Listening to Prof Neil Greenberg, consultant occupational psychologist and forensic psychiatrist at King’s College London, you might think he is describing the psychological conditions of a war zone, not the NHS in 2021.

He talks about “frontline psychiatry”; the threat of “moral injury” in the line of duty; the need for a military-style covenant to protect traumatised NHS staff; the importance of camaraderie, psychological action plans and a supervisory “buddy system” for beleaguered NHS workers.

Before he joined King’s College, Greenberg spent 23 years in the armed forces, studying and developing new methods of treating the victims of battlefield trauma. His work in the field of trauma risk management (TRiM), including through the specialist trauma therapy consultancy he founded in 2001, has taken the treatment of conditions such as post-traumatic stress disorder to new depths of understanding. And since last April, he has been applying these lessons to the battle against Covid-19 at the new Nightingale hospitals.

“The fact is there are a lot of distressed people [in the NHS] at the moment,” he says. “There are NHS staff who have been damaged by this. We need to make sure that they are getting the right level of care.”

To that end, last week a team from KCL published the findings of a major study into the effects of the Covid-19 crisis on frontline intensive care unit staff, the results of which Greenberg has said should be a “wake-up call” to NHS leaders and politicians.

Of the 709 healthcare workers from nine English ICUs anonymously surveyed last June and July, 45% displayed symptoms of “probably clinical significance”, indicating conditions including severe depression, severe anxiety, problem drinking, thoughts of self-harm and suicide, and PTSD.

The findings are distressing enough in themselves. But taken as they were at a time when infection and hospitalisation rates were relatively low, what effects have the past six months of attrition had on healthcare workers?

“By November and December things had gone back to where they were [in July],” says Greenberg. “We expect that when we survey now it’s going to be more severe than back in June and July. The more exposure to trauma the higher the dose [of trauma].”

Further rounds of mental health surveys carried out in September, November and December will bear out the figures and new surveys are due to start this month. Given the alarming increase in infections, admissions and deaths since September, it seems inevitable that time and added pressures will have taken their toll.

And not just on staff in the NHS, or even just in intensive care. While the KCL survey in July only focused on ICU staff, since then the team has expanded its remit to include a wider range of health service staff. And it can’t stop there, says Greenberg, the social care system is a “hugely worrying set-up” as well.

“There are a whole range of specialities who can’t deliver the care they want to. The ramifications for this are huge across the whole health and social care system. The challenges they have [in social care] are immense.”

With military reference points never far from his mind, even with the rollout of the Covid-19 vaccine now under way, Greenberg compares the current atmosphere for NHS workers psychologically to that of an army base he experienced in Iraq – a base that was coming under intense shelling every day.

“We’re living in this state of perpetual uncertainty,” he says. “When we had troops in Iraq they were often in bases that were rocketed 10 or 15 times per day. In those circumstances you have to learn to live with that uncertainty, and focus on things you can control.” Health and social care staff are having to learn the same skill.

At an individual level, Greenberg says what health and social care staff can control is their own approach to mental wellbeing. They can do this by sharing painful experiences with colleagues and loved ones, creating a “meaningful narrative” for dealing with traumatic cases, and engaging in professional reflective practice sessions – safe spaces in which to open up about internal psychological strain.

At ward level upwards he wants better support mechanisms for staff. “Hospitals need to ensure that staff, working during the pandemic, have sufficient ‘psychological PPE’ to prepare for the traumatic nature of their work,” he says. “Alongside proper preparation, the provision of effective team support, better identification of vulnerable workers, and timely access to evidence-based treatment are all likely to make an important difference.”

In July the Department of Health and Social Care launched the NHS People Plan, with a wave of new initiatives and support systems focused around health and mental wellbeing, including taking on 2,000 supervisors trained to recognise signs of psychological strain in frontline staff.

But NHS leaders and politicians must surely be reflecting on why it took a crisis on this scale to bring in measures like these. Take-up of schemes such as the supervisors and the buddy system have been, Greenberg admits, “variable”, from trust to trust. “But it’s a start,” he says.

It may take months or years to be able to assess the true psychological toll of the pandemic on NHS and social care sector workers. In the meantime the fact that many more doctors, nurses and healthcare assistants are going to suffer is painfully inevitable. The only hope is that they get the support the KCL survey shows they desperately need.

“It would be a complete moral travesty if in two years time you’re reporting on the case of an NHS worker who couldn’t get access to care, someone who has been damaged by saving lives,” says Greenberg. “These people have absolutely given their all on behalf of the nation.”

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