Transcript: Episode 17
What's happening to healthcare during the pandemic?
Vivienne Parry 0:02
Hello and welcome to Coronavirus, The Whole Story and award winning podcast series all about Coronavirus as seen through the multifaceted lens of researchers and staff here at UCL. I'm Vivienne Parry, a writer, broadcaster, UCL alumna and throughout the pandemic, your guide to everything Coronavirus. And I do mean everything. We've bought you the latest research and stories on being in lockdown getting out of lockdown how the pandemic started out my end, how people have been coping who's been struggling, and the economic engineering, medical, social, behavioural and even artistic perspectives on lockdown. Now, when we began this series, I think we all imagined that we will run out of stories to tell by well we gate tops yet here we are in week 17. The pandemic is here to stay. UCL researchers have so much more to tell us and we have loads of great ideas for episodes to come, so to make sure that we're firing on all cylinders, we're going to make a short pitstop for a bit of r&r, if that's okay by you, and we'll be back at the end of August.
Meanwhile, for today's episode, we thought we would look not a Coronavirus itself but the impact that it's had on other illnesses which of course haven't gone away. With me today are a cardiologist, a neurologist and an oncologist to understand how lockdown and social distancing measures have affected normal health care. So let's get started. My first guest this week is Amitava Banerjee alternative Ami, who's an associate professor in clinical data science at UCL, and an honorary consultant cardiologist at UCL hospitals. Ami is a specialist in heart failure and combined his work as a practitioner and as a researcher in epidemiology, biostatistics and public health to improve health care for patients and leads on cutting edge research projects on the nature of cardiovascular diseases, and the efficacy of medication assessment. My second guest on this episode is Professor Giorgios Lyratzopoulos who is a professor of cancer epidemiology and leads on UCL epidemiology of cancer health care and outcomes group. His research focuses on how cancer is tested and diagnosed and variations in treatment management and patient experience. My final guest this week is Professor Nick Ward, a professor of clinical neurology and neuro rehabilitation at the UCL Queen Square Institute of Neurology. He also works with Same You, a charity that supports and aids the recovery of people with brain injuries. In partnership UCL, Same You have been making brain injury rehabilitation accessible online during lockdown. Ami, let's start with the big picture. We've all been focused on deaths from COVID-19. But there's been a wider impact, isn't there?
Amitava Banerjee 3:01
Yes, certainly. I think excess mortality and less deaths have been in the news and in our minds because the Office of National Statistics has been diligently producing weekly statistics throughout the pandemic. But firstly, even under the heading of mortality, it's not just COVID related mortality, but there's been a peak, which matched the peak in the COVID deaths and non COVID deaths. So whether it was cardiovascular disease or cancer in March, April, there was a there was a peak reported by Office of National Statistics. And also, there's what we call increased morbidity. So that's the quality of life other than the effect on mortality, whether that's having to be admitted to hospital, whether that's being able to follow your usual activities in your daily life. Those those have all been affected during this time.
Vivienne Parry 4:06
So how have these non Covid related deaths risen during lockdown? What do you think are the main reasons? I mean, obviously, it changes in lifestyle, but what about people who were already unwell.
Amitava Banerjee 4:21
So you're right to use the term during lockdown, but also, there were some increase in non Covid deaths observed early on even pre lockdown. Now that could be related to coding or mis coding in the early stages where, for example, in care homes, that there was some Covid deaths, perhaps that were attributed to other causes. And it also could be as a result of that various large scale insults to society, such as a pandemic, you do see increases in for example, any attendances, rates of heart attacks. And that has also been written about. But during lockdown itself, there are several reasons that we've seen an increase. Firstly, there's been a profound pressure on health systems and health care services, such that the focus on COVID has meant that we've not been able to provide all of the care for other diseases that we would want, we were able to meet that required capacity because, for example, operating lists were cancelled, clinics have been cancelled and so on. But that also there's been a change in behaviour of both patients and of clinicians, such that patients might have been less likely to attend hospital with their symptoms of chest pain or their history of cancer or to seek treatment. And so this has led to a situation where we have seen reduced diagnosis and reduced treatment in non-Covid diseases.
Vivienne Parry 6:12
A lot of people must have been very frightened, particularly with the condition that you look after so much with heart failure because people are elderly in the main with heart failure. And they fear that if they get COVID-19, that will be the end of them.
Amitava Banerjee 6:29
You raise a great point Vivienne that there's a direct effect in people with underlying conditions such as cardiovascular disease where they have an increased risk of having severe infection or dying from Coronavirus in the first place. So there's a direct effect on people with cardiovascular disease. But there's also this indirect effect, which we're talking about here, which is that the services for cardiovascular disease may be affected by the pandemic. So The patients I've been looking after, for the most part, we're not on the official list of patients to be shielded that the government announced on March 22. But based on discretion of themselves and their doctors, many of our patients with heart failure and cardiovascular diseases have been staying at home and sheilding because of their age and other comorbidities, which made them feel that their risk was too high. And that's not just you're in lockdown. There's difficulties of whether deciding whether they want to return to work or should return to work, how soon they should think about doing other activities and so on. So it's a very confusing time all around.
Vivienne Parry 7:46
Are we back to normal levels of attendance yet?
Amitava Banerjee 7:50
In my own specialty, I don't think we have evidence that we are back to fully normal attendance. That's for two reasons. Firstly, there's some trepidation to release all the existing capacity in case of second waves as we are still easing lockdown and in the process of various measures, but also because opening up for example, surgical lists and procedure lists is a different proposition in the COVID era where you have to be doing much more stringent cleaning and other measures in between cases. So, the number of cases that you can do has also been reduced. So I think it will be some time in reality before we can return to normal in inverted commas.
Vivienne Parry 8:40
So it's really in your field it's had a very considerable impact. Let me turn to Yoryos now. How has Coronavirus and lockdown impacted cancer patients?
Georgios Lyratzopoulos 8:51
It's one of the questions one of the disease areas that is by previous colleague, Dr. Banerjee mentioned it has been indirectly affected by the pandemic. And the these indirect effects are across the board and across the spectrum of services and actions that need to happen when patients first first of all develop symptoms of that may be due to cancer or even when in the pre Covid era, they will get in an invitation to attend for screening for for example, for colorectal cancer to complete the screening test, or attend for colonoscopy. All the way down to treatment of diagnosed patients and treatment for cancer is quite complex. It takes several different events. For example, some of them may have surgery, that will of course give a lot of diagnostic investigations before surgery. They then may go on to have other radiotheraye or chemotherapy and these will be requiring repeat attendances to hospital and, and so on. So all these very complex healthcare delivery system has been disrupted because of capacity constraints because of infection control considerations at the peak of the epidemic. And of course, as Dr. Banerjee was mentioning earlier, also because of patient behaviour haven't been affected by the epidemic. So, it isn't cancer is an example of the many diseases that the healthcare delivery system has been disrupted very seriously.
Vivienne Parry 10:41
So, you're seeing likely impact from people not going to screening you're seeing likely impact from people having their treatments interrupted. And presumably you're also going to see deaths which will occur earlier than they should going on for several years ahead because people's cancers will not have been diagnosed perhaps until a later stage. And we know that treatment is less effective and more difficult. The later the cancer is diagnosed.
Georgios Lyratzopoulos 11:11
Yes, unfortunately, this seems to be a mathematical truth. Although, of course, because of the short intervening period between the epidemic and where we're now, we don't have a fully robust observed data. Although modelling studies seem to suggest exactly what you mentioned, the other complexity here, it applies to cancer, perhaps it applies to other disease areas as well. The accumulation of these negative impacts and excess mortality that is if you want disease specific is going to accrue differentially for different cohorts of patients. For example, they diagnose patients who might have had deferred or altered treatment regiments from what would have been perhaps optimal may be at more immediate risk, but the patients who, whose diagnosis has been delayed because the screening programme is has stopped working temporarily. That kind of harm, if you want will only be seen after several years in the future. So it is not an easy task to quantify exactly how big this impact will be. And of course, one doesn't wish was wasted for it to be for any harm to be minimised by more rigorous more successful control of the pandemic, and more more well resourced ability of the healthcare system to continue to operate as much as normal in spite of the pandemic.
Vivienne Parry 12:46
What's the backlog like for diagnostics, because that's often the rate limiting step in cancer, isn't it? It's the it's the diagnostics the MRI scans. You know, the various procedures that are used to diagnose the endoscopy is friends.
Georgios Lyratzopoulos 13:00
I honestly cannot give you an exact hard answer on on that. And frankly, I don't even know if it's very well known because we will have even gone parcial picture known to different hospitals and different services right now, but I'm not aware of that evidence, which will be very variable for different diagnostic investigations. I think it will be substantial. And it's likely to be a moving face because of course, colleagues will be doing their best to get over the hump, but I don't know how bad it is right now.
Vivienne Parry 13:36
Do you think that there are still patients who are worried about coming in and not confident enough to book an appointment? And and what do you think can be done to persuade them that it's okay to come in there?
Georgios Lyratzopoulos 13:51
Yeah, I will touch on the latter. I think the again, I think this is not unique to cancer, I would imagine applies to all other diseases. areas, the first step in mitigating the harm that has been inflicted upon patients with other diseases is to keep it under control. If COVID-19 is managed well if as society because that's a societal, therefore they will maintain the activity levels low, then we have a chance of mitigating the indirect harm that has been done to patients with other diseases from healthcare related disruption. So that i think that's that's the key. And to answer your first question, I suppose them absolutely the more safe we we can have a service in terms of infection control, risk management, that nothing is being managed very well right now, the more people can be confident to seek help if you want to, quote unquote, as normal. I think I think there is an issue of those talents rather to the masses, to get to To all patients and relatives that and it says is normal for primary care is open for consultations. Although there is of course a risk that some This message is not getting through to absolutely everyone.
Vivienne Parry 15:14
Thank you very much for that.
You aren't listening to Coronavirus the whole story our podcast brought to you by UCL Minds. If there's a question about Coronavirus, you'd like our researchers to answer, email us at email@example.com or tweet at UCL. We'd also really appreciate it if you could complete a little survey which can be found on the UCL Minds website if you haven't had a chance to do so yet. Let me now turn to my third guest today, because a regular theme on this podcast is of people and organisations adapting to lockdown and working out how to make things work remotely Nik, I know that this is something that you and your team have achieved in brain injury, rehab. Fasting, tell me a bit about the work that you did before lockdown.
Nick Ward 16:10
So I'm interested in brain injury, which is essentially made up of people who add trauma to the head. So what we call traumatic brain injury, usually due to things like road traffic accidents, falls, or assaults, or due to stroke in which you have a disruption to the blood flow to part of the brain leading to death of a number of of brain cells. Were interested in the rehabilitation of people with brain injury. Because this is the main form of treatment. Most of the focus is generally medicine is at the emergency and so that we're good at the first few hours and days after brain injury. So this is this is really about saving lives. But after this patients may stay in hospital for their rehabilitation or there may be discharged home for rehab to continue in the community. But rehab services are generally fairly under resourced, especially in the community. So we're not really providing appropriate levels of support and treatment for patients, we're essentially under dosing them. So some of the things that we're doing at Queen's square are really to address how we can increase the dose and intensity of some of the rehabilitation interventions that these people require.
Vivienne Parry 17:18
And has pandemic affected this work.
Nick Ward 17:21
I mean, it's in the ways that we've already talked about him instead of really wide ranging effects. But in the early phases of the pandemic response, the focus was obviously on saving lives. But the main impact on stroke and brain injury patients was that there rehabilitation programmes were going to be cut short, because of the perceived need to free up acute beds. And because it was felt the community rehab teams were not really able to go in and support them. So we felt that we were going to be left with a cohort of people who are now home much earlier than normal, but we're not going to receive any rehabilitation treatment or support and essentially increased levels of social isolation and Generally feeling abandoned. So we've kind of realised that we needed to come up with a new way of reaching out to these patients in a way that we hadn't hadn't done before. And at the same time, as you mentioned before, UCL has been partnering with the same new charity which was set up by the actress Emilia Clarke and her mother to look at ways of improving treatment and support for people with brain injury. So saying you wanted to do something useful in the pandemic, but something that was related to their particular vision in promoting recovery from brain injury. So they did some fundraising for the UCL coronavirus response fund. And we use the money to set up the neuro rehabilitation online programme or enrol, as we call it in enrol for us was a completely new service. So it was established very quickly, in order to provide group based online virtual rehabilitation and support for patients who had recently been discharged and probably discharged earlier than they would otherwise have done and what this programme did was allowed one or two clinicians or therapists to work with groups of between, say two and 15 patients at a time with the pet with a therapist remote and the patient's in their own home. And the range of groups that we were able to offer were things like functional fitness, working on patients gait and balance arm and hand function, but also communication and cognitive difficulties. emotional problems was things like fatigue management, and also being able to reach out to the carers of those patients as well. And the aim overall was really to complement not really replace the community rehab teams, but as I said before, the community rehab teams were stretched prior to COVID-19. So at the beginning, this was really one of the only things that was able to get into these people's homes to help them
Vivienne Parry 19:44
and have it gone down.
Nick Ward 19:45
So pretty well, actually. I mean, I think there was some anxieties about whether people would cope with doing things online. Out of all the we've probably will have treated about 90 patients so far we've only had three who couldn't participate for technical reasons. So I think patients have generally loved it, to be honest, I mean, we're going to have some formal evaluation of the programme soon quantitative and qualitative. But the informal feedback, the kinds of things, the quotes that patients send us that we put out on our Twitter account is, is very heartwarming. The other thing that I think people are anxious about the idea of doing this kind of thing in groups, maybe not a very English thing, but actually people really warmed to it. And we think you know, that forming the the peer support that came out of those groups is really important. And clearly some of those patients are going to stay in contact with each other after the programme is stopped. So hearing their stories is quite powerful. And actually, there's there's one, there's a I mean, we have quite a few really nice quotes, but there's one particular quote, one of our patients sent in, in relation to the worry about participating in groups and she said it reminds me of when I was at school, coming out with exam thinking I was the only one who found the exam hard but once we'd all shared our feelings, I realised that we all thought the same and it was kind of reassuring. So it's that kind of engendering that kind of not just that you're in the hands of high quality technicians, but also that peer support is actually is very powerful.
Vivienne Parry 21:11
And I must ask you this, but I want because I was wondering, are you one of the few specialties that actually has seen a decrease in numbers because they were actually decreasing incidence of brain injuries because there weren't, you know, cyclists out there weren't cars on the road.
Nick Ward 21:33
Yeah, so that. So in terms of stroke, it's definitely true that the number of people who were presenting to the acute services dropped quite dramatically, probably down to about 50%. And with traumatic brain injury, we don't have very good numbers, but you're probably right, people were not out and about so they were less likely to have those kinds of injuries. So that kind of the worries that we had in the beginning that we'd have people coming through the stroke. Brain Injury pathways as normal, but we would have to essentially move them through the normal pathway much, much quicker, didn't didn't quite come to pass, actually. But of course, that stores up a problem down the line in that, you know, we don't know what's going to happen to those patients. We don't know when they're going to present. Because it's it's certainly we don't believe that the numbers of people who are suffering from stroke dramatically reduced as we just think that they just didn't present at the moment.
Vivienne Parry 22:26
It's another one of the COVID mysteries, isn't it? There are many of them. But I wanted to ask you all because Nick has really illustrated something that the way that services have pivoted and online, which perhaps might have been coming anyway has suddenly had to arrive very quickly indeed. But it it's an opportunity. You know, it's been terrible, but it is also an opportunity. urea. So I wondered whether that was true for oncology. Have you been able to, for instance, move over to a much more home based caste system?
Georgios Lyratzopoulos 23:07
Yes, these kinds of innovations are indeed part of the change in the healthcare delivery system that is taking place for all disease areas. And yes, it also affects the cancer pathways starting from primary care as you as we have heard and read from our primary care colleagues, who have a critical role in the early stages in the early part of the spectrum of the cancer pathway, they have transformed the model of consultation into digital by default, of course, as an initial three hours and people can be seen in person is should there be a need similar innovations have been reported in the follow up of cancer patients. You know, these are patients who are diagnosed and treated and the require aftercare for checks. And some of those now will have been done online. Of course, there is a limit to how much you can go with substitution of healthcare encounter related events with digital appointments. Clearly, some, you know, there are some core diagnostic investigations and some treatments have to be delivered in physical spaces. But yes, definitely there is innovation and for the good and once COVID has been, you know, has gone, some of these innovations will still be with us, and they will be to the benefit of patient care patient experience, and perhaps even to the efficiency by which we run our healthcare system.
Vivienne Parry 24:46
And is that is that what you've seen me as as well, I mean, it's anything particular that you think has, has already changed.
Amitava Banerjee 24:53
There's no question that COVID has forced a change in The way digital innovations happen, for example, in a period of a week or two at the beginning of the pandemic, we were able to access electronic health records and online clinics in a way that we hadn't been able to, in some cases for years. And that has changed the way we can do things. But as your your says that, I don't think we can say that it's a panacea for our replacement for face to face care and whether it's diagnosis or treatment, some of those things do undoubtedly require seeing people face to face. And my concern is that we know that there are long standing inequalities in health care, even in a publicly funded system like the NHS based on you know, sort of karmic status based on ethnicity. For example, and if we're not careful and paying attention, then digital health and innovation could broaden those inequalities rather than, you know, being an equaliser. So because it's reliant on digital literacy on health literacy as well.
Vivienne Parry 26:23
But it's also down I think one of those things that's been needed for a long time which is appointments in outpatients where, you know, some someone needed but actually, some of those appointments probably weren't needed, and has put an additional burden on patients.
Amitava Banerjee 26:58
I would say the opposite in some ways. He said that some of my long term patients have a particularly those who have been shielding have greatly valued even a phone call sometimes, because that's the social contact that they've been missing. And having a continuity of care like that is actually one of the great benefits of the NHS, whether in primary care or secondary care
Vivienne Parry 27:25
areas, outpatient appointments are all totally with point. Let me stay with you me and just ask you, whether there are any structures or protocols that you'd like to see put in place to make health care, lockdown proof.
Amitava Banerjee 27:48
I do think that the, the harsh reality is that the non COVID effects of this pandemic were produced Vegetable if not at least reducible by acting earlier and in a coordinated fashion with clear messaging. And by that I mean earlier locked down by that I mean, coordinated testing and tracing and so on. So, that actually is is as much a priority as pushing for reopening all of the services. But we you know, we are where we are and now, I would say, you know, when you say lockdown proof, I think the most important thing is to educate both the public and patients and as well as, as health professionals that chronic diseases and the non covid diseases which are also acute Don't go away during a pandemic and so people who need to seek health care must be able to do so during that time, but but I don't have a magic bullet or approach called to predict these things. But mainly one thing I'd say is that emergency preparedness or pandemic preparedness hasn't traditionally included non infectious diseases or chronic disease treatment or things like neuro rehabilitation. I think we've all learned that we should have a much broader view of of preparedness,
Vivienne Parry 29:22
you're asked what's the view from the oncology side? Because actually, during COVID, what we saw was some hospitals opening which were dedicated to cancer, which were kind of dead COVID free, well, hopefully COVID free zones. Do you think we'll see more of that?
Georgios Lyratzopoulos 29:44
Absolutely. It's definitely in the in the phase where now and who knows it may last for another several months at least. So the maybe if you want to infection control, which has always been the part of the background activity, in hospitals and GP practices may be has been transformed. It will, it will it will be a different and different activity in the coming months with hopefully a more regular screen of staff now that it seems that the diagnostic technologies that can test for COVID become more easily accessible and they allow for much more regular testing that can be a great breakthrough, I think in terms of protecting services protecting stuff and protecting patients therefore, and of course, in terms of the going back to some discussions we had with Amit and Nick. Definitely the consideration. I mean, he was always, always a task and in NA not to have a super flus healthcare encounters, but even more so in the in the current phase and in the future.
Vivienne Parry 30:59
Like how about From your point of view, is online rehab something that you're going to stick with? And how are you going to sort of future proof your services?
Nick Ward 31:14
Yes. I mean, it's, it's a really good question and come into the question of doing online medicine. I think for screening, you know, online consultations are quite good, partly for the reasons that you, you mentioned, especially in a hospital in central London, where we might be bringing patients from all around the country, and sometimes you feel that it wasn't necessary to bring them from that far away. So I think for screening, it will be useful. But for treatment in something like neuro rehabilitation, where there are multiple different types of treatment, they're all quite complex, and they interact. I think we'll have to see I mean, it's definitely true that when we started up and roll, we saw it as a pragmatic means to an end to deal with a unique situation. And none of us thought that it was a gold standard treatment, but I'd have to say that we've There are things that we have learned and that I've been surprised by, by this mode of provision of rehab services. It's not, it's not going to take over because, you know, there are aspects to it that don't quite work. There's definitely elements, key elements that require face to face consultations and treatment. But some of the things that we talked about already demonstrate that this form has its own intrinsic value. So we talked about the peer to peer support. We talked about the ability to deliver cognitive and emotional support in a way that's not really done in community rehab, juicing social isolation. So I mean, what we're gonna have to do within role is really pick the bones out of it and understand what are the active ingredients and then how we embed those in things like community rehabilitation services and move forward. So we just we just have to learn the lessons about what the good bits are, but not thing that we do. I mean, this is not going to be a cost cutting exercise. It's not necessarily cheaper to deliver online therapy. You may be able to You may be able to reach more people, but it's not necessarily the case. And there are lots of things that we're going to need to learn about that.
Vivienne Parry 33:05
listening to all of you. Actually, we've already come a long way, it seems to me because right at the very beginning when it was all utter chaos, and actually order is being created, and there are some extraordinary opportunities that have come up to change medicine, for the better and probably at a time when it was already poised to do that. It's been a pleasure having all three of you here and thank you for taking time out of your very busy clinical lives. You've been listening to Coronavirus the whole story. The episode was presented by myself Vivienne Parry produced by UCL with support from UCL Health of the Public and UCL Grand Challenges and edited by the very splendid Cerys Bradley. Our guests today were Dr. Amitava Banerjee, and professors Georgios Lyratzopoulos and Nick Ward. And if you'd like to hear more of these podcasts from UCL Minds subscribe wherever you download your podcasts or visit to ucl.ac.uk forward slash Coronavirus. And whilst you're there, just a reminder, fill out our survey. The podcast is brought to you by UCL Minds bringing together UCL knowledge, insights and expertise through event, digital content and activities open to everyone. Well, Chris and I are going to be packing our buckets and spades and taking a short break. It's been absolutely wonderful presenting this podcast every week for 17 weeks. Not sure we thought that it would be that long, but it's been splendid. We're going to be back again at the end of August with more updates and interviews from UCL researchers and I'll be looking forward to being with you once more. Bye for now.
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