More than five years since the onset of Covid-19, how do doctors reflect on the experience and lessons learned? David Lynch reports
On the final day of 2019, the World Health Organisation’s (WHO) office in China noticed a media statement from the Wuhan municipal health commission mentioning cases of ‘viral pneumonia’.
“In the weeks, months, and years that unfolded after that, Covid-19 came to shape our lives and our world,” the WHO said in a recent statement marking the fifth anniversary. Many lives were “changed and lost”, but the WHO also expressed “gratitude to the health workers who sacrificed so much to care for us”.
Ireland reported its first case at the end of February 2020. Across the country, doctors and other healthcare professionals were rapidly engulfed by an unprecedented public health crisis.
In March 2020, the then IMO President Dr Padraig McGarry captured the sombre mood of many in the profession. He warned that “our health services will be seriously challenged over the coming weeks” and Irish society faced an “unprecedented challenge”.
Today Covid-19 is no longer permanently in the headlines. But its legacy for the health service continues.
In November, the Government announced the formation of an independent evaluation panel to report on the country’s pandemic response (see panel below).
The panel, chaired by Prof Anne Scott, began its work this month. It is expected to submit a final report in approximately 12-18 months. Described as a “comprehensive evaluation”, it will cover hospitals, community healthcare, and nursing homes, as well as the wider economic and social response.
“From a medical perspective, the important focus for us would be on problem-solving,” Prof Matthew Sadlier, Chair of the IMO consultant committee and Consultant Psychiatrist, told the Medical Independent (MI).
Prof Sadlier said the evaluation should identify areas of learning “for when these things [pandemics] happen again”. Furthermore, it needs to be “empathetic to people’s situation at the time”.
“You can only act based on the knowledge you have at the time… not on retrospective knowledge,” he remarked.
The perceived threat level and the resource constraints at points during the pandemic were factors in decisions and actions taken. For example, Prof Sadlier recalled in the early weeks the country could undertake a relatively small number of Covid tests every day. Thus, the evaluation should be empathetic to the situation that was at hand. “That is essential,” he said.
Public health
The working lives of public health doctors were particularly impacted by the pandemic (see panel p5). The Irish Society of Specialists in Public Health Medicine (ISSPHM) informed MI that it welcomed a focus on “learning from Covid”, including “additional learning” that may have been identified in the post-pandemic period.
The ISSPHM spokesperson said the evaluation should help identify continuing gaps in the public health service.
The impact of lockdowns and other measures on psychiatric services was often discussed during and after the pandemic. Prof Brendan Kelly, Professor of Psychiatry at Trinity College Dublin and Consultant Psychiatrist at Tallaght University Hospital, Dublin, told MI it would be “very helpful” if the evaluation panel looks at the experiences of people with pre-existing mental illness.
It is important to consider how multiple forms of social exclusion came together to worsen their experience of the pandemic. “It would also be useful [to consider]… research that examines not only factors that led to anxiety and distress, but also the foundations of the resilience that many people demonstrated.”
Echoing Prof Sadlier’s observations, Prof Kelly said “most importantly” the panel should distinguish between “two kinds of questions”.
While remote working had some benefits,
it was no substitute for face-to-face support for many people
“First, based on what we know now [in 2025], what would we do differently in a similar situation? Second, based on what we knew then [in 2020-22], was the available knowledge used as best as possible? These are quite different questions with different lessons.”
An IHCA spokesperson told MI there should be a “full review” of acute hospital capacity immediately prior to and during the pandemic. This would allow an understanding of how the hospital system responded to such a threat and the impact on other services.
The IHCA would also like to see modelling undertaken to determine the level of acute and ICU capacity necessary to adequately deal with a similar
future pandemic.
“There will be 352 ICU beds in the system by the end of 2025. And, while the Programme for Government has pledged to increase ICU capacity by at least a further 100 beds, that would only bring the total number of critical care beds to around 450. ICU bed numbers needed to increase to a minimum of 579 more than a decade ago, according to the 2009 Review of Adult Critical Care Services.”
The spokesperson also noted that more single occupancy rooms are required in acute hospitals to reduce the risk of Covid-19 and other infections spreading between patients.
Mixed perspectives
From a five-year distance, there are mixed perspectives on the legacy of Covid-19 on the health service.
To a “certain extent” the system is “back to where it was before”, said Prof Sadlier.
While there has been a move towards greater use of “online medicine”, this was not as pronounced in his own specialty. “In psychiatry it was just not suitable… where it did work [it] was in a very limited fashion.”
On the pandemic experience of “telepsychiatry” Prof Kelly said many people with enduring mental illness have literacy problems or are homeless. Therefore, they have impaired access to technologies.
“While remote working had some benefits, it was no substitute for face-to-face support for many people.”
It is now understood that people with pre-existing mental illnesses, such as schizophrenia, are substantially more vulnerable during a public health emergency than was previously imagined.
“They have reduced access to physical healthcare most of the time, and the pandemic widened that healthcare gap dramatically.”
Other legacies
Other legacies of the pandemic on doctors’ working lives are particularly visible.
“This might sound trivial,” said Prof Sadlier, “but one legacy for doctors has been clothes. The whole hospital now wears scrubs, nobody works in tie [and suit]. So bizarrely it [the pandemic] made a sartorial change, it may be a little bit trivial, but I think it is very interesting.”
He also noted that the health service and the public are now “more sensitive to infectious diseases… to flu prevention”.
“I think we are probably better at hygiene. It will be very interesting to look at things like other infectious disease such as MRSA and to see has there been any change in those numbers.”
He added that more meetings now take place online. “I’m on a couple of HSE committees that used to meet in person [pre-pandemic], people got the trains up from around the country, that has all moved to an online format.”
Leadership
The “resilience of healthcare workers, including hospital consultants” was strongly evident during the pandemic, according to the IHCA. The crisis also demonstrated the ability of localised hospital leadership to operate independently while delivering the “most optimal outcomes possible” in a scenario of extreme adversity.
A recent Association survey of its membership found that 72 per cent of consultants believed this collaborative format of leadership to be optimal. The experience of Covid-19 showed that when authority is devolved to individual hospitals, they could re-organise, restructure, and reconfigure services themselves to great effect and with great efficiency.
Wider public
Regarding the wider public, the pandemic “exacerbated existing mental health issues”, according to Prof Kelly. This was due to widespread anxiety, isolation, financial insecurity, and uncertainty.
“Vulnerable populations, especially people with pre-existing mental health conditions, experienced heightened psychiatric distress and increased risk of Covid-19.”
He added mental health services “adapted as best they could”, but the challenges were significant.
However, people displayed “great resilience” amid the major turmoil caused by the pandemic. This is a major theme of Prof Kelly’s book, Resilience; Lessons from Sir William Wilde on Life After Covid (Wordwell Book; 2024).
“Many people found ways to cope well with dramatic shifts in circumstances they had not experienced before.”
While the pandemic brought much anxiety and loss, people found ways to be resilient and persevere.
The mechanics of evaluating Covid
Speaking in the Dáil in November, Tánaiste (then Taoiseach) Simon Harris said the Covid-19 evaluation panel will provide a final report in 12-18 months. He also outlined that it may submit interim reports on specific modules before that deadline.
The overall objective of the evaluation “is to learn for the future”. The Government believed a fact-finding and ‘lessons learned’ approach would ensure wide cooperation of relevant players and a timelier conclusion.
“A statutory inquiry with powers of compellability would inevitably change the dynamic of the process and participation in it.”
The panel will carry out a documentary analysis of plans, reports and other work already undertaken across Government and internationally to review specific aspects of Ireland’s response.
The Tánaiste noted that the “precise nature” of the public aspects of the evaluation would be a matter for the panel. However, it has been agreed that submissions will also be sought from specific individuals, cohorts or their representatives. There will be a public consultation to hear accounts of the “lived experience” of those who want to participate.
There will be “public events” to facilitate discussions and private sessions for “deeper information gathering” and the probing of submitted materials.
An evaluation of the nursing home sector is promised as part of the review. The IHCA regards a key lesson to be the need to enable our older population to remain in their own home for as long as possible or be provided with safe nursing home care.
“There is increasing evidence to show that highly dependent persons can live safely and more happily in domestic settings, provided their required homecare supports are in place,” the Association spokesperson told the Medical Independent.
Therefore, the evaluation panel should explore the need for a systematic reform in the way nursing home care and older persons’ care is delivered in order to “avoid a repetition of the problems experienced during” Covid-19, taking particular account of the report of the Expert Panel on Nursing Homes.
The pandemic in primary care
The ability of general practice to “pivot quickly” was demonstrated during Covid-19, according to Prof Claire Collins, Chief Operating Officer at the Irish College of GPs.
General practice was able to adopt new ways of working and showed great flexibility and adaptability.
During the height of the pandemic (December 2020), Prof Collins co-authored a paper in the Irish Medical Journal titled ‘Long-term impact of Covid-19 on general practice must
be assessed’.
She said connectivity with patients is critical to general practice, as is its ability to reach patients by maintaining continuous delivery of care and patient safety. She told this newspaper the pandemic underscored the key role of general practice and the importance “of resourcing it adequately”.
In addition it showed the importance of inclusion of general practice leaders in the development of health policy and service delivery design.
“The impact on specific areas of need such as in rural areas and urban deprived [areas] should be considered [as part of the evaluation panel].”
In terms of the long-term changes to health systems, it is “early days” for the outputs of academic research.
“However, research is ongoing across multiple countries into the appropriate and effective use of digital health.”
One example of such research is the ESRI’s recent paper ‘Remote consultations in general practice in Ireland: Who is missing out?’
At the height of the pandemic (2020/2021), 39 per cent of respondents who had had a GP consultation in the previous four weeks reported that their most recent consultation took place remotely, according to the research.
However, this fell to just 10 per cent in 2022/2023. In recent years, a number of GPs have publicly raised concerns over the ‘digital divide’ and how some patients may not have access to remote consultations or prefer not to use telemedicine.
According to the co-author of the ESRI paper, Ms Ellen McHugh, the research found that older age groups were less likely to report that their most recent GP consultation took place remotely. Women, people with private health insurance, and those with a long-term health condition, were more likely to report that their most recent GP consultation took place remotely.
“This analysis does not specifically look at what is driving the results,”
Ms McHugh, ESRI Research Assistant, told the Medical Independent. However, she added that international literature suggested that lower utilisation rates in some cohorts could be driven by difficulties in using or accessing the technology required, cohorts presenting with symptoms less suitable for remote consultations, or preferences for in-person appointments.
Public health doctors: What a difference five years make?
In January 2020, the public health committee of the IMO was readying itself for planned strike action in its campaign for consultant contracts and increased public health resources.
Instead, a few weeks later, public health doctors were thrown into the pandemic response. By the end of the crisis, they would emerge with consultant status and a major public health reform programme that continues today.
The Irish experience of the pandemic saw “health prioritised over the status quo”, a spokesperson for the Irish Society of Specialists in Public Health Medicine (ISSPHM) told the Medical Independent.
This prioritisation included the temporary implementation of policies like universal care, data systems for monitoring of vaccination nationally,
and efficiently using data gathered to serve the population.
However, since the height of the pandemic, “the culture has moved away from flexible problem-solving even though huge crises remain that require the same broad approach”.
In general, the pandemic “highlighted the need to invest in public health”.
The ISSPHM recognised that the HSE’s public health reform programme has begun. However, “not all” the necessary enabling structures have been developed or resourced.
In September 2023, the report of the public health reform expert advisory group (PHREAG) was published. The PHREAG was charged with examining the public health response to the Covid-19 pandemic. It found that Ireland’s excess mortality was among the lowest in Europe and globally and that high vaccination rates were attained. “To the great credit of all involved, this was all achieved despite some weaknesses in our public health system in Ireland,” read the report.
The ISSPHM spokesperson said the PHREAG had recommended the development of a Department of Health-led national public health strategy.
“This was a requirement to enable a number of other recommendations within the report including the need for cross-department and cross-sectoral coordination on health and wellbeing.”
The spokesperson said this Departmental-led strategy has not been developed. In its absence “the HSE is moving forward with an internal public health strategy… but it will not have the scope and effect envisaged by the PHREAG report and indeed the WHO report into Ireland’s public health system”.
In terms of lessons for public health, the ISSPHM pointed to the importance of prevention and a whole-of-government approach to the “wider determinants of health” during non-pandemic periods.
The ISSPHM also said the PHREAG report had highlighted the need to strengthen public health leadership within the system. This has been progressed at regional level with the inclusion of directors of public health within regional senior leadership teams.
However, the recommendation to include the national public health leads on the HSE executive management team and public health representation on the HSE board had not taken place, said the spokesperson.
The formation of the six new health regions had also impacted the current public health reform process. The proposed hub and spoke model is “creating uncertainty from a governance perspective and fragmenting national and regional public health”.
The Society also noted that the development of multidisciplinary public health expertise has been hampered by the HSE’s pay and numbers strategy. This has prevented recruitment into some newly established public health teams, it stated.
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