The Interview

Why did you choose the title Intensive Care for a book that’s about general practice?

At the beginning of the pandemic there was a lot of emphasis on intensive care units and hospitals. And that was necessary, but at the same time I felt there was a huge amount of quite extraordinary work going on in the community, by GPs, district nurses, carers, charity workers, and the extent to which my colleagues were being stretched wasn’t particularly well represented in the media. Intensive, as you know, means being stretched to the limit, pulled in different directions. And care is something we do for others, but it’s also an emotional attitude of attentive compassion, of kindness, and delivering it can be a privilege as much as it can be a burden and a responsibility. I wanted to put a bit of a spotlight on the care that I’d seen delivered in the community over this past year, both urban and rural.

How have GPs been affected by the pandemic?

We’ve been dealing with the virus, of course, but our year has been even more dominated by the effects of the restrictions. Very quickly we saw a rise in consultations about mental health, anxiety, insomnia, panic attacks. Alcoholism was on the rise. There was also a surge in homelessness caused by rising family tensions with lockdown, as people who ordinarily would have gone to stay with friends or relatives couldn’t do that. Their situation became unliveable, so they ended up on the street. All of this was going on at the same time as our usual practice was already heavily restricted to keep staff and patients safe and keep footfall through the practice to a minimum.

How did you feel about the Thursday clap for the NHS?

I liked it! It was the only time of the week I saw my neighbours. We’d all go out on the street and shout to one another, ask how each was getting on. But some of my colleagues hated it – they felt they were just doing their job, and that the NHS should get more funding, and better pay and conditions for some of the lower-paid workers, rather than just a clap once a week.

What are the kinds of mental health repercussions you have witnessed in general practice?

So many, from people who have lived through the worst year of their lives, to others who have paradoxically felt better somehow – particularly those with agoraphobia. I had one agoraphobic patient who felt a lot better once no one was allowed out of their houses – she even came off medication. Lockdowns are terrible for human beings, we’re social, gregarious animals. And so giving us month after month of lockdown means we have to suppress so much of what comes naturally to us as human beings.

Did you note particular changes at your Edinburgh practice?

Under normal circumstances, I was seeing 20-30 patients a day. Covid meant seeing five or six, face to face. The rest were phone appointments, or with video calls. And they’re reasonable as a stop-gap, as a kind of triage, but they’re no substitute for real consultations. We’re taught as GPs to pay attention to body language, silences: what the patient doesn’t say, as much as what they do say. And on the computer screen or on phone all that is lost. So many of my patients would tell me the thing that was really bothering them just as they prepared to leave the consulting room – that’s all gone now. You work sometimes in a practice that looks after people who are homeless.

How has that affected your view of the pandemic?

The slogan “everyone should protect their own front door” was very prominent early on in the pandemic. But an awful lot of people don’t have their own front door. I was impressed, though, with the speed with which solutions to homelessness were found. The Edinburgh charities Streetwork, The Bethany Trust and Cyrenians work to reduce and mitigate homelessness all the time, but suddenly they were given a remit and funding to solve the problems. This was in the general public’s best interest. That need to protect the most vulnerable, to protect everyone, reminded me of the times in Edinburgh’s history when public health doctors – charged with controlling smallpox – would go to the boarding houses in the cheap parts of town and pay all the residents to be vaccinated. It’s a kind of pragmatic compassion.

The life expectancy for men who are sleeping rough in Scotland is just 46, and for women it’s even worse, at 41. That’s far lower than the life expectancy in any of the poorest countries in the world. And suddenly there was a focus on this part of the population who have the worst health outcomes, the worst chances in life, and empty tourist hotels were being opened up to accommodate them. Many had their begging income dry up overnight and were withdrawing from alcohol or heroin. Others were coming in under a roof for the first time in years, even decades.

You make a pithy point about Prince Charles recovering from Covid at Balmoral when others were barred from visiting holiday homes. How did you and your colleagues feel about this kind of exceptionalism?

Yes, there are quite a few cases of double standards around: Dominic Cummings, SAGE’s Professor Neil Ferguson and, memorably, the Chief Medical Officer of Scotland, Catherine Calderwood, who was spotted visiting her holiday home after fronting the campaign telling others not to. The Prince Charles thing struck such a chord in Scotland because so many communities in the Highlands were pleading with people not to visit in an attempt to escape the virus, so that their resources would not be overwhelmed. You act as a locum on Orkney.

How did this self-contained island population handle the outbreak?

They were very much protected – it was so much easier to stop people coming in and out. Within days the ferry was closed except for essential travel. The hospital turned around testing very quickly; in June you could have a Covid test result in two hours. And, in my experience the people there were very, very careful – even crossing the street so as not to share a pavement. All despite the low numbers of cases there.

Were you frustrated by the problems getting hold of PPE?

The WHO said we should wear protective gowns, not aprons, but they weren’t available. So we had to make do. It made me think of that old joke about asking for directions, and being told, “Well, I wouldn’t start from here.” But we had to start from where we were, which was a relatively small stock of PPE stockpiled for the swine flu, much of it already out of date. We realised back in the spring that the system whereby all our gloves and masks were made in China or south-east Asia was unsustainable. In this kind of situation we needed a way of scaling up production of PPE more locally.

Were you surprised the Government hadn’t made better plans for a possible pandemic?

We had done quite a bit of prep for the last big scare – swine flu – but that fizzled out quite quickly. I think people were wrong-footed because coronavirus has a different transmission mechanism to flu. 30 per cent of people who are spreading Covid don’t have any symptoms, so it was impossible to isolate the virus swiftly because so many people were passing it on without knowing. Of course, we missed so many opportunities to control the virus, such as stopping all the ski holiday flights back in February and March, enforcing quarantine properly, and testing all arrivals into the country. All things that we’re only doing now, a year in. What do you make of the closure of schools? This virus doesn’t have a strong affinity for children, which is a relief. And there’s far less spread between children than there is between adults. I’m appalled that a year on we’re still having to close schools, when the Government hasn’t even implemented the most basic checks at airports. What does that say about our society – that we close schools but not airports?

Children are bearing much of the impact of Covid when it’s a virus they shake off fairly quickly. I feel heartbroken for the way they’ve had their schooling and social lives so disrupted, at an age when socialising and getting out into the world are so important. Do you think Nicola Sturgeon has had a better approach to coronavirus than the English Government? Nicola Sturgeon has been more cautious; she closed down things earlier and relaxed restrictions more slowly. The situation in Scotland looked very bad at the start of December, but is improving because restrictions were maintained over Christmas. And we went into the same lockdown as England with less than half the virus prevalence seen there.

What particular dates, or stages of the virus’s advance were most memorable for you?

On 13 January, when I first heard news reports, I thought, “Interesting, there’s a new virus in China. I wonder how quickly they’ll get control of it.” Then on 13 March we had our first death in Scotland. Four days later, on 17 March, the practice felt oddly quiet. Then the PM advised everyone to stop going out. And on 18 March we were told all the schools in Scotland would close on Friday, 20 March. So many of those early dates are burned into my brain. And then, 9 November – the happy day the first vaccine – the Pfizer one – was approved and shown to be safe. That was a day to celebrate. When the virus retreated with summer did you think that was the end of things? I could sense it was going to come back and was surprised by how many people were going off on holiday. We should have had testing and enforced quarantine, but there were a lot of competing demands. Understandably, the business lobby pushed to open things up again, but the economic damage is going to prove more long-lasting because of that push. Covid has led to extraordinary innovation.

In the book you mention a GP you know who’s helped develop a new form of iron lung?

Yes, Colin Speight. He is part of a team creating a kind of iron lung ventilator that would cost less than £200. It’s an alternative to ventilation and much better for the lungs than being intubated in an ITU. They’re doing trials through Southampton University and in Bangladesh. It’s an amazing project, called the “Exovent”, done on a not-for-profit basis and with everyone on the team a volunteer.

You say in the book you were struck by the parallels in Daniel Defoe’s A Journal of the Plague Year. Yes, it’s an odd book, isn’t it?

It reads like a contemporary account, but is actually semi-fictional. Defoe was only five during the Great Plague, but based it on the diaries of his uncle. It’s said to be more accurate than many other supposedly journalistic accounts of those times. These phrases kept jumping out of me; they express exactly what we’re going through – although this pandemic is far less severe. One in three sufferers died of the plague; with coronavirus it’s closer to 1 in 50 who test positive die of it (so, 2 per cent). Defoe’s account feels very modern, and loads of his phrases seem helpful somehow for our situation.

There were further parallels in your exploration of the history of viral outbreaks, disease and medical care in Edinburgh.

I chart a kind of potted history of public health in my own city, Edinburgh, from the medieval plagues, when they boarded out sufferers in huts at Holyrood, through the later plagues and into the kind of infectious outbreaks that happened once the networks of Empire were established: cholera, typhoid, tuberculosis. It’s a fascinating story, too, how we came to have modern hospitals – the current Royal Infirmary is the fourth incarnation of that institution, and part of the book takes a walk through time, and around the city, to take a look at those other incarnations.

Edinburgh was a pioneer in public health back in the nineteenth century, and I talk a little in the book about a physician called Henry Littlejohn, who introduced mandatory smallpox vaccination for infants. He also started the system of paying doctors to notify certain diseases, so that outbreaks could be identified, and introduced a kind of codification of cause of death. For every case notified the doctor would be paid a couple of shillings; if it was found later that the doctor had failed to notify the authorities about a known case, a fine of forty shillings would be imposed. The system we have in place today giving us Covid statistics is a legacy of this innovation. I heard enquiries to Scotland’s death certification service doubled at the start of the pandemic, as doctors sought advice for the dilemmas they faced in deciding whether to put ‘Covid-19’ as a factor on the death certificates they completed.

Do you worry there have been unnecessary, or untimely, deaths because patients have been too worried about infection to consult doctors?

Absolutely, and the mortality figures bear this out – far more people have been dying of non-Covid complaints this year than would usually have been the case. And, anecdotally, we’re seeing cancers present to the GP much later because people are either frightened of the virus or don’t want to bother us when we’re busy. One good thing about this second wave (the only good thing!) is that this time round people seem less reluctant to come forward.

Did you become ill with Covid over the past year?

Well, probably, but I’m not sure. I was ill with exhaustion, headache, nausea and fever back in May, but tested negative. And I’ll never know now whether I am one of the 30% of people who have the virus but test negative, or whether it was just something else.

How has the pandemic altered our relationship with death?

Already, we in the West could be said to have an odd, slightly sanitised view of death in comparison with some cultures. And to have to endure these months and months of funerals with only a handful of mourners, it has been really, really difficult.

Have there been any silver linings?

I have to say it’s been impressive to see what people can do when they really come together, trust one another’s professionalism, let the red tape fall to the floor and put funding where it’s needed. Look at how rapidly vaccines have been developed; look at the way homelessness was solved almost overnight; look at the way people came together to celebrate the NHS. There’s a huge amount about this past year of which we can be proud and thankful for. I hope we keep hold of the best of it as we get past this pandemic, which we will.

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Gavin Francis has worked as a surgeon, emergency physician, medical officer with the British Antarctic Survey and as a GP. He’s author of the Sunday Times bestseller Adventures in Human Being, which was a BMA Book of the Year, and Shapeshifters. His books have won the SMIT Scottish Book of the Year Award, the Saltire Award for Non-Fiction. He writes for The Guardian, The Times, The London Review of Books and Granta.

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