It’s the winter everyone in the NHS was hoping would be avoided.

Responding to a pandemic in the midst of intense pressures seen at this time of the year has put Kent hospitals under immense pressure.

Medway hospital chief executive James Devine speaks to KentOnline

But there is hope “we’re on the cusp” of a way out of a dire situation, the likes of which might never be seen again.

Medway NHS Trust chief executive James Devine says the hospital has been under extreme pressure since the first coronavirus cases started emerging this time last year.

“Any winter is very busy in the NHS. We see higher numbers of admissions and a very different patient profile,” he says.

“That’s been true to some degree this year but with a higher number of Covid positive patients too, certainly over the last couple of months.

“It’s been fairly consistent since October time.

“If we compare that to admissions earlier in spring, we’re seeing 150 more people in hospital this time than we did in the first wave.

“It’s a very busy hospital and has been for the past year.

“Since September we’ve been in a sustained position regarding admissions and it hasn’t materially changed in the last few weeks.

“We’ve had a few days of fewer admissions and I’m hopeful that’s the start of a downward trend.

“With the national measures we’re hoping to see a similar picture with the positive impacts of lockdown.”

These months will later become known as the Covid Winter in the history books and while most winters for the NHS are tough, the turning point in the pandemic – shrinking case rates, third lockdown, schools closed and the crucial vaccinations rolling out – it could well be happening before everyone’s eyes.

The hospital itself has just completed its 5,000th vaccination and the pace shows no sign of slowing down with appointments booked throughout the day, seven days a week, Mr Devine says.

“We’re on the cusp of getting slightly over the line with the vaccine and admission numbers coming down,” he said.

“We certainly don’t want to see people thinking they can interpret the rules in a slightly different way.

“If we can get through the next few weeks, we’ll get into that warmer weather and a little over the line and start planning for spring and summer.

“We’ve seen the very clear national message about the next few weeks and that is continued pressure. Medway is no different."

Mr Devine echoed the calls from health secretary Matt Hancock on Monday who said "we don't want to blow it now" as he urged the public once again to stick with the lockdown measures and staying at home as the vaccine roll out continues to gather pace.

“We’ve benefited from working with our colleagues across Kent for mutual aid when they see peaks and we’re not, we rightfully provide help in the same way in any winter," Mr Devine added.

“The next few weeks will continue to be busy but I’m hopeful that slight downward trend is a positive impact of people following the instructions.”

He added there had been more patients in the second wave but against the backdrop of the vaccination programme provided “a really encouraging sign”.

“We can look further ahead about getting back to some degree of normality.

“We know there’s patients who would ordinarily come in for elective and we’d like to get up and running with those procedures as quickly as possible.”

"We’re on the cusp of getting slightly over the line with the vaccine and admission numbers coming down..."

He said vaccinations, the hand-washing, face masks, social distancing and “respectfully accessing healthcare services” like using 111 and GP and pharmacy provision that don’t need ambulance and hospital support were helping.

“It’s about all of us using wisely the access routes for healthcare but particularly 111 as a direct triage service based on your presenting symptoms.”

Occupancy rates and reviewing capacity

Bed space has been close to and over capacity for several months.

Mr Devine said: “During any winter, we look to open as much capacity as we can to have as many beds as possible but primarily to keep the flow moving from the emergency department and into the main hospital.

“We’re sitting at around 96-97% occupancy, which is better than 104% but no doubt the hospital is extremely busy and there are very few beds available.”

He added investment over the last few years had allowed the hospital to increase the number of beds and building “a couple of new wards”.

“This was in preparation for winter but also for patient profile we see at different points of the year.

“We opened an additional ward space – not fully – but to increase our bed capacity by 15 in the last couple of weeks.

“That has certainly eased some of the pressure.”

As capacity in critical care wards and emergency departments peaked over the Christmas and New Year period, Medway transferred patients to hospitals as far afield as Leeds and Bristol.

Mr Devine described the measure as a “last resort” as part of the three-times daily review of capacity in critical care to ensure beds are open for extremely ill patients coming through the doors.

“There’s a very good network across critical care units and they’re constantly speaking with each to free up capacity.

“You want to start and end the day with spare capacity knowing you are likely to need it based on ambulance admissions.

“It’s never something we want to do and they are patients identified as safe to travel and be assured they can be provided with care they would have received in Medway.

“It’s absolutely a last resort. We review our bed position multiple times a day but three times formally – in the morning, around lunchtime and late afternoon/evening.”

Staff absences and morale

The chief executive hailed staff for their resilience for the “relentless pressure” they had been working under.

He said: “Morale, despite the challenges and how tired people are and the relentless pressure, has been incredibly inspiring and we can be very proud of the way people in the hospital have managed themselves.

“The way our teams cope and their resilience is quite remarkable.

“I know first hand many here have made very personal sacrifices to come to work and spend time away from their family.

“Just thinking about the simplicity of that, it’s quite incredible. Our team have done that and done that every day for the last year.”

Absences across the hospital trust hit 11% earlier this month but Mr Devine said this had fallen to nearer 6% allowing more beds to be opened.

He said the “biggest challenge” with staffing which “ordinarily is our greatest strength” is a good number of the workforce lives locally.

“That has lots of positives for people working for their local hospital and really wanting to go that extra mile because it’s their friends and families they’re caring for.

“Perversely during high prevalence of cases it means that’s our workforce affected.

“In cases we’ve seen asbsence rates high and I’m pleased to see it come down.

“We can open additional capacity because we can safely do that by having nurses, doctors, physio, therapy teams and all those other great people.”

Mr Devine added it was a boost for colleagues to see people come back to work and the team camaraderie it brought to the hospital after absences through Covid, other illness and isolation.

“That undoubtedly is a positive impact and we’ve certainly seen that since Christmas.”

More deaths but also more patients

The number of deaths of patients from Covid at the hospital has been far higher in the second wave compared to the spring 2020 peak.

Since September, there have been 482 recorded deaths to January 18 with 69 in the past week alone.

The total since the pandemic stands now at 668 with 186 coming in the first wave from March to August.

Mr Devine said while there have been more recorded deaths, mortality rates were more than 10% lower because of “many, many more” patients who have been treated in the second five-month period.

“We’re seeing more patients in the general admitted wards than in wave one and we’re seeing significantly more coming through the emergency department,” Mr Devine said.

More than 3,000 patients have visited A&E with Covid or Covid-like symptoms and discharged directly from there.

The majority of patients are in the higher and more vulnerable age ranges but Mr Devine said the hospital was treating a wider age range of Covid patients in the second wave.

“In the first wave we saw more elderly patients but we’ve seen more patients in their 20s, 30s and 40s than we did in the first wave.

“It’s not all about age, it could be existing medical conditions in some but not in all.

“I think that reinforces the messages around you might not need hospital admission or sadly pass away but it’s absolutely right for all of us to follow the rules.

“You might not be affected so dramatically but you could be carrying it and don’t know who you’re passing it to.

“Regardless of admissions or the ages of those who sadly pass away, all of us absolutely have to follow the rules to get back to some degree of normality after the spring.

“In the hospital, we see first-hand the impact of this awful virus, and the impact it has on both our colleagues in the hospital, and the loved ones of those that sadly pass away. This is serious, and we must all take it seriously.

“It isn’t something that only impacts upon those who are older or who have other medical conditions; it can impact on us all, and we must all do our part to protect each other.”

Legacy of the pandemic

While the vast majority of the pandemic has been extremely difficult, Mr Devine says there will be positive changes and good to come out of it for the entire health care network.

"A real benefit I think we need to take in the next few months is how all component parts of health and social care have worked together.

"Previously, you might argue they've been quite individual in nature.

"But the Covid pandemic has really shown how our council and ambulance colleagues and other acute hospitals and mental health have all pulled together physical resources and the workforce.

"It's really broken down barriers that may have existed between organisations.

"We couldn't done this on our own and need our colleagues for mutual aid but also to share ideas about adapting patient pathways, keeping colleagues motivated right through to logistical and sharing the load.

"I would hope we can keep the strength of those relationships going in the next 12 months."

He added the strength of virtual appointments had been a real positive and would be something the hospital will be looking to continue.

"Who knew that 18 months ago we would be doing our meetings and interviews via Zoom and MS Teams.

"But for a large parts of our population it's a preferred method and certainly in some cases more efficient.

"We're looking at keeping that going which of course frees up capacity on the hospital site."

Struggles to contain Covid on 'hot wards'

Cases have been reported during the second wave of the hospital struggling to separate Covid and non-Covid patients.

Mr Devine said high admission numbers meant the "shape of the hospital" had been changed with services being provided on specific wards.

"It was effectively split into three key areas of red (confirmed Covid), amber (suspected Covid) and green (negative for Covid).

"You wouldn't want to put a possible Covid patient into a green area, where you know those patients are not Covid positive.

"We test through the hospital and people may not display symptoms until day two or three and that's why we test on admission days three and six and nine."

"It's a challenging logistical problem because we're having to do that multiple times per day..."

Patients suspected with negative results can then be moved to green areas and up to red if tests come back positive.

"It's a challenging logistical problem because we're having to do that multiple times per day for 500 patients in some cases.

"Then we're relying on the speed of those test results which has been stronger in wave two in terms of turn around time and capacity."

Ambulances queuing outside

"The demand of ambulance is something we work with Secamb on every single day.

"That's based on demand when we look back over weeks, months and years and predict the number of ambulances we might see on a given day.

"We can use some of the past to predict the future and we do that to look a few days and weeks ahead.

"In the last few months there's been higher demand for higher category patients – these are patients who require emergency care right now.

"Sadly, when other patients come to the ED they are waiting slightly longer than any of us would want.

"But when you've got such demand on patients that need life-saving treatment there and then, often they are the ones that get transferred to the intensive care beds.

"It is a real challenge each day to manage the demand we have.

"But it's right we prioritise based on their clinical need and that's frustrating for some but I apologise profusely to those that do wait longer than any of us want them to."