Introduction
The medical profession has been at the forefront of the national response to the COVID-19 pandemic. Alongside other healthcare professionals, they have treated the sick, contributed to innovations in therapeutics and rapidly reimagined whole new ways of working. Inevitably, leaders of the medical profession have been thrust into the national spotlight with a degree of public scrutiny rarely seen. Medical leaders have been tasked with inspiring and setting the strategic direction for the response, as well as providing a bridge between the profession and those in power. The medical profession and its leadership have demonstrated extraordinary collaboration, flexibility and dedication over the course of the pandemic.
Nevertheless, there have been some elements of the pandemic response that could have been improved upon from the perspective of the medical profession. These range from those decisions that were entirely reasonable at the time and their flaws only revealed on retrospection, to those that could have been prospectively judged to be without a clear rationale.
The pandemic has highlighted how highly our society values good health at both the individual and population level. Emerging from the pandemic we still face a myriad of major threats to the health of the nation, including the older and increasingly multimorbid profile of our patients, the obesity crisis and increasing health inequalities combined with record level elective care waiting lists. The medical profession should be at the forefront of tackling these issues and helping to shape a cross-government response. The pandemic has provided an ideal lens through which to scrutinise the potential of the profession in leading effective responses to these major challenges.
Numerous reviews and reflections on the COVID-19 pandemic are being carried out, with a public inquiry expected in due course. The Academy of Medical Royal Colleges (the Academy) has been closely involved in many significant decisions during the pandemic and offers a unique contribution to the reflections of this time. This report and its accompanying film draw on the reflections of some of the most senior medical leaders during this unprecedented public health crisis. Analysing written submissions and interviews from the leaders of 17 royal colleges and faculties, the current and immediate-past Chair of the Academy and a leading patient representative, we look at some of the strengths and weaknesses of the profession’s response to the pandemic, highlighting how the medical profession and its leadership can shape a healthier post-pandemic future for the nation.
Collaboration
Siloed working across healthcare professional and national organisational teams can present barriers to providing efficient and effective care to patients. Excessive bureaucracy, infrastructural challenges and service pressures typically perpetuate these issues. However, faced with the unknown threat of COVID-19, we witnessed a renewed sense of collaboration across the profession.
When you’re in a pandemic situation with a relative level of chaos. it’s more important than ever that in medicine we pull together.
Medical leaders brought together their collective wisdom and leadership capabilities at rapid pace. An impressive example of this collaboration was the sharing of information relating to management approaches for COVID-19 patients in intensive care units. Discussions and information sharing with colleagues from across the country and with other nations allowed for rapid changes in clinical management approaches as more evidence emerged and experience was gathered.
We had conversations with people in Italy … we avoided their mistakes and picked up on their successes and adapted these approaches to our patients.
We had to change, we had to adapt, we had to be nimble
This collective leadership approach filtered through to those working on the front-line. Bureaucratic obstacles dissolved and extraordinary displays of flexibility led to modified clinical pathways and new ways of working. Members of specialty teams volunteered their services in unfamiliar clinical environments, new ways of information sharing between different clinical teams and units were developed, and we witnessed a renewed appreciation for the importance of generalist medical skills in our workforce. Taking time to appreciate the professional challenges faced by your colleagues mitigates the protectionism that we too often see at both the organisational and individual level.
It revealed you cannot change something in one part of the system and it not impact on another
Maintaining this collaborative instinct is essential for developing the multi-professional and integrated care that our patients increasingly require, and that the advent of the Integrated Care Systems (ICSs) highlight as the desired trajectory for our healthcare system.
A united front
Medical leaders displayed a united front to the rest of the profession on a number of contentious issues that emerged. Issues such as Infection Prevention Control (IPC) guidelines, and promoting continued mask wearing after so-called “Freedom Day” are notable examples of this. In the uncertainty of the pandemic this togetherness brought coherence and calm that engendered trust among those on the front-line. For a profession that relies instinctively upon empiric evidence in order to inform opinion and policy, it was vital to embrace the unavoidable uncertainty in the evidence-poor zone of the early stages of the pandemic.
That reassurance provided a high level of confidence at a time when certainty was lacking in so many areas
A consequence of the relative evidence-vacuum was vigorous discourse amongst members of the profession and scientific community, with many presenting opinions contradictory to official policy or consensus. While differing opinions are an inherent part of science and medicine, these debates were often represented as confusion and chaos in parts of the media and medical profession. This exacerbated already high levels of anxiety and stress among the profession. The need for rational and calm debate highlighted the importance of medical leaders in coordinating consensus and being a point of trusted and consistent communication on these issues, both to the profession and public.
From the outside it could look like we didn’t know what we were doing … but we were learning on our feet (as new evidence emerged)
The Academy, like other membership organisations, are familiar with needing to find consensus among members that may have different priorities. Managing tensions between specialties’ priorities can at times, make obtaining a single professional voice challenging. Added to this, medical leaders often have to balance their responsibilities to their clinical colleagues working on the front-line and their wider commitments to improving population health.
We are all ultimately here for the patient … but how we see it is through the lens of our specialty.
As medical leaders we play the ultimate balancing act … balancing what’s needed for politicians, colleagues, and patients
While tensions between specialities were largely cast aside during the pandemic, there were inevitably some disagreements that exemplified the potential for fragmentation across the profession. An example of this was the decision to extend the time between receiving first and second doses of the vaccine. In a future where we envisage the medical profession playing an even greater role in shaping healthcare policy, internal conflicts will require strong leadership to negotiate. Therefore, the continued challenge for organisations such as the Academy is to ensure that views represented to those in power are balanced, considered and have a collaborative consensus.
We need to keep what we had during covid … which was the wider lens of working for the population’s health.
Trust
Trust is a free asset that oils the wheels of the system for rapid pivots in approaches.
In the rapidly changing and anxiety-inducing context of a pandemic, trust between those providing front-line clinical care and their leaders is essential. The trust seen across the system has facilitated the sorts of agile and flexible responses that have been required during the pandemic. And while clear governance structures and data informed action are important, these do not always function well when changes in approach need to be implemented at speed. The centre must trust the healthcare professionals and local leaders who deliver healthcare at the front-line. Trusting and empowering colleagues to take the lead on various programmes of work throughout the pandemic has been crucial to many of the rapid and impressive innovations seen across the system. The success of the vaccination programme and the challenges experienced in early periods of the Test & Trace programme speak to the importance of effective regional delegation. In a future where ICSs will be given increasing responsibility for commissioning, organising and delivering care, a flow of trust from the centre to the regions must be maintained.
You can either trust professionals to get on with the job or you can check them with performance management, regulation … this can be demotivating and deprofessionalising
Similarly, trust by the medical profession in their leaders at the centre is essential for the effective and efficient implementation of wider top-down policy decisions. The willingness of the medical profession to go the extra mile to keep up with dynamic shifts in healthcare delivery models in accordance with guidance from the centre during the pandemic illustrates this mutual trust. This trust is earnt and maintained by leaders in the profession using a scientific and evidence-based rationale for representing the best interests of patients and the profession to those in power.
Losing trust is really easy. Some of the examples from the pandemic of senior politicians misusing trust … we see the damage that causes.
Trust from patients and the public in the medical profession has also been demonstrably important during the pandemic. Without high levels of public trust in the medical profession social distancing regulations and the vaccination programme would have been unsuccessful. Our medical leaders were highly visible across the media and generally maintained the united, transparent and consistent messaging that was crucial in bringing patients on the journey with us. Reassuring them that there was sensible leadership and strategy in place to protect them and their loved ones from the virus was the ultimate moral duty for medical leaders during the pandemic.
The reason we’ve had such a stunning response to the vaccination programme in the UK, is that the public have trusted those delivering the vaccine, the scientists and even the government.
Unfortunately, the command-and-control leadership style that necessarily dominated many parts of the pandemic response meant it became increasingly difficult for medical leaders and their representative bodies to systematically consult patients in policy and strategic decisions. Patient experience of healthcare can too easily be regarded as a luxury element of quality clinical care and can be perceived as more difficult to maintain under times of extreme stress for the healthcare system. We know that poor patient experience can lead to patients feeling disempowered and less engaged in involving themselves in their own healthcare. In a future healthcare landscape where patient empowerment is crucial for making progress in areas such as health inequalities and obesity, we must ensure that patients are always at the heart of our design and strategy irrespective of the levels of pressure on the healthcare system.
Golden opportunity for public engagement in health
There is a real opportunity where we as doctors can push some of the big public health agendas. We’ve seen a sense of a collective and an appreciation for the role we can play for our neighbours and communities in enhancing health.
The public are beginning to increasingly believe that there is science behind policy decisions… the understanding of the science behind policies allows a more potent lever for change.
Society’s awareness and literacy in public and personal health related issues has arguably never been higher. During the course of the pandemic the public have engaged in discussions and thinking around their personal risk of COVID-19, the risks versus benefits of receiving a vaccine, and the need to take collective responsibility for protecting vulnerable members of the population from the virus. This may well leave a legacy of an enhanced sophistication of the public health and medical narrative amongst many members of the public.
It may be that greater familiarity with the concept of public health and personal responsibility for health, may in time bring other benefits as people become more accepting of public messaging around health improvement and the self-care.
It’s about us as doctors opening up the conversation around the wider determinants of health. It’s not just talking about current health, but future health.
This may also be a moment for engendering greater personal empowerment of the public and patients in promoting their own health. The importance of modifications in determinants of health such as diet, exercise and other lifestyle factors have relatively little traction, not just among some patients but also at times amongst members of medical specialties that do not focus on public health. If greater numbers of healthcare professionals take responsibility for discussing and understanding the wider determinants of the health of their patients combined with an enhanced impetus from patients to modify their own approach to health, this may represent a moment of real opportunity for the health improvement agenda.
Indeed a greater appreciation of the psychosocial determinants of disease may promote a rethought model of medical care, which moves away from the idea that a biomedical solution is always available.
We’re seeing a better balance in social discussion between the power of the biomedical approach, and the limits of this approach to medicine.
We have permission to go wider than we have before. I think society will accept it and politicians will accept it better.
Speaking truth to power
Some have levelled criticism at medical leaders for not advocating more vociferously during the pandemic for government policy that had a clearer public health basis. They argue that our medical leaders have at times failed to speak truth to power and have been complicit in perceived policy failures, which have hampered the overall response to the pandemic.
Medical leaders and most representative bodies such as the Academy have no statutory power. Their influence is dependent upon being perceived by those in power as a respected and well-reasoned representation of the views of the medical and scientific communities. They rely upon being invited into the room by policy makers where they are then able to exert soft power in order help inform and shape policy. Inevitably therefore, a balance needs to be struck between constructive challenge and disruptive criticism. If perceived as being too disruptive or politically threatening, then they are more likely to be pushed out of the room and unable to exert ongoing influence on important issues. On the other hand, if seen to be taking too weak a stance or straying from an apolitical and scientific line of argument, medical leaders may lose their credibility and the trust of the wider profession and public.
It’s about staying in the room, choosing your public battles, keeping constantly on the soft power, and deciding where you go really hard and large.
The intensive media focus on the pandemic and the public’s general reverence for the profession has provided an unprecedented platform for medical leaders to have their voice heard and to exert influence over policy makers. It is important to remember that the majority of the influence of medical leaders occurs outside of the public eye. Many medical leaders regard their greatest successes to be the inadvisable policy decisions that are stopped behind the scenes prior to being fully formulated. Naturally this influence is harder to appreciate by those external to the conversations.
When you have responsibility for balancing all these considerations, you have to be clear, measured and careful in what you are saying, so that you don’t ostracise the politicians, your patients, your colleagues.
In contrast to trade unions such as the British Medical Association (BMA), it is important that medical royal colleges and faculties do not stray into party political territory. Aside from the aforementioned considerations regarding when to spend political capital, this would contravene the limits of their operation as charitable organisations. There are also decisions that have major implications for wider society beyond the realms of health, such as the imposition of lockdowns, that only government has the mandate to decide upon. However, there have been many issues of contention during the pandemic that have been in the grey-zone between medicine and politics which medical leaders could have perhaps been more courageous in negotiating. For example, perhaps medical leaders could have more clearly voiced their concerns with the organisation and effectiveness of Test & Trace or denounced the abolition of Public Health England midway through a pandemic. A majority of public health decisions are closely intertwined with strong political currents. There are almost always wider political considerations that infiltrate public health decision-making processes and to pretend that health is exempt from these extrinsic political influences is naïve. This will be particularly the case for issues such as health inequalities and obesity, where the politics dictating the scope and nature of the response will be strong.
If doctors want to make a bigger difference to our patients and community’s health, then we have to be more politically savvy.
Exacerbating these challenges in speaking truth to power for medical leaders is the difficulty in persuasively advocating for a particular decision when the evidence that exists in the area is weak. In the midst of an evolving pandemic without the familiar comfort of evidence and data to support decision-making, the potential impact of many policies was not prospectively clear to see. Taking a strong stance against power therefore becomes infinitely more difficult for our leaders, and the merits of presenting a unified front on a seemingly reasonable stance tend to dominate.
The pandemic has highlighted that if medical leaders wish to continue to operate as the bridge between the profession and power, then effectively operating in the grey-zone between medicine and politics is essential. The challenge for medical leaders is therefore to represent the science and views of the profession in a way that is appropriate for this arena. This requires political astuteness, a sense of timing, and a keen eye for which battles to pick.
We’ve got to be clear about what we bring to politics… being scientists, bringing an evidence-base, being a patient’s advocate, and understanding the services and system.
Workforce and training
We’ve trained very similarly [for years]. The pandemic gives us a chance to look at what we actually need from our healthcare workforce in the future.
The pandemic has highlighted the need for a renewed focus upon equipping our workforce with the right skills and conditions to deliver the highest quality of care to patients. With the expected surge in critical care bed requirements during the pandemic, the system redeployed vast numbers of healthcare professionals to unfamiliar clinical settings in order to provide this support. A workforce capable of cross-skilling in different settings will enable healthcare organisations to better contend with acute surges in demand for care, such as during a future pandemic or bad influenza seasons. In expanding and redefining individuals’ professional identities within multi-professional teams, it is possible to breed a happier and more professionally fulfilled workforce.
Allied to the idea of workforce flexibility is that of ensuring our workforce have greater competency in a more generalist medical skillset. This was particularly important during the pandemic where these skills were required for managing many of the patients hospitalised with COVID-19. Generalist skillsets are also heralded as a key enabler for the healthcare system to better contend with the increasingly aged and multimorbid patient population receiving medical care. It is hoped that the pandemic will provide an impetus for ensuring training programmes and ongoing professional development value and reward healthcare professionals who acquire and maintain generalist skillsets that improve the efficiency and effectiveness of the management of a wide range of patients.
The pandemic has also demonstrated the vital importance of prioritising the welfare of our workforce. In treating patients with COVID-19, the workforce were suddenly putting themselves and their families at risk of contracting the very disease they were treating. The unrelenting pressure of the work at various points during the pandemic, as well as the emotional strain of seeing many patients becoming seriously unwell has taken its toll on an already stretched workforce. We must ensure that the resources and focus placed upon workforce welfare during the pandemic are maintained as we move forwards into a future where healthcare demand will only increase.
I feel I have an opportunity to be vocal about my experiences (of depression and anxiety during the pandemic), to make it normal, and for others not to be frightened.
The people at the heart of medical leadership
What is notable among our medical leadership is that the majority continue to practice clinically alongside their leadership roles. Beyond the inherent credibility that this offers our leaders when representing the profession to power, this provides a humanity to their leadership. During the course of the pandemic medical leaders have experienced the deaths of colleagues, felt the strain on the front-line, and had a profound shared experience with the rest of the profession they lead. The strength and power of our leaders and representative bodies therefore comes from the humanity at their core and the unshakeable focus upon providing quality care to patients. Combining humanity with scientific reasoning has always been central to the medical professional identity and cannot be forgotten amidst all the politics and wider strategic considerations.
There is an undeniable power of the narrative of yesterday my patient, yesterday I saw… that is almost unique to (medical leaders).
Looking to the future
Emerging from the pandemic, there are daunting challenges on the horizon for the medical profession, government and wider society. The pandemic has provided a platform for reimagining the potential contribution of the profession to shaping a healthcare system and workforce more capable of contending with these challenges. We require strong leadership at both a national and local level that promotes collaboration and trust across a dynamic healthcare system that has patients at the heart of its thinking. Medical leaders will need to be courageous, shrewd and politically astute in their approach to interacting with power. Retaining a focus upon the interests of patients and displaying the humanity inherent to the practice and leadership of the medical profession should be a guiding principle in unlocking a healthier and happier future for the country.
Acknowledgements
With thanks to the following individuals for their contributions via either written submissions or interviews:
Dr Adrian Boyle, Vice-President of the Royal College of Emergency Medicine
Dr Bernard Chang, President of the Royal College of Ophthalmologists
Dr Anne De Bono, Immediate Past President of the Faculty of Occupational Medicine
Dr Jeanette Dickson, President of the Royal College of Radiologists
Professor Andrew Goddard, President of the Royal College of Physicians
Professor Mike Griffin, President of the Royal College of Surgeons of Edinburgh
Mr Alastair Henderson, Chief Executive of the Academy of Medical Royal Colleges
Dr Adrian James, President of the Royal College of Psychiatrists
Ms Ros Levenson, Chair of the Academy Patient and Lay Committee
Professor Carrie MacEwen, Immediate Past Chair of the Academy of Medical Royal Colleges
Professor Ravi Mahajan, Immediate Past President of the Royal College of Anaesthetists
Professor Martin Marshall, Chair of Council, Royal College of General Practitioners
Mr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists
Professor Ronan O’Connell, President of the Royal College of Surgeons in Ireland
Dr Michael Osborn, President of the Royal College of Pathologists
Dr Alison Pittard, Dean of the Faculty of Intensive Care Medicine
Professor Maggie Rae, President of the Faculty of Public Health
Professor Helen Stokes-Lampard, Chair of the Academy of Medical Royal Colleges
Professor Jackie Taylor, President of the Royal College of Physicians and Surgeons of Glasgow
Professor Angela Thomas, Immediate Past Acting President of the Royal College of Physicians of Edinburgh
Professor Russell Viner, Immediate Past President of the Royal College of Paediatrics and Child Health
