Matt Morgan: Sitting on the binBMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n2767 (Published 16 November 2021) Cite this as: BMJ 2021;375:n2767
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Dr Matt Morgan’s letter on BBC R4 Today programme (19 Nov 2021) uses an analogy of cracked pottery as a plea to the public to help support the waning motivations of all who have been involved in caring within this horrible pandemic. It was an emotionally stirring and beautifully written piece describing some of the dichotomies exposed during the pandemic, from uncertainty to divisions, from celebrating lives saved to remembering deaths witnessed. Yet even the fundamental analogy itself seems cracked considering the widespread recognition of the brokenness of our profession and society, one which he begins to recognise in his BMJ article Sitting on the Bin (1).
Several research studies performed on wellbeing and burnout within the last year indicate more than just cracks in the individuals working in healthcare. In ICUs, an over 50% rate of features consistent with Post Traumatic Stress Disorder (PTSD) (2) and 30% at high risk of burnout this year (3) signify a broken workforce. The GMC training survey demonstrated the worst burnout rates of trainees since 2018 (4). Further staffing crises loom over our heads, with a real-terms drastic shortage in nurses (5) and doctors (6). There can be no doubt that healthcare workers are already broken.
Organisationally, on the back of years of underfunding, the already long backlog of surgical and clinical waiting lists is set to increase, with a predicted increase in avoidable cancer deaths (7). This is mirrored in the dramatic decrease in uptake of cancer screening, with Cancer Research UK estimating 3 million less people screened in late 2020 and 42% lower rates of people starting cancer treatment pre-pandemic (8). GPs have been completely overwhelmed by demand, and ambulance services are unable to cope with the public need (9).
Even nationally and internationally, the reality of health inequalities has been exposed through COVID19. From the increased mortality rates amongst BAME populations (10), to the worldwide differentials in vaccination rates between high income countries and low income countries (only 6% of the African population are vaccinated, while we in UK continue to boast almost 70%) (11)(12). This, and the ever-worrying climate emergency which permeates every aspect of society, means that we can no longer pretend that we are able to hold it all together.
I stand with Dr Morgan in a call to action for the public and authorities. Oncologist Dr Sam Guglani used a similar analogy to write compellingly about the fragility of the human condition in his exquisitely written Lancet essay Clay (13). Yet, there is redemption from being broken, and so, I will take their pottery analogy further from where they leave. The Japanese art of Kintsugi picks up where they leave off. In Kintsugi, the artist repairs broken pottery with resin and gold, accentuating the cracks, but also painting on motifs based on the lines of repair. The result is a beautiful piece of pottery elevated beyond the sum of its broken parts, which continues to serve its original function. But how then do we rebuild a resilient healthcare system?
There must first be recognition of brokenness. The literature is clear and the evidence is indisputable; our systems have crumbled and failed. A denial of our brokenness will merely encourage further patch-work and quick fixes, both of which are fragile approaches to safety (14.) Instead, multi-level scrutiny of our systems can help to identify the places where transformative change is needed (15). Better understanding of interdisciplinary and cross-sectoral conceptualisations can help map the broken pieces onto the aspired finished product; a resilient and robust healthcare system and workforce. In addition, we must move away from the traditional “hierarchy of evidence” to better appreciate the complexities of the modern world we live in (16). We cannot continue to operate in institutional silos.
But let’s also be clear, change is already happening. Practitioner health and wellbeing resources are being made readily available to support struggling healthcare workers. This attempts to mitigate the shock of a crisis. Reorganisation of workloads and staffing levels may be a more sustainable way to engineer resilience into systems. Beyond that, the dramatic increase in resilience research should provide valuable insights to help us anticipate, adapt and learn from this crisis. An example is the need to learn from other sectors. This has already been the case for previous advances in resilient healthcare, in particular patient safety improvements such as the Surgical Safety Checklist. Within the pandemic, there has been increased collaboration with faith-based organisations, which have vital roles to play within whole-of-society resilience and safety (17).
Kintsugi of rebuilding our broken system has already begun, but it requires effort, patience and perseverance, much like the art itself. Only then can we hope to achieve an evidence-based, complexity-informed and cross-sectoral approach towards rebuilding of whole-of-society resilience.
1. Morgan M. Matt Morgan: Sitting on the bin. BMJ 2021;375:n2767. doi: 10.1136/bmj.n2767
2. Greenberg N, Weston D, Hall C, et al. The mental health of staff working in intensive care during COVID-19. medRxiv 2020:2020.11.03.20208322. doi: 10.1101/2020.11.03.20208322
3. Vincent L, Brindley PG, Highfield J, et al. Burnout Syndrome in UK Intensive Care Unit staff: Data from all three Burnout Syndrome domains and across professional groups, genders and ages. J Intensive Care Soc 2019;20(4):363-69. doi: 10.1177/1751143719860391
4. GMC. National Training Survey 2021 London: General Medical Council; 2021 [Available from: https://www.gmc-uk.org/-/media/documents/national-training-survey-result... accessed Nov 2021.
5. Buchan J, Ball J, Shembavnekar N, et al. Building the NHS nursing workforce in England London: The Health Foundation; 2021 [Available from: https://www.health.org.uk/publications/reports/building-the-nhs-nursing-... accessed Nov 2021.
6. Gregory A. Shortfall of 50,000 doctors may overwhelm NHS in winter, BMA warns London: The Guardian; 2021 [Available from: https://www.theguardian.com/society/2021/sep/13/shortfall-of-50000-docto... accessed Nov 2021.
7. Maringe C, Spicer J, Morris M, et al. The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study. Lancet Oncol 2020;21(8):1023-34. doi: 10.1016/S1470-2045(20)30388-0 [published Online First: 20200720]
8. CIT. Evidence of the impact of COVID-19 across the cancer pathway: key stats: Cancer Research UK; 2021 [Available from: https://www.cancerresearchuk.org/sites/default/files/covid_and_cancer_ke... accessed Nov 2021.
9. Tilley C. GP practices forced to divert calls due to overwhelming demand: The Pulse; 2021 [Available from: https://www.pulsetoday.co.uk/news/scotland/gp-practices-forced-to-divert... accessed Nov 2021.
10. Larsen T, Bosworth M, Nafilyan V. Updating ethnic contrasts in deaths involving the coronavirus (COVID-19), England: 24 January 2020 to 31 March 2021 London: Office of National Statistics; 2021 [Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri... accessed Nov 2021.
11. Boakye-Agyemang C, Oka S. Less than 10% of African countries to hit key COVID-19 vaccination goal Brazzaville: World Health Organisation; 2021 [Available from: https://www.afro.who.int/news/less-10-african-countries-hit-key-covid-19... accessed Nov 2021.
12. Mathieu E, Ritchie H, Ortiz-Ospina Eea. A global database of COVID-19 vaccinations: Nat Hum Behav; 2021 [Available from: https://ourworldindata.org/covid-vaccinations?country=GBR accessed Nov 2021.
13. Guglani S. Clay. Lancet 2021;398(10317):2144. doi: 10.1016/s0140-6736(21)02740-9
14. Anderson JE, Watt AJ. Using Safety-II and resilient healthcare principles to learn from Never Events. International Journal for Quality in Health Care 2020;32(3):196-203. doi: 10.1093/intqhc/mzaa009
15. Rangachari P, J LW. Preserving Organizational Resilience, Patient Safety, and Staff Retention during COVID-19 Requires a Holistic Consideration of the Psychological Safety of Healthcare Workers. Int J Environ Res Public Health 2020;17(12) doi: 10.3390/ijerph17124267 [published Online First: 2020/06/19]
16. Greenhalgh T, Papoutsi C. Studying complexity in health services research: desperately seeking an overdue paradigm shift. BMC Med 2018;16(1):95. doi: 10.1186/s12916-018-1089-4 [published Online First: 2018/06/21]
17. El-Majzoub S, Narasiah L, Adrien A, et al. Negotiating Safety and Wellbeing: The Collaboration Between Faith-Based Communities and Public Health During the COVID-19 Pandemic. Journal of Religion and Health 2021;60(6):4564-78. doi: 10.1007/s10943-021-01434-z
Competing interests: No competing interests