Lost patients, abandoned mothers, unsupervised students, dangerously unwell people left to roam the community.
It has not been the official picture during a pandemic in which politicians have repeatedly insisted the NHS could and would cope.
Accounts from frontline staff tell a different story, however. Their anonymous descriptions are not of ‘coping’, but of overstretched midwives fearing for the safety of pregnant mothers and newborn babies; of mental health professionals unable to section dangerously ill people due to an absence of beds; of nurses locking themselves away to weep; of potentially fatal breakdowns in communication as beds were frantically moved around.
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The Manchester Evening News has spoken to frontline staff across a range of specialisms, hospitals and trusts to find out what really went on in the NHS last month, how it felt, and what it means for the future.
Their accounts are those of a demoralised workforce. Virtually all said they feared - or knew for sure - that patients had been put in danger, but felt powerless to stop it.
Burned out and traumatised, many had either been too scared to speak up, or felt ignored when they did.
‘One admission away from disaster’
Over the past month the M.E.N. has spoken to more than a dozen doctors, nurses, administrative staff and technicians of all different levels of experience, across trusts covering the majority of Greater Manchester, in fields from mental health to midwifery to management, to find out what Omicron looked like from the frontline. We have also spoken to a small number of staff in trusts outside Greater Manchester, in order to compare.
What emerged was a story not only about the latest wave of Covid, but the ones before it - and, underneath it all, the chronic state of national NHS staffing that long predated this pandemic.
As the Omicron wave hit, Greater Manchester again cancelled its non-urgent surgery in January, a sign of desperate bed and staffing shortages. In the words of one junior doctor at the time, ‘if it’s not going to kill you, we’re probably not going to do it’.
The number of Omicron cases needing hospitalisation may have been fewer in comparison to cases of other waves, but the highly transmissible variant had a crushing effect on an already overwhelmed NHS workforce.
At its peak, around 15 per cent of Greater Manchester's NHS staff - a figure in the thousands - were isolating because of contact with the strain, or had tested positive themselves. Some came forward with stories of how they were unable to go back to work to help their skeleton-staffed hospitals because of delays in receiving PCR results, as the testing system was under such demand amid skyrocketing Omicron infection rates.
At the same time, patients who had their treatments previously delayed because of the pandemic or had put off seeking help, gradually getting more sick, began showing up in their droves at A&E, often needing admission to hospital.
The increasing demand became yet another problem for the NHS, as a chronically underfunded social care system - plagued by Omicron staff absence and outbreaks of its own - effectively shut care homes to new residents, and could not provide support needed in order for people to be discharged from hospital.
By the end of January, more than 1,000 people, medically fit for discharge, were stuck in the region's hospitals - taking up one-fifth of the beds needed for new patients flooding through the hospitals' doors.
So, even with those non-urgent surgery cancellations, hospitals were stretching their staffing thin while demand was so great that, for many, the situation felt unsafe.
“Every shift is a knife edge,” one intensive care nurse said in the middle of January, at a time when intensive care numbers were under close external scrutiny.
She said the reality was somewhat different to the reassurances being given externally, in her hospital at least.
“You’re one admission away from an absolute disaster, every single shift.
“All it would take is one really poorly patient coming in for incredibly unsafe practice to happen.”
Intensive care nurses such as herself were being pulled away from their specialist wards onto general wards in her hospital, she said, which were acutely feeling the pressure from rising Covid numbers and lack of staff. It meant if a critically ill patient was subsequently admitted to ICU, her expertise would no longer be available.
ICU is meant to be staffed by one specialist nurse to two patients at the most, but usually one to one.
“It feels really unsafe every single shift,” she added.
Guideline staffing ratios - the number of nurses or midwives per patient on a given ward - are not set in stone but vary from specialism to specialism, trust to trust. But repeated crises, including the Mid Staffs scandal of more than 15 years ago, have shown the critical nature of getting it right.
A junior doctor in a different Greater Manchester hospital told the M.E.N. he was fairly sure safe staffing ratios were being breached in early January, despite - and he was one of several to use the phrase - being constantly ‘guilt tripped’ to work and plug the gaps.
One student midwife, in a different hospital, said she had been frequently working in situations during Covid that she wasn’t qualified to handle, as students were brought in to fill in for absences. She had repeatedly worked on a postnatal ward where only one qualified midwife was on duty, when the recommended number of midwives on that particular ward was five.
‘Very dangerous’
“It can be quite scary at times,” the student midwife said, describing what it's been like trying to learn on the job during Covid.
“I've been in situations where I've been left in emergency situations totally on my own as a student.”
On one occasion in recent weeks she had been left dealing with a bleeding mother without supervision, unable to find anyone to provide advice, she revealed.
“Which, again, shouldn't be happening, but it's due to staffing. And it's not that they don't want to support you, there just physically aren't enough people there," she said.
Midwifery had been suffering from a particularly acute staffing crisis long before Covid - and the responses from all three midwives spoken to for this article bear this out.
A second, qualified midwife, working in a different Greater Manchester trust, agreed that the situation last month was ‘very dangerous’.
“Women are coming into my clinic. I’m asking them how the baby’s movement is and they say ‘it’s fine now, but last weekend, it wasn’t moving a lot’. I ask if they called triage and they say ‘I called and called and I couldn’t get through’. Actually, there are going to be times when that baby isn't OK.
“It’s that bad that [staff] aren’t picking up the phone on the 24/7 urgent line.”
The thought of accidentally putting a mother or baby at risk due to a mistake, due to an untenable workload or just sheer exhaustion, was literally keeping her awake at night, she said.
“If the worst was to happen and we stayed late, we were on our 13th hour of our shift and we hadn't had a break, the trust would say ‘you’re autonomous, you should have said you were unsafe to work’.”
“We all know that that's what we're supposed to do, but when there is literally nobody around to take over from you, or you’re in an environment where the culture is just to push on and push on to the detriment of yourself, what do you do?”
In response, Greater Manchester health leaders tell the Manchester Evening News that they are ' are not aware of issues related to trust phone lines being regularly unanswered', but say short-term closures of 'particular services' in maternity have occurred during periods of increased staff sickness absences.
Back in ICU elsewhere in Greater Manchester, the nurse said beds were being moved around so frantically that, on occasion, patients were being ‘lost’.
At some points doctors had ‘no idea’ where in the hospital patients on their list were, she said; whether they were on a ward or on ICU overspill.
“The patients can go two, three days and no doctors come to see these patients.
“The communication is so shocking. You're ringing the doctors and saying ‘why haven't you come to see these patients?’ And they say ‘I had no idea I have patients with you’.
“Definitely delayed decision making, and delayed investigations.”
‘Are they going to attack somebody?’
Some of the most brutal assessments came from mental health professionals.
One community mental health nurse told how ‘sectioning’ a patient - the assessment carried out under the Mental Health Act that leads to someone becoming an inpatient on a compulsory basis, due to the risk they pose themselves or others - had become impossible in some cases, because there simply weren’t any beds.
Staff were declining to go out and assess such patients, he said, because ‘there’s nowhere to detain people to’.
“It’s a system failure. I don’t think that’s just one trust - there’s issues with staffing, morale - but it’s a much bigger problem…We have patients now that are roaming around in the community that three specialists have agreed need to be in hospital.”
Echoing the midwifery teams who describe being so stretched they were unable to pick up the phone, he added: “We were told not to take any live calls on the 24-hour helpline until we had worked through a backlog of voicemail messages that had never been higher, but so many people were off, that we couldn’t get to them.”
The same community mental health nurse, approached a second time this week, said things had not improved.
A paediatric mental health nurse last month said she had seen a ‘threefold’ increase in the number of young people being admitted to hospital ‘who are really vulnerable and have extremely high risk behaviours’. She, too, raised concerns about safety.
“Despite the best intentions of staff, we cannot keep these children safe in a paediatric setting due to the environment, more than skill set.
“We are waiting months, often, for the right social care provision or inpatient mental health setting to be found.
“The demand massively outweighs what we can provide, and staff do not feel safe and do not feel we are doing what is needed for vulnerable young people.”
Both agree the burden of extreme mental health needs is often falling on families.
“Medical patients and families are also impacted, because they are witnessing distressing incidents,” says the paediatric mental health nurse, adding that the issue was not management failure but a lack of anywhere else suitable for the children to go.
“We are just taking on more and more without any solutions.”
The community mental health nurse was - and is - particularly scared of potential consequences where severely ill adult patients are concerned.
“Patients that could go home and murder someone are being let down,” he said.
“This model is currently unsustainable. The resources aren’t there to give people the appropriate care when it’s needed.
“Are they going to attack somebody, or are we going to get them into hospital in time before that does happen?”
He tells of relatives ‘treading on eggshells’ around dangerous patients who should be in hospital, but are still living at home; of an 80-year-old mum being assaulted by a ‘clearly psychotic’ son.
“It impacts on patient safety, patient care, the general safety of the public in the community.
"It impacts patients on the wards because we, as community nurses, members of the home treatment, crisis teams, and more, are being asked to go onto wards to cover staffing absences - people that haven’t had any previous ward experience or haven’t worked on wards for years. They don’t know the layout of the ward, they don’t know the patients.
“Sometimes there’s only one qualified member of staff on a ward during a shift. It’s dangerous - from a patient safety perspective and from a staff perspective.
“Sometimes our safety can feel disregarded. I don’t think you could overexaggerate that people’s lives are being put at risk.”
The Manchester Evening News put the concerns and claims raised by our sources to the Greater Manchester Health and Social Care Partnership (GMHSCP) - a body which brings together all of the organisations who have a say in health and social care in the region, such as councils, hospital trusts, and charities.
They confirmed that 'during the Omicron wave, high levels of infection amongst staff meant that some inpatient wards did have to close for a short period of time'.
This 'changed the way some services were provided for several weeks' because of 'significantly fewer staff and more patients to be cared for', though this was 'not unique to Greater Manchester or the North West'. All the while, a 'large increase in young people needing urgent support' - 'sooner than anticipated' - lead to 'stressful and difficult' waiting times.
As far as Mental Health Act Assessments go, 'clinical priority' of those needing to be 'sectioned' is being considered amid an 'increase in demand for inpatient services throughout the pandemic', as phrased by the health bosses. 'Contracting inpatient beds from the independent sector' and 'improving support in emergency departments' are proffered as solutions.
NHS leaders have also insisted that 'some community staff who held professional registration were required to be redeployed to inpatient wards however, roles were not outside of a person’s skill set and staff were not asked to undertake clinical duties they’re not qualified or trained to do' - and that the staffing strains have now 'stabilised and are improving'. Though, this is in conflict with sources on the ground.
‘People are crying every single day’
For staff themselves, the impact has unsurprisingly been severe. A workforce now expected to clear a national backlog of up to 11m operations is broken. It was already ‘on its knees’ before Covid, said the ICU nurse, but Omicron felt like ‘now we're just face down on the floor with someone's foot on the back of our neck’.
“People are crying every single day,” she said in January. “I joke about it, but me and one of my colleagues had this little area in the hospital that we would just go to cry and then they locked it because of Covid.
“It’s not what you go into nursing for. A side effect of this is emotional exhaustion. You just have nothing left to give and I just feel like I'm giving terrible care with every shift.”
A junior doctor in a different trust gave a similar view.
“Morale is very low," he said. "There's a lot of discontent between the workforce and the management. I'm not even condemning the trust, it’s the whole situation.
“Our finals were cancelled. One day we got an email saying ‘congratulations doctor, you’ve graduated’ and the next week we were put on a ward. Ever since then, I haven't really had a break.
“It takes quite a toll. You’re tired all the time, some weeks working over 60 hours.
“Some older staff have the attitude of ‘in my day, we had to do a lot more, what are you complaining about?’ But that’s not particularly helpful. Maybe in their day a lot more patients died, more doctors burned out. There are rules for a reason.
“I think junior doctors are really quite angry with how they're being treated. No one's had a break for the last two years.
"Everyone's exhausted."
A community midwife agrees.
“We’re beyond treading water, we’re sinking. And you just feel deflated. You become a midwife because you want to do good. We’re very good at coping with stress. But the anxiety is so real now, and people are just leaving.
“The relentless mental strain is too much. I don’t get any job satisfaction from seeing a woman for 10 minutes and nipping in and out. It’s a conveyor belt.”
The community mental health nurse agrees: “It’s robbing Peter to pay Paul, we don’t have any staff spare. Staff are burning out.”
An overstretched radiologist says Covid ‘was just the final straw’; an emergency medical technician says that it was ‘soul destroying to see so many colleagues upset’ in the last 18 months.
One senior hospital manager says the level of trauma imposed on staff in the past two years is severe and potentially long lasting - even for the most experienced among them.
"In their ten or 20 or 30 years, they've not worked through a period of as intense pressure as the start of January," he said. "It will have been the most pressure they've ever experienced."
And even the best-run hospitals have pushed their staff to the brink.
"Patient-staffing ratios have gone right to the absolute edge… On the edge of safe staffing."
What do Greater Manchester health bosses say?
Leaders at Greater Manchester Health and Social Care Partnership (GMHSCP) admit already-war weary staff are suffering in the face of annual winter pressures, record levels of demand, and the stresses brought by high rates of staff absence.
Sarah Price, interim chief officer of GMHSCP, said: “Responding to the Covid-19 pandemic has without doubt been one of the toughest crises for health and care services to manage. The ever-changing and evolving nature of the pandemic has meant that we’ve had to adapt fast with each wave, and each variant. Staff have worked tirelessly to maintain services and deliver the highest quality care to local people.
“We are profoundly grateful to staff across Greater Manchester for their unwavering commitment during a period when NHS and care services are under sustained pressure for reasons including fatigue following two years spent responding to the pandemic, the impact of annual winter pressures, record levels of demand for our services, and high rates of staff absence.
“Our priority, as always, is to provide safe and high-quality care for people in Greater Manchester and to always be there for people who need our help urgently. In line with the national picture for the NHS, we faced extreme pressure on services at the start of the year with Covid infections rising rapidly amongst staff and patients, as well as continuing high levels of significant need and demand for inpatient admissions.
"We recognise that there are significant backlogs within mental health services, in the face of both rising demand and long-standing challenges which have been exacerbated by the pandemic. There is much work underway and planned to try to tackle issues and drive recovery including recruiting staff to expand services and capacity, such as running additional clinics and digital appointments. We are also working more closely with housing and voluntary sector partners to support people leaving hospital, increasing online services, and supporting access to early help and prevention.
“Our staff come to work to help people, support patients and their families, deliver vital care and save lives and do that, treating thousands of patients every day. We know staff have endured so much over the past two years, which is why we have stepped up wellbeing programmes whilst continuing to develop recruitment and retention programmes.
“We want to reassure the public that the NHS will be there for them when they need it. We would urge anyone with health concerns to continue to come forward for help and treatment in the usual way, using their local emergency department only for serious illnesses or injuries. Please remember you can call 111 or use the online service day or night to get urgent health advice and support quickly, and closer to home.”
However, the proposed solution of 'running additional clinics and appointments' to deal with the NHS' creaking capacity is frequently criticised as lip service by medics from across the Greater Manchester system, who say there simply is 'not enough people in the system'.
'Who will staff these extra clinics?' They ask.
‘A perfect understaffing storm’
As the government seeks to wind down its Covid response, the NHS is now gearing up for the immense backlog of work that has built up in the past two years.
Greater Manchester re-started its non-urgent operations in mid-January but already had a more than 400,000-strong backlog before the most recent ‘pause’.
So while the intense period of the Omicron peak has reduced, the longer-term impact - both on staff and patients - is real.
Ultimately, says everyone spoken to for this article, all Covid did was expose the chronic and crippling lack of workforce planning within the NHS.
“Covid has just exacerbated the problems,” says the student midwife, who describes her profession as ‘undervalued’. “It's not created them. They were already bubbling under the surface. It's just we've got to this absolute crisis point and you add a global pandemic on top of it.”
One senior hospital manager agrees that this has been years in the making, with staff and patients now bearing the brunt.
“There is a perfect storm staff wise,” he says.
“Poor national long term planning, the impact of Covid and variable attention paid to wellbeing, retention and the impact of trauma. The pressures and gaps in social care are being felt across the system in particular.
“Now is the time to prioritise the recovery of the numbers and well-being of the workforce, alongside recovery. One is not possible without the other.”
Only last Monday, new NHS England Chief Executive Amanda Pritchard nodded to the huge gap in government workforce strategy within the NHS.
“The experience during the Omicron wave must be the final reminder, if one were needed, that a long term for the workforce is essential,” she tweeted.
Likewise, Greater Manchester health leaders share this view - saying, particularly of maternity and mental health services, 'Covid-19 pandemic exacerbated existing pressures, including staffing, on maternity services and the wider NHS, which meant services had to adapt'.
It should be no surprise to NHS management then, that staff are speaking in the way that they are, even if many told us they felt unable to speak up internally - or in some cases, had done so, to no avail.
“Staff are aware of the many ways available within their own organisations to raise concerns, some of which they are free to do anonymously, and their own professional duty to raise concerns where they see risks to the safety of patients or our services," continued GMHSCP's Sarah Price, in response to the staff members who say they have not felt comfortable, or have had no success, using the internal safeguards said to be in place.
"We would urge all staff to use those channels so we can address issues immediately and continue to provide safe care to the people of Greater Manchester."
But the ICU nurse said she had ‘done things within guidelines for years' and knows what safe nursing looks like, but ‘nobody listens’ to her concerns, so she decided to speak to the press.
One midwife said she ‘didn’t trust’ the anonymous reporting system internally within her hospital, having spoken out about safety concerns in the past, only for it to not go down well.
“It was like I’d told on them, almost.”
The impact of recent times is already creating a new set of problems.
A board meeting of the Northern Care Alliance - which runs hospitals in Salford, Bury, Oldham and Rochdale - revealed earlier this month that while Covid-related absence is now coming down, sickness for other reasons is rising. The trust was ‘middle of the pack’ in terms of the North West, meaning it is an issue across the board and not limited to this city region.
"The main reason for the increase is stress and anxiety among our colleagues,” Chief of People Nicky Clarke told the board.
‘We’re burned out before we've started our career’
No wonder. The junior doctor describes ‘inundated’ waiting lists.
“I don’t know what’s going to happen when we eventually start doing elective lists again. There’s going to be mountains of patients to get through and I don’t think we've got the workforce to deal with that efficiently.”
An administrator who spends a lot of time making sure patients get their surgery dates agrees.
“Some doctors have 500 patients waiting.
“I did a paper calculation for one of the consultants I work for - if I was to consistently get patients in, it would take me one-and-a-half years to get through the backlog, and there’s more new patients coming in all the time. And that’s just for one consultant.
“My department is one of the busiest in the entire hospital, and that’s how behind it is. I try to tell patients this all the time so they don’t shout at me, but they still do. People aren’t so supportive as when they were clapping for the NHS.”
Some of those spoken to were positive about management in their trusts. Several said they were not to blame; ‘we have some managers in my trust that are very motivated and are role models, but I think they are crumbling now, themselves’, said one midwife.
The junior doctor, too, said he ‘feels for management’.
Fundamentally, however, it will be these same staff who have to clear the immense backlogs that are slap bang in the government’s line of sight.
Some spoken to were thinking of quitting, or had reduced their hours for the sake of their own health.
For the next generation of staff, meanwhile, there are other worries.
“We’re in the last nine months of our course now, and we feel like we should be fitting all the pieces together and not really thinking ‘oh my goodness, there's so many things we've missed’,” says the student midwife of her course.
“Coming up to qualifying in September, a lot of us are really worried that we're not going to have the proper skills that we need going into the midwifery profession.”
Almost half the students that began on her degree course have now left, she says.
“A lot of people feel so burned out. And we’ve not even started our career yet."
If you have been affected by the NHS crisis and want to speak anonymously, contact helena.vesty@reachplc.com.
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