lack of engagement with frontline clinicians who are implementing this vaccine programme and dealing with the NHS pressures has led us to this point.

“Moving forward we urge a rapid reassessment of the strategy as a whole with a clear plan that has had frontline clinician input, so that even if we are deviating from certain guidelines, we are doing so together and with the backing of the science.”

Dr Vinesh Patel, from the GP committee of DAUK, said: “There are a great many concerns that the change in vaccine strategy and dosing regimen has been communicated poorly and represents an attempt to stem public health failings.

“There appears to have been little to no involvement with frontline clinicians in making this decision, and subsequently chaos is ensuing…. (the change in strategy) is a huge gamble, and one made without the data to back this strategy.”

The full article can be accessed here: https://news.sky.com/story/covid-19-batches-of-oxford-astrazeneca-coronavirus-vaccine-arrive-at-uk-hospitals-ahead-of-roll-out-12177510

“We see extremely high numbers of what you would recognise as psychological burnout. The problem is that, you know, you might say that we’re in the peak of this in a week or a couple of weeks from now, and perhaps things will start to get better. But in terms of the work for the NHS, it certainly won’t stop there, and we have long backlogs of planned care that has been cancelled that we’ll need to catch up on.

And then obviously we will need to come to terms with what’s happened. But we won’t be able to just stop, we won’t be able to give everybody a break. They will need to continue on, and that’s when I think that we will really see the real surge in problems with mental health.”

Dr Natalie Ashburner, DAUK Vice-Chair

Medscape UK’s latest online survey of more than 1000 doctors highlights how working through COVID-19 has impacted their mental health and personal lives.

The number of doctors reporting burnout increased to 37% this year from 22% when we last asked in 2018.

“This latest survey absolutely aligns with what the Doctors’ Association UK is hearing from members,” commented Dr Natalie Ashburner, wellbeing lead for the Doctors’ Association UK (DAUK).

“NHS staff were already suffering from high rates of burnout and mental illness in the context of a decade of chronic underfunding of services, lack of staff, and erosion of pay and working conditions.”

Danger Pay 

More than half of doctors thought overtime or danger pay would be appropriate. Instead, most doctors in England got a 2.8% pay rise said to be in recognition of frontline work, but described as “a metaphorical slap in the face” by the British Medical Association.

As well as burnout, nearly 1 in 5 doctors said they were clinically depressed.

“COVID-19 has drastically exacerbated these pre-existing issues and the result is that dedicated, highly skilled staff have been pushed to the point at which they are unable to cope any longer,” Dr Ashburner said.

View the entire article here: https://www.medscape.com/viewarticle/940129

The number of doctors reporting burnout increased to 37% this year from 22% when we last asked in 2018.

“This latest survey absolutely aligns with what the Doctors’ Association UK is hearing from members,” commented Dr Natalie Ashburner, wellbeing lead for the Doctors’ Association UK (DAUK).

“NHS staff were already suffering from high rates of burnout and mental illness in the context of a decade of chronic underfunding of services, lack of staff, and erosion of pay and working conditions.”

Danger Pay

More than half of doctors thought overtime or danger pay would be appropriate. Instead, most doctors in England got a 2.8% pay rise said to be in recognition of frontline work, but described as “a metaphorical slap in the face” by the British Medical Association.

As well as burnout, nearly 1 in 5 doctors said they were clinically depressed.

“COVID-19 has drastically exacerbated these pre-existing issues and the result is that dedicated, highly skilled staff have been pushed to the point at which they are unable to cope any longer,” Dr Ashburner said.

Second Wave

Thirty-six percent worked longer hours during  the pandemic’s first wave.

“The same staff who worked on the front lines during the first wave of the pandemic, many of whom have been traumatised by the experience, are now tackling the second wave.

“We cannot place insurmountable pressure on staff who are suffering from psychological distress, at high risk of mental illness and just expect them to cope.”

Clap for Carers

Nearly 7 in 10 doctors said ‘Clap for Carers’ did not boost morale in the long term.

“Whilst the ‘Clap for Carers’ was appreciated, it did little more than paper over the cracks when the true causes of low morale in the NHS run much deeper,” Dr Ashburner said. 

Most doctors experiencing burnout/depression were not planning to seek help and 30% were not aware of workplace help programmes.

Dr Ashburner commented: “Prioritising the wellbeing of NHS staff must be at the forefront of the action plan to tackle the second wave of this pandemic.

“Adequate and effective equipment, sufficient numbers of well rested and supported staff and appropriate remuneration for their work are essential.”

Among burned out doctors, 47% were considering early retirement. “The NHS is haemorrhaging staff; without addressing this and without also achieving parity of esteem for mental health services, we risk not having a workforce left to care for us,” Dr Ashburner told us.

Full article here: https://www.medscape.com/viewarticle/940129

Dr Natalie Ashburner, wellbeing lead for the Doctors’ Association UK, which is also supporting our initiative, says: “We are incredibly pleased to hear of the initiative and appreciate the kind gesture of gratitude for NHS workers.

“The simple yet thoughtful gifts of care essentials will not only soothe NHS workers’ dry skin and chapped lips but also provide them with a much-needed boost of morale and a reminder that the nation is rooting for them.”