Amid further news of a Covid-19 vaccine breakthrough, interventional cardiologist Professor Adrian Banning from the University of Oxford reflects on the latest developments, the impact of the pandemic on healthcare and how the outbreak can instigate positive change within the NHS.
In a week where prime minister Boris Johnson set out a new three-tiered restrictions framework for England once the country emerges from full lockdown on December 2, there was some positive news in the fight against Covid-19. Following reports that Pfizer’s vaccine could be given the green light in the UK by the end of the week, it has emerged that the vaccine being developed by AstraZeneca and the University of Oxford may be 90 per cent effective at preventing people from contracting the virus, according to preliminary data.
Health secretary Matt Hancock has confirmed that the UK has 100 million doses of the Oxford-AstraZeneca vaccine on order and it is expected that this will also be rolled out in the New Year.
Although an optimistic Hancock says that the government is looking with “high confidence” that things can “really start to get back to normal” after Easter, the extraordinary amount of work and dedication from the healthcare sector and wider populace which has gotten the country to this point must not be forgotten. In recognition of these efforts, The Leaders Council of Great Britain & Northern Ireland has been in dialogue with a number of healthcare leaders and consultants from different departments to share their thoughts on the latest developments, as well as providing some insight into the challenges that the pandemic has thrust upon their arm of healthcare.
Cases rising, hospitals empty
Speaking exclusively to The Leaders Council of Great Britain & Northern Ireland, Adrian Banning, Professor of Interventional Cardiology from the University of Oxford’s Radcliffe Department of Medicine, explained that the initial lockdown period beginning in March brought with it a handful of career firsts for him, most notably emptier hospitals.
Prof Banning said: “The surprising thing was that in the first lockdown we suddenly saw empty hospitals for the first time certainly in my career, which is the opposite of what we expected. We found that people were too frightened to come to hospital and so there was a dramatic reduction in the number of emergency admissions concerning patients presenting with heart disease.
“Here in Oxford we saw a one-third reduction of people presenting themselves to emergency services with heart attacks, and people were coming to us with chest pain less often. What we now know is that those reductions correlated with an increase in sudden death in the community. What essentially happened was people had heart attacks at home, chose not to come to hospital and unfortunately died at home. There is good data to suggest during that initial phase beginning in March, that this was happening all around Europe.”
In order to remedy this, Prof Banning explained that the NHS was forced to be proactive in reaching out into communities and pushing the message that it was safe to attend hospital in emergency circumstances, and over time the issue of patients staying away from hospital corrected itself.
“We were able to get the message out there that it was safe for people to come to hospital with emergency illness and in summer we saw a correction of these circumstances as people began presenting themselves again. These were individuals who had been too frightened to come to hospital who had maybe been suffering symptoms for some weeks or months and we found ourselves having to deal with a patient backlog.”
While many patients are now attending hospital again and the numbers of emergency cases are roughly back to expected levels for this period of the year, Prof Banning warned that there are still cases of people who remain reluctant to go to hospital, particularly for elective procedures and in non-emergency situations.
He said: “Where we are at now is that emergency numbers are around what we would expect them to be. Some people do remain reluctant to come to hospital particularly for elective work and non-emergency scenarios, people are having difficulty accessing GPs and GPs are finding difficult to refer people to hospital pathways, and these pathways are slower than normal due to the allocation of beds and staff to actually keep beds open.
“When it comes to hospital capacity, it is not just a question of physical capacity and beds, it is a case of whether there is enough staff to nurse the number of patients. This is prone to being impacted by factors such as staff illness, staff fatigue and people who are not able to work in a clinical environment due to medical issues.”
A new illness and how to support each other in a time of uncertainty
One of the other significant firsts that Prof Banning experienced in the early stages of the pandemic was the sheer impact that the uncertainty surrounding the Covid-19 virus had on medical staff, owing to the early unknowns of the severity of illness and how staff could expect to protect themselves amid a shortage of personal protective equipment [PPE].
Prof Banning elaborated: “I have been in the sector long enough to remember the uncertainties of when AIDS emerged and people were afraid of dealing with people’s blood, but I don’t ever remember uncertainty like we had around Covid in March. There was a lack of information, a lack of PPE and there was worry within medical teams of how we protect ourselves. There were unknowns about the severity of illness, and we knew that we were putting ourselves at risk. For the first time in a generation since the emergence of AIDS, I feel that this was the only time I have known health workers feel exposed by coming into work over March and April certainly.
“The hospital environment is a very strange place at the moment. There are no visitors, and we are restricted in what we can do as staff in the sense that we can’t always sit and have coffee with colleagues anymore. Quite often sitting down with colleagues and discussing experiences is a real coping mechanism for us and we are discouraged from doing so now. It has really made us aware of how important this dialogue is within our coping mechanisms and you can’t always do this over mediums like Microsoft Teams.”
Will the NHS learn the lessons of enhanced technology?
When asked about how the pandemic has accelerated the digitisation of healthcare and how this could alter the provision of health services in future, Prof Banning explained that while some positive aspects of remote meetings and consultations will certainly be in place for the long-term, the NHS can look to use the pandemic as a watershed moment to explore how certain pathways of healthcare can be improved to bring about beneficial change within the service, as opposed to reverting the NHS to its pre-pandemic normal.
“There are certainly some positives to come out of this period and a huge one is using IT for meetings of multidisciplinary teams and sharing medical images. It is a lot easier to do this electronically than physically and has been a huge step forward. Virtual and telephone consultations we have learnt can be great but sometimes difficult depending on the patient in question. We see some advantages and some disadvantages and of course some of these will continue.
“I do think a lot of remote aspects could be here to stay and some aspects of what we do we should not go back to. We cannot roll out remote consultations en masse but the new system of messaging that we are now using is better than what was in place before, with multidisciplinary team meetings taking place electronically being a major part of that. Genuinely, I think we can look at all clinical pathways and look at what can be done differently or better. Most healthcare pathways were developed organically rather than designed and we can take a step back now and design more effective pathways rather than going back to where we were.”
In Prof Banning’s view, it is the temptation to revert back to normality rather than using the pandemic to look at where there is room for improvement which remains a worry, and he feels that much more decisive planning in this area is required going forward.
“Within the NHS in August and September, we saw too many people trying to get the health service back to where we were rather than take advantage of what we have learnt and think of what can be done differently and how, if at all, we can redesign. This is still going on to an extent and it feels as if everyone is a bit confused about where we are, and it is difficult to plan on a daily and weekly basis.”
Medical research takes a backseat
An expert in interventional cardiology, Prof Banning specialises in performing translational research into mechanisms of injury in PCI and understanding reperfusion in ST elevation myocardial injury. In his work, Prof Banning has previously demonstrated the importance of Troponin elevation after PCI, since it reflects new myocardial injury detected by MR imaging. He has also explored changes in blood flow in these newly injured areas and investigated the impact of opening chronic occlusions on myocardial function.
Prof Banning also heads up the Banning Group, a research group which aims to understand how to optimise heart function in patients presenting with atherosclerosis. Its current research revolves around investigating how to predict outcome in ST elevation myocardial infarction and how therapy can be better tailored to those patients most at risk of adverse outcomes. Unfortunately, much like other arms of the health service, this research was effectively paused by the Covid-19 outbreak which will hamper medical treatment not just in the short-term, but also in the long-run.
Prof Banning recalled: “Covid-19 has been extremely disruptive to medical research. At one point all research outside of Covid was effectively closed down for two to three months. It is still struggling back into full flow, but it is imperative that we continue to find solutions for unmet needs other than Covid, be that advanced cancer or heart disease.
“In our own research, we have had to stop recruiting patients to trials and monitoring of trials has been difficult. We have produced imaging of the heart to gauge the impact of new treatments, but patients have not been able to come in and get the imaging and see results. So, the pandemic has pushed current treatments back but will have a profound effect on future treatments and progress since everything has stalled. For instance, we had to halt a PICSO trial completely for four or five months and we are only now back recruiting.”
Furthermore, the Covid-secure protocols which are now necessary across healthcare, particularly the need to use increased amounts of PPE, have also had an impact on research and the administering of treatment.
Prof Banning said: “The PICSO study required administration of different catheters in a catheterisation laboratory to patients having heart attacks. I now have to do this wearing all manner of PPE so it is a challenge for me and the team physically, but it is also intimidating for patients. In emergency research, you cannot prepare patients to have heart attacks, so emergency patients are brought into a catheterisation lab and you must try to explain to the patient the procedure you are going to be undertaking on them and inform them that you are conducting research during their treatment to try and make the heart attack smaller. It takes a lot of trust from patients to allow us to do this when they cannot see you properly and read your language and in this environment it is more of a challenge trying to recruit patients into trials.”
Indeed, one great unknown of the whole pandemic is whether in the long-term it will act as a factor of encouragement to draw patients into wanting to take part in medical research, or whether it will prove to be a deterrent.
Prof Banning added: “It is an interesting question as to whether all of this will make patients more enthusiastic about medical research and keener to be participants. I think it could do in the long run, but we don’t know the answer to that question for sure yet.”
How long will be living under the new normal?
Reflecting on the recent breakthroughs in the quest for a Covid-19 vaccine, Prof Banning was hopeful that the health service could look forward to some return to normality by the spring or summer of 2021, yet it will still be left facing the challenge of a substantial work backlog which may see some work outsourced to private healthcare providers.
He said: “I think vaccines will inevitably be the ‘saviour of the day’. Whether it is the spring or the summer, I envision things will return to normal around then. However, we do have a backlog of work that needs to be picked up on, and how we do that is a challenge in the context of what is an exhausted NHS infrastructure.
“The period of January to March is always a challenge for the NHS, and this coming year it is going to be tougher than ever before. It is not going to be possible that NHS staff will suddenly kick into overdrive and do 130 to 140 per cent of our workload. A slight worry is that the NHS will probably start to commission private providers to do work when we do not have enough nurses, physiologists, or radiographers in the country. The private providers will, therefore, be taking work away from the NHS. We have a real manpower issue and I worry that what could happen is that we begin magnifying those shortages by facilitating private providers to take on this work. I am not against private providers, but I want to see an equitable approach from government across the potential providers there are.”
Reiterating his view that the NHS should look at the Covid-19 pandemic as an opportunity to reinvent itself, Prof Banning was optimistic that health figureheads could be more open to change within the health service than ever before.
“We do have to view this as an opportunity. The NHS has an emotional priority in the UK and up to now it has really precluded wholesale change because people were too afraid to talk about it. Society may never have this opportunity again, so we must see this as a chance to evolve the NHS in an unprecedented way. As long as any change is clearly transmitted and for the good, I think people are open to it.
“One good thing we have seen during this period which could be a positive change for instance, is a reduction in that small number of people who misuse casualty and A&E services and have instead been dialling 111 over the last few months rather than attending hospital unnecessarily. This is something we can look to continue with, and we have to facilitate other ways of enabling patients to access healthcare without coming to hospital. For those people who are perhaps anxious about physically coming into hospital premises and may suffer from mental health issues, we can set-up virtual consultations rather than have them present themselves here. We can redesign pathways and make that a real positive to come out of this.”
The importance of positivity in leadership
Another positive aspect that Prof Banning has seen throughout the pandemic is the manner in which leaders within healthcare have faced up to such a challenge and led their medical teams by example despite such unprecedented levels of anxiety among staff.
Paying tribute to the efforts of all within the sector, Prof Banning said: “Crises remind you of how important people perceive your reaction to things to be when you are a leader. It reminds me of how careful I need to be in representing positivity. In the early stages of the pandemic, this was crucial when we lacked both information and PPE. I could have easily have thrown my toys out of the proverbial pram and sulked in a corner, but people look to you for guidance on how medical teams can protect themselves and their patients during a health crisis and everyone has stepped up to the plate to get us to where we are now.
“The responsibility of leadership in healthcare was never more acute than in March and April and leaders have had to represent themselves in their best way, and even I have had to keep many frustrations to myself because it wasn’t the time for that. Where we are now, healthcare leadership is focussing more on trying to flatten the hills in the road, particularly over research, and trying to keep momentum and optimism. We are recognising that probably in six months’ time, things will become easier as the vaccine starts to take effect.”
Taking a moment to reflect on a personal bereavement as a result of the ongoing pandemic, Prof Banning shared his view that Covid-19 has had an impact on people’s perceptions of risk and made them more aware of their own mortality, which could act as an instigator for positive change and motivate more of the population into making positive lifestyle changes amid a boost in general health awareness.
Prof Banning concluded: “On Friday, I discovered a colleague of mine, a professor in Leicester with whom I’ve worked for 30 years had died of Covid. It is a reminder of the severity of this illness in a small group of people. There is a human cost to this which is not to be underexaggerated.
“I do think this virus has impacted on people’s perception of risk. I talk to people with anginal chest pain and part of my role is to ask them whether they want to persist with medication to prevent that pain or think about physical intervention such as a coronary stent or coronary bypass operation and people are more aware now that there are two sides to every coin. Not everything works out perfectly and people have been reminded that there are potential downsides to every approach be it physical or percutaneous and they do not always work out properly. People are more aware of their mortality and they are understanding that people do die despite what medicine can do. Over the years the ability of medicine to offer solutions has increased, but society has been reminded that we can’t always just provide a cure for everything.”
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