Toby's story

Toby Garrood
Clinical Director in Specialist Ambulatory Services

“I was in charge of outpatients during the first wave. The hardest thing for me was balancing risk. Everyone was worrying about critical care and the frontline. But that doesn’t stop people getting ill from other things. How do you get the balance right?

There was an exponential rise in admissions during March. There was real fear that the NHS might be overwhelmed. Outpatients was de-escalated to provide doctors and nurses for the frontline.

That was clearly right. But the number attending outpatients fell sharply, by up to 80% in some services. There was a sharp fall in emergencies too. People with serious conditions weren’t coming in. There were anecdotal suggestions that people were dying at home.

We put a lot of effort into ensuring those in trouble and at risk of coming to harm, got the help they needed. We ramped up remote consultations – most by telephone and some by video – from less than 10% to 80%. The NHS Long Term Plan projected a modest increase over five years – and we achieved a massive increase in a week.

As far as I am aware there was very little harm, despite the cancellations. We kept a close eye and if patients had come to harm we would have heard about it. The hospital did an extraordinary job of keeping people safe. We kept the show on the road.

We maybe over-resourced the frontline at the start. But you have got to prepare for the worst. Still it took a while for us to find our voice, to represent the needs of outpatients, to find the right balance.

There were difficult conversations at times. The power balance tilted in favour of the frontline at the start. People didn’t always get that you had to keep a minimal level of service for outpatients.

The only time I got frustrated was when I wasn’t being listened to. Then I had to say, 'You cannot have more of my staff'. It was always round the deployment of staff.

It is about everyone listening to everyone else and understanding their position, their risks. That is quite hard to do under pressure.

Some patients stayed away because they were scared, others because they didn’t want to burden the NHS. We had to manage the risks and ensure those who needed help got it.

We switched all patients to remote consultations by default. Most were telephone but some were video – we were the largest users of the 'Attend Anywhere' NHS video platform. The feedback we got was that patients liked remote consultations. But this was in a context where they were grateful to get hold of a doctor at all. They also liked being able to access a doctor at home. Even now, many people are terrified of going out.

I have been an advocate of remote consultations for some time but there is a huge spectrum of opinion. I had colleagues who were adamant it would never work. Since lockdown, however, they  have become big fans. When you have to do something you learn a lot, very quickly.

There are some exceptions, such as dermatologists who need a higher level of definition than a video screen provides.

We had a huge spike in telephone calls from patients at the start asking what should they do. But when we updated the website with a list of FAQs the calls plummeted. It is not exciting work but it is incredibly important – keeping patients informed. I put a lot of time and effort into persuading other services to do it. People underestimate the importance of very simple things.

We have over 1 million outpatient appointments a year and we had to cancel a huge number. But we have already cleared almost half the backlog. A lot have gone virtual which has helped. Referrals from GPs also plummeted and though they have rebounded they are not back up to the level they were.

We are far more confident now. We don’t expect the impact of a second wave to be as great. We have learnt a huge amount in the last 6 months. The intention is to keep outpatients going at 100%. We have had to ensure social distancing in the clinics and we may have to extend hours to accommodate patients. If you run out of space the only thing you have got is time. 

My wife is a GP and we have 3 children, one was doing A-levels and one GCSEs. In early April, I was in a meeting, we were all working crazy hours, we were very worried about what was coming next, and the Prime Minister announced exams were being cancelled. That was the low point for me.

On top of that we were all expecting to catch it and get very ill as well. You realise everyone has their own issues, as well as the professional ones. It’s about being mindful of other people. The way we relate to each other will be different in the future.

The sympathy the NHS got was great – but I found it embarrassing after a while. I know people who lost their jobs. I was happy just to have a job. It was lovely but it made me feel a bit uncomfortable.

It was an exciting time for anyone who enjoys a challenge. There was an extraordinary can-do atmosphere – an absolutely unified vision that we had to make this work. It was stunning the way people stepped up and the compassion they showed for each other. It was the most satisfying time of my professional career. The atmosphere will stay with me for the rest of my life. 

We learnt we can cope. I really do feel now that nothing is impossible.”