The changing tide

There seems to have been a shift in mood, attitudes and behaviours over the past couple of weeks, as covid-19 leaves its heavy footprints following its sweeping devastation. It's not over yet. But in the UK, despite lockdown still being in place on paper on many counts, increasingly we are seeing scenes of packed beaches and tourist spots, packed trains, unmasked faces in the crowds. Whilst this has brought joy and freedom to those defiant enough to voluntarily break free from the confines, conversely it has brought fear to many more who continue to adhere to the public advice by staying at home and safely distancing. The plain disregard of others' health concerns are being taken for granted by those willing to take their own risks, and this discrepancy in the interpretatation of the advice is only getting wider. Agreed, the government information hasn't always been clear, particularly lately, and it hasn't reached out to all the people of all social classes (not everyone will have ever afforded a cleaner for example, so making this dilemma a topic for discussion is not appropriate for many). But there is the matter of common sense, and ownership of responsibility, and the flouting of these things is what is doubtless feeding the flouting of the advice and risking future spikes in covid infections.

After a nation brought together by a health crisis, which has by today, at the time of writing, taken more than 37,000 lives, the highest in Europe, we have seen rainbows, applause, solidarity, community spirit, fund-raising, discipline, support for mental and physical health, volunteering, and an NHS which has defiantly torn down the red tape and rapidly adapted, with all the skill, knowledge, technology, and selfless devotion of those working within in it, to try to defy the invisible assailant that is covid-19.

Yet as the peak now appears well behind us, with fluctuating but lower numbers of deaths and cases showing a very clear downward trend, there seems to have been a change in the atmosphere-I sense there is growing discord, blame, judgement, anger, rebellion in the air. People are understandably desperate to get back to earning, and impatience, boredom, cabin fever, and frustration are rising-the novelty of the extended enforced "holiday" is wearing thin for many now.

And there seem to still be pockets of concern in areas of the country which have been behind the curve until now-Weston Hospital in Somerset has just closed 48 hours ago due to the pressure of numbers of covid patients-a surprise indeed. Or is it, with the weather being so glorious and this seaside town being one to attract tourists? So here I find myself judging people's behaviours, but it's hard not to make an opinion from the other side (especially the healthcare side) when it's put right in front of us. The fear of further spikes in the next two or few weeks is a worry for many. Then there's the matter of Mr Cummings, whose early misjudged travel across the country in March, with covid symptoms has made headline news: his will was to safeguard his child, is understandable, but he was carrying around risk to others too, and this visibly conflicted with his own postion on the matter. To be exposed, and in his elevated and prominent status through the pandemic, has given the media and its viewers none other than an opportunity to judge, and to blame, and with clear health risks at the fore during a health crisis, this opinion can be justified. This mood appears to be sweeping across our screens and in our homes and in our hospitals.

And as the call to end the weekly Thursday evening Clap for Carers and the NHS has gained momentum, tomorrow evening will see the 10th and final week of this ritual, which intially brought emotion, support, optimism, charity, and empathy for so many. Engineered and energised organically over the weeks, it has marked a renewed respect and gratitude for the work done behind closed doors, which I hope will not be taken for granted once Thursday evenings are silenced, as the recognition of the intensity and risk associated with fighting the covid pandemic must not be forgotten, but neither must it go unnoticed that this skilled work was going on well before the pandemic, thus making the fight against it even possible, and it will continue to do so as it always has done.

Indeed the aftermath of the plight of those vocational healthcare workers, having been catapulted through the emotional highs and lows of a time in the profession that will never be forgotten and hopefully never repeated, is yet to be known, but recognition of their fragility must continue to be recognised, identified, and addressed, or a far greater crisis will infest and infiltrate our NHS and everyone is responsible for not letting that happen.

I personally have documented some of my own perspective of the past several weeks in this blog. I have found opportunities to reflect, and to learn, both at work and outside of work. I've already blogged about my internal conflict surrounding the lack of access to cancer services for patients during the pandemic, probably because I'm a former cancer patient myself, and couldn't imagine being told I was limited in my choices for treatment simply based on the timing of my univited disease. Like anyone, I have found it challenging telling a young patient with melanoma that we couldn't offer him the usual pathway for lymph node biopsy to further define his prognosis because the timing of his disease diagnosis, at the start of the pandemic, saw a stop in tertiary referrals to carry out this procedure due to the restrictions the pandemic forced upon the cancer services. In the end he paid a small fortune to have it done privately when this was the only option with a surgeon who was still just about able to offer this before further restrictions may have afflicted his private service for this also. But what price is there on one's health? I know I would have done the same.

I have found it difficult breaking bad news of malignant melanoma to a patient on the telephone, not able to hold a hand, to engage in the normal way I would if face to face, yet the steel and strength I still felt from her was admirable. And only 2 days ago, a longer standing patient of mine who developed metastatic disease in recent months whilst under my care, was admitted to our hospital with a fall, was found to be covid positive, and has now succumbed-I can from a distance only summise that it was covid that took her, but in this case may have saved her from the ravages of her metastases which had riddled her body in a short time. I have contemplated since which of the two I would rather have been released from my fate with.

On the positives, I have learnt and given training to my team on the new digital platform which I was pivotal to introducing pre-pandemic, and which has come unto its own as the whole team have embraced remote working in dermatology using photographs and thus reducing the unnecessary footfall in the clinic and bringing urgent patients to the procedures and treatments that they actually need. And we have had the opportunity to write about our experiences for the British Association of Dermatologists summer newsletter-learning from one another in healthcare has been and will be invaluable, as we all strive to recreate an NHS that has been reduced to ground zero and the lessons we have so quickly gained must take us forward as we build better and more efficient and accessible services. Dare I say that the public have a part to play in this too, and respecting healthcare services for what they are most needed for in all the sectors of primary, secondary, and tertiary care, will also be key.

Resuming my own surgical practice for skin cancers in our department last week has brought me the same pleasure I have always had after this 6 week hiatus of working behind closed doors, albeit with the new look of full PPE, and the introduction of "Hello, my name is Dr Sam, and I'm here from outer space", just to break the ice with the patients when they walk through my procedure room door! But as a patient said to me only yesterday, "don't worry, I understand these are the times we are now in".

Outside of work I have taken the opportunity to bring Permitted To Pause to life, to begin to propagate its message to our profession not only during, but I hope well beyond the pandemic. I have felt compelled to engage in fund raising in small ways-the Run for Heroes, and with the sale of the Permitted To Pause NHS postcards to raise money for the charity Doctors in Distress, which I have no doubt will be increasingly needed from this day onwards, to save the mental health of those who have been battling quietly over these past weeks, many I'm sure alone in their heads.

I have had kindness and support shown to me, from my husband, family, friends, colleagues, and have done my best to do the same for them, as everyone's experience over the past weeks has been different, and individual to them. My heart has swelled from the distanced interactions with all my immediate family, the highlight always being any engagement with my younger brother who has the biggest part of my heart, and someone who understands my head as much as I understand his, and perhaps more than we both realise.

So as the tide changes, as the covid pandemic further unfolds, and diminishes, as the "new normal" evolves, and as small pockets of our lives, our work, our friendships, our relationships, our health, and our future-proofing slowly come back to life, we must remain kind, supportive, caring, defiant, resilient, and also learn, of course, to pause, to reflect, to restore, to learn. And perhaps we should all take care to put aside blame, judgment, and anger, as after all, this life event was a global natural disaster, totally unplanned, unrecognised, univited, and hugely disabling, but we have fought and we are conquering, and in the wake of such tragic loss, we must remain insightful, alert, and ever thankful.