Andy Cowper explains how individual heroism by front-line colleagues is not going to aid in this time of crisis where covid19 is going to alter the NHS significantly and enduringly.

“Do what I please, gonna spread the disease

Because I wanna.”

Howlin’ Pelle Almqvist of The Hives, ‘Hate To Say I Told You So’

It might be a bit harsh to judge the Great British Public’s reaction to the Covid19 pandemic by splitting the country into a Venn diagram bubbles of the scared and the stupid.

But judging by the low levels of compliance with official recommendations about social distancing and the tidal waves of panic buying, it wouldn’t be terribly inappropriate. There are A Lot Of People in those two bubbles’ crossover area.

Friedrich Schiller wrote in his 1801 play ‘The Maid Of Orleans’ “against stupidity, the gods themselves contend in vain”. Schiller was not wrong, and stupidity (unlike hand sanitiser gel) is not scarce.

It’s not all the public’s fault. It feels as if I’ve been writing incessantly in these three linked articles for the BMJ and in my last column here about the sheer ineptitude of the government’s communications response. It’s probably why I’ve been playing The Hives song quoted above quite a bit.

I’m writing this column while listening to prime minister Boris Johnson’s Sunday press conference. Oh dear. His answer to questions about greater enforcement of social distancing discipline, that “we will think about this very actively in the next 24 hours”, is not totally reassuring.

Mr Johnson’s evident reluctance to curtail public liberty is of a piece with his journalism: it’s not clear whether this amounts to a political philosophy, since it’s not clear that Mr Johnson believes in anything other than his becoming Prime Minister, as his two diametrically opposing newspaper columns on Brexit proved.

Columnists, eh? Can’t trust them further than you could spit them. (Spitting is of course discouraged for public health reasons.)

Certainties are in short supply at present, but I think there are a few which can form part of our conversation during our time together created by the return of this column.

The first is that Covid19 is going to alter the NHS significantly and enduringly. It will also alter the nature and tone of conversations around public services. This isn’t fully clear to most people yet: it will become clearer as the death rate rises and the pressure stays on for months and months.

It is not an original insight to observe that running hospitals over 85 per cent bed occupancy is inefficient, let alone pointlessly stressful for the clinicians and colleagues working there.

There will also be a broader conversation about resourcing the wider public sector, as well. Local government has been pauperised b losing almost 40 per cent of its central funding since 2010. The criminal justice and penal system is in a deep mess. Education is immune or protected. And then there is the need to decarbonise our economy.

These are conversations for another day once the worst of the coming crisis is over. But they are coming.

It is not an original insight to observe that running hospitals over 85 per cent bed occupancy is inefficient, let alone pointlessly stressful for the clinicians and colleagues working there

In the same category will sit a big conversation about why the NHS is where it is going into this crisis, i.e. financially in the red, short of staff and modern facilities and technology.

Those fights will need fighting at that time however to seek them now is an activity for fools.

On a more prosaic level, protracted social isolation means that we can expect there to be increased demand on maternity services in December 2020-January 2021 and for some months thereafter.

Those familiar with the birth rate among Christians nine months after the end of Lent and Advent will not need to be told this. On a less happy front, the same ‘cooped up’ driver may well also mean higher resource demands on mental health services and those for domestic violence.

One positive to come out of this will be the emergence of a new generation of clinical leaders. There is a thoroughly impressive amount of ‘just getting on with it’ at present, which is strongly clinically led. I’ve had heartening reports from current clinicians of how their present experience of working side-by-side with managers, rather than in the traditional power-hierarchies has been thoroughly welcome.

Not all of these clinicians currently stepping up to leadership roles will want to carry it on beyond the crisis period, but a few will have got the taste. Positive behaviours can be learned, and an awful lot of negative ones can be lost, if some effort goes in to so doing.

The NHS system would be very stupid indeed to lose this opportunity to make the most of increasing the number and mix of clinical leaders showing a desire to lead, and I believe and hope that it is not stupid. But it will need someone to do something about it, otherwise just as it arose organically, it will decline in the same manner.

Bowie vs. Stranglers

There is another predictable thing, and this one is not so positive. In fact, I’d like to enlist HSJ readers’ help to make sure it doesn’t happen. You can call it the ‘Bowie vs. Stranglers’ dichotomy.

I am referring of course to their classic 1977 songs ‘Heroes’ and ‘No More Heroes’.

Both songs are great, but with the Covid 19 crisis, we need the cynical punk nihilism of High Cornwell and Jean-Jacques Burnel more than we do The Dame. (And I heart The Dame.)

Individual heroism by front-line colleagues – from cleaners to porters to clinicians to medical scientists - is not going to get us through this. It is much more likely to get the heroic’ individuals harmed or killed. Leaving us numbers down, which we don’t want.

The last line of Schiller’s classic play is “pain is short, and joy is eternal”. The problem is that death is also eternal, and putting the line in context, it’s spoken by Joan of Arc who is about to be consumed by the fire that will kill her.

So please do me a favour: make sure the understandable temptations of heroism for those at the front line are understood as siren songs: ones we should resist. People are going to die from this thing: let’s try to make sure our people are not among them.