Reflections, future innovations and learning from Covid-19

Clinical imaging and radiotherapy NHS services were already under mounting pressure pre-pandemic. The announcement by the Prime Minister on 12 March 2020 changed the approach nationally.

Services started looking at the preparations already made and what further decisions were needed quickly, including the decision to pause non-urgent, elective activity. We are now more than two years on from when the UK first went into a national lockdown to control the spread of Covid-19. Our lives have changed and so has the way we work.

It seems a very long time ago. Not quite comprehending what was coming our way, services were reconfigured at pace. The initial data modelling suggested that Covid-19 would lead to a 4% hospitalisation rate of those infected, with 30% of patients requiring admission to critical care. Of those admitted to critical care, it was estimated that 50% would die¹. How were we going to respond to this and ensure that we maintained services for patients?

There were so many challenges and unprecedented pressures on frontline teams and a key area of focus was looking at arrangements for staff, with the priority of maintaining safety but being mindful of any impact on our ability to deliver services. We found ourselves in fast-changing situations and it was difficult to get clarity on the new processes and actions we needed to put in place. This created huge anxiety and successful leaders needed to remain objective and release repeated reassurances, often without confidence in their own message.

Supporting staff was paramount and was not just about those delivering frontline services, it included developing plans for those who were clinically vulnerable, self-isolating or pregnant and creating ways for them to work differently, such as telephone consultations, remote radiotherapy planning, reporting and vetting requests from home. Home working became routine for those who could do it, and clinically vulnerable staff were immediately told to shield at home. Everyone needed laptops and the IT teams were awesome in the way they stepped up. Virtual meetings became the norm and suddenly Microsoft Teams was the go-to app. What would we have done without it? We have, however, learned to take five minutes between meetings to avoid complete self-combustion – it helps.

Meetings and training were cancelled unless business critical, and we found ourselves in a command-and-control structure that was supportive in decision making. Keeping in touch with staff can be challenging at the best of times but now the dynamic really felt different. Communicating via MS Teams was a novelty at first but that soon wore off. Nuances are missed and things land differently somehow. Also, daily visits around the department to catch up with clinical teams could not be justified, leaving a feeling of anxiousness and disconnection from teams. It’s still there.

In the very early days of the pandemic, the advice was to continue running services as near to normal as possible. It was, however, immediately evident that we needed to reconfigure services to allow for separation of patients with Covid-19 from those without. While not essential for the diagnosis of Covid-19, imaging plays an essential role in assessing the severity and progression². As a result, “hot and cold” patient pathways were created, patient flow was redesigned and additional assets sought to limit the movement of patients and equipment through hospitals.

Across radiotherapy and radiology services, in line with the National Institute for Health and Care Excellence (NICE) Covid-19 Rapid Guideline (NG162)³ and national expert opinion^4,5, we rapidly implemented a number of initiatives to maintain our services, while minimising transmission risks and preparing for a significant reduction in capacity due to staff sickness and redeployment.

The rapid period of change involved redesigning departments, creating safe waiting areas, redesigning rotas and doing them again to try to fill gaps created by staff isolating, learning about PPE “donning and doffing” and FIT testing. Other changes included:

• Reducing face-to-face contact. In radiotherapy, treatment reviews were changed to telephone appointments or cancelled if there were no problems, unless patients were having concurrent chemotherapy or were complex.
• Setting up new processes for telephone consent prior to treatment.
• Patients attending appointments without family members. This was really difficult for patients who rely on friends and family to support them.
• Minimising time in the waiting area (encouraging patients not to arrive early, advising them to stay in their car until ready for treatment), with teams phoning when they were ready.
• Assessing for Covid-19 symptoms on arrival at the main entrance and mandating hand washing on entry.
• Patients with suspicious symptoms were diverted for isolation/testing before reaching the department.
• Devising a risk stratification framework to aid decision making, balancing the risk of cancer not being treated optimally with the risk of the patient becoming seriously ill from Covid-19. Also taking account of patient-specific risk factors, including comorbidities and any risk of them being immunosuppressed.
• Urgent implementation of strategies to reduce demand for radiotherapy, such as the new five-fraction breast regime in line with the Fast Forward trial, and patient risk. During the high-risk Covid-19 period, the risk to some head and neck patients meant they received more radiotherapy fractions in place of the SACT-DAHANCA regime.

In preparation and readiness for an overwhelming number of patients with Covid-19, plans were made to create additional capacity in Nightingale Hospitals. Within days, teams were established to set up temporary hospitals. Walking into the building at Nightingale Hospital Bristol for the first time and seeing the construction coming together was a sombre experience.

Everything was unknown. What did we need to do first? Where was the equipment coming from? How would we staff the unit? The team was pulled together from organisations across the region and, in the space of a few weeks, the hospital was created and ready to use if required. The overwhelming impression was the desire from individuals to work collaboratively to create solutions and provide care to patients, despite the challenges they faced.

In a time of unprecedented pressure and anxiety, rainbows began appearing everywhere, such as in windows and on roads. NHS staff were hailed as heroes and recognised for everything they were doing to treat patients. The free onsite parking for staff was welcomed and valued by staff, as were the many generous donations from many companies and the public to make life a little easier and raise morale. It really meant a lot to staff, who were feeling worried for themselves and their families as well as wanting to provide the best care for their patients.

It is well documented that the pandemic has affected the mental wellbeing of the workforce as a result of factors such as the increased workload; the intensity of working in different, Covid-19-safe environments; the strain from dealing with trauma, including bereavement; and worrying about being able to provide high-quality care. We have all been affected. No one had factored a pandemic into their plans and sustaining high performance, continuously, in a stressful environment, was just not realistic.

A senior colleague said: “We are doing everything we can. Self-doubt is a good thing… In fact, it might be a superpower. You acknowledge that you don’t know everything. You can’t have bravery without fear.”

It has become more acceptable to be open about one’s mental health – this is something we should sustain, if we can. Some staff reported struggling and described their experience as a trauma and disruption of their core beliefs, while others mentioned having a new appreciation of life. Staff wellbeing provision, including psychological wellbeing services, was improved.

Early in the pandemic, student radiographers suddenly found their placements halted. Many missed their placements altogether for their own safety and in line with minimising the footfall in departments. To support students and provide opportunities for them to gain experience, universities and departments have developed new ways to supplement the traditional time spent in departments on placement. For example, the introduction of virtual reality in teaching sessions, the use of simulation with whole-body phantoms and changing rota patterns. In Sheffield, students were reintroduced by redesigning rotas and offering off-set technique discussions, which were so well received that they will be kept. A pilot project, run between the allied health professions faculty at Sheffield Hallam University and Weston Park Cancer Centre, is well under way to deliver clinical placements away from the cancer centre.

We have adapted and changed the way we work and live and, particularly, how we use digital platforms. As we emerge from the pandemic, this is likely to be the new normal, offering connectivity that has previously been difficult to achieve. We need to continue embracing technological advancements and new ways of working in all areas of our lives.

Virtual Support Tool technology is currently being piloted in departments nationally, providing opportunities for expert advice to be given to CT and MRI radiographers from another radiographer in a hub from another location. The supporting radiographer can observe the scan room, control room and console, and communicate with radiographers to provide support and assistance. This is a very different approach from providing guidance and support. Adopting this technology may offer new opportunities to give support and training in the workplace, provide innovative ways to increase placement provision, and offer staff and students unique training experiences in addition to the delivery of online education via virtual platforms.

The change in the way services have been delivered as a result of Covid-19 has highlighted some of the benefits of separating acute and elective services, bringing into focus the development of Community Diagnostic Centres (CDCs)⁶. While there are huge advantages to developing these services, until there is sufficient staff to operate the facilities there is additional pressure placed on existing services and staff.

We made fantastic progress to manage the outbreak thanks to the tremendous efforts of everyone in services and organisations. We are so proud of our teams and the brilliant way they have stepped up, caring for patients with the same dedication and kindness they have always shown, regardless of Covid-19.

We were all hoping that, in 2022, we would be in a different position but, sadly, we are not. Omicron has driven a steep rise in staff and patient infection, with an uptick in demand on our hot linac and requirement for acute hospital services, so we all need to remain vigilant and keep our spirits up as much as we can. Teams continue to do an amazing job in very difficult circumstances.

Colleagues shared some lived experience comments and, reading them, we believe there has been some post-traumatic growth and there have been new possibilities:

“We came up with new ways of working very quickly – we cut through the red tape.”

“It took a crisis for us to leap forward. How do we consolidate that learning?”

“Resistance to change has changed!”

“Relating to others has improved family relationships.”

“Personal strength I didn’t know I had.”

“Spiritual change – I believe there is more to life.”

“This crisis has restored my faith in humanity.”

In the 2021 edition of Imaging & Oncology, Hindle highlighted the importance of looking after ourselves and our colleagues⁷. A year on, the significance of doing this is just as important, if not more so, particularly as the rate of staff burnout increases.

The importance of supporting staff to enable them to cope with the demands of their role had been highlighted before the pandemic. Without support, staff are less able to bear the burden and are at risk of burnout and detachment⁸. Staff who feel unsupported experience higher levels of stress and, as a result of self-preservation, this can lead to a reduction in the level of compassion demonstrated and thus the level of care given to patients.

As we move into a period of recovery, it is important that we, as leaders, place an emphasis on nurturing environments that foster the delivery of compassionate care. Compassionate leadership has a profound effect on the health, wellbeing and engagement of staff, improving clinical effectiveness, patient experience and safety⁹. Creating opportunities for staff to feel supported, valued and safe not only achieves kindness and compassion for patients but also for each other. Or more simply put, when you care for staff, they care for patients⁹.

As we hopefully move forward to a period of recovery, we are presented with an interesting paradox. The conflict between providing compassionate care while delivering an efficient service, striving to increase activity and reduce waiting-time targets places departments under increasing pressure to maximise efficiencies. It would be all too easy to focus on reducing waiting times and, if not careful, create a “conveyer belt” environment and objectification of patients¹⁰. This would not place patients at the centre of care and would fall short of addressing the diverse needs of individuals and providing compassionate care. A culture of metric-driven healthcare risks creating an environment where staff may be fearful of failing to meet performance targets and this, in turn, is a contributing factor in compassion fatigue¹⁰ and leads to reduced attention to distress. In these circumstances, the ability to deliver compassion is inhibited.

Compassion begins with attending to yourself and allows for better interaction with those we work with and care for. As pressures mount with Covid-19 and the inevitable recovery period that follows, departments will come under even further scrutiny. It is therefore essential that leaders of organisations ensure they place value on the wellbeing of staff and patients, creating cultures of compassion while balancing the requirements and challenges of services under pressure.

Karen Smith is Senior Manager, Radiation Services, at Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust.

Elizabeth Ladd is Head of Imaging, South West, at NHS England and Improvement.

References

1. Ferguson N, Laydon D, Nedjati-Gilani G et al. Report 9: Impact of Non-Pharmaceutical Interventions (NPIs) to Reduce COVID19 Mortality and Healthcare Demand. 2020. Available at Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf Accessed January 2022.

2. Kooraki S, Hosseiny M, Myers L, Gholamrezanezhad A. Coronavirus (COVID-19) outbreak: what the department of radiology should know. Journal of the American College of Radiology. 2020; 17:447-451.

3. NICE. Covid-19 Rapid Guideline: delivery of radiotherapy (NG162). 2020. Available at www.nice.org.uk/guidance/ng162 Accessed January 2022.

4. The Royal College of Radiologists. Coronavirus (Covid-19): clinical information. 2020. Available at https://www.rcr.ac.uk/college/coronavirus-covid-19-what-rcr-doing/coronavirus-covid-19-clinical-information Accessed January 2022.

5. The Society of Radiographers. Covid-19 information and resources. 2020. Available at https://covid19.sor.org/ Accessed January 2022.

6. Richards M. Diagnostics: Recovery and Renewal. Independent Review of Diagnostic Services for NHS England. 2020. Available at www.england.nhs.uk/publication/diagnostics-recovery-and-renewal-report-of-the-independent-review-of-diagnostic-services-for-nhs-england/ Accessed December 2021.

7. Hindle L. Looking after ourselves and our colleagues. Imaging & Oncology. 2021: 12-16.

8. George MS. Stress in NHS staff triggers defensive inward-focussing and an associated loss of connection with colleagues: this is reversed by Schwartz Rounds. Journal of Compassionate Health Care. 2016; 3.

9. West M, Eckert R, Collins B, Chowla R. Caring to Change: How Compassionate Leadership can Stimulate Innovation in Health Care. London: The King’s Fund. 2017.

10. Crawford P, Brown B, Kvangarsnes M, Gilbert P. The design of compassionate care. J Clin Nurs. 2014; 23: 3589-3599.