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"Clap for Carers" and other empty promises

A Q&A with Dr Talya Greene on how NHS workers fared during the pandemic

In early 2020, Dr Talya Greene was in the middle of a sabbatical in the UK, having moved temporarily from the University of Haifa, where she is an Associate Professor and Head of Department of Community Mental Health, to collaborate with colleagues at the Division of Psychiatry, University College London.

At first, Dr Greene and her colleagues were exploring opportunities to study mental health among trauma survivors, but no sooner had they established their plans, COVID-19 arrived. They quickly revised their focus and decided to study the pandemic, an unfolding disaster that would likely have catastrophic effects on the UK’s healthcare workers. They launched the COVID Trauma Response Working Group to help coordinate responses to the pandemic, and since then they’ve examined the pandemic’s impact on health and social care workers through the Frontline-COVID Study. They have tracked not only clinicians but the full spectrum of health employees. Their study demonstrates how weaknesses in the health system were exacerbated by the pandemic, and why it’s important to fill these gaps to manage the mental health effects of COVID that are still to come.

Dr Talya Greene, Associate Professor, University of Haifa

1. Tell us about launching the Frontline-COVID Study two years ago.

TG: I'm usually based at the University of Haifa in Israel but just before the pandemic I was on sabbatical at the Division of Psychiatry at University College London. I had connected with Dr. Michael Bloomfield and Dr. Jo Billings—UCL colleagues interested in trauma—and we talked about setting up a special interest group centered around different aspects of trauma. My personal expertise is in the area of mass trauma and disaster management and the long-term impact of things like exposure to natural disasters, terror, war or fires and so on. When it became clear that COVID had real potential to cause a major crisis, we realised we needed to act. In response, Dr. Bloomfield, Dr. Billings and I set up the COVID Trauma Response Working Group. This was a collaboration between academics and clinicians with expertise in trauma. We engaged with local NHS trusts and hospitals and trauma specialist services to try to understand the needs on the ground. Local trusts and hospitals were contacting us and saying we don't really know how to prepare for this, and we don't know how to prevent trauma and mental health problems among our staff. So we tried to provide expert guidance based on published research and best available evidence. But a lot of those studies focused on military contexts, and we wondered how applicable they were. We felt that healthcare, education, and social care had different structures and so we set up the Frontline-COVID Study.

2. So the study grew from outside requests and developed from there?

TG: It was essentially the result of a request from the field—from policymakers and managers—for evidence on how to support health and social care staff during the pandemic. We set up the COVID Trauma Response Working Group in March 2020 and launched the Frontline-COVID study in May 2020, which was immediately after the peak of the first wave. I think there was something about frontline health and social care staff that we felt was distinct from previous research, such as their dual exposure risk. While healthcare workers are prepared to deal with death and serious illness, the COVID pandemic affected everyone in and out of work. So they’d be at work and they'd see terrible things and deal with really intense and unsafe work conditions at times. Then they’d come home and have to deal with children who were struggling with Zoom school and partners who were also trying to juggle their work while caring for family members and parents who were at risk. This gave a sense that there was no escape from the situation. I don’t think we’ve really dealt with a situation like that in the UK for at least a generation or two.

3. Did you see this across the health professional spectrum, or did you see it among certain groups of healthcare workers?

TG: There has been a lot of understandable focus on doctors and nurses working in critical care where it was unimaginably intense, challenging and traumatic. But they were not the only groups affected. Nursing staff, care home staff and people across the healthcare system were also dealing with difficult situations. We also reached out to porters, cleaners, pharmacists, administrative staff, and security staff to account for the entirety of the healthcare system. That’s unusual in health research and as a result, it's harder for those groups to access support. You know, in the beginning we were clapping for the NHS, but actually there were lots of groups with insecure contracts who weren’t quite sure whether they were considered part of the NHS or not. They weren’t always sure whether they ‘counted’ or even whether they could access support. We found that trauma, depression and anxiety were actually spread across healthcare roles and settings. It is important to think about those groups that aren't always included in research.

We also reached out to porters, cleaners, pharmacists, administrative staff, and security staff to account for the entirety of the healthcare system. That’s unusual in health research and as a result, it's harder for those groups to access support.

4. Did you find that levels of mental health symptoms in your study correlated with COVID waves and peaks?

TG: The truth is there's no one-size-fits-all. We did see that when situations were calmer, then there was some recovery on average. But I think what's really clear is that different people react in different ways. Some people actually had like an inoculation of stress resilience following the first wave. They had more tools to deal with future waves. Whereas for other people, the burnout and distress gradually built up. In the first wave, there was an adrenaline rush and the idea that “we're all in this together” and we just need to pull together for a few weeks to get through this. And then when we're facing a second wave, a third wave, a fourth… That chips away at a lot of people's psychological coping resources and they get fatigued. So some people are struggling all the way through, while others get better, and others get worse. And of course, many people seem to cope and won’t require specialist support or psychological treatment, but that doesn’t mean that it isn’t also hard for them. One of the important lessons is that we need to work hard to identify those vulnerable people that aren't necessarily the majority but are likely to need specialist support or interventions, and we need to make sure that these are available and accessible at an early stage.

5. What is happening with the study at the moment?

TG: We wrapped up the quantitative study but we have some qualitative studies alongside it. We’ve reached out over time to see how healthcare professionals and their families are doing now. I'm also setting up a similar longitudinal study looking at healthcare and social care staff in Israel where I'm based. We’re trying to unpick current traumas, exposure and stress related to COVID, as well as those that aren’t related to COVID, to improve our ability to detect individuals who are ‘at tipping point’—who are at high risk of developing clinically significant levels of distress—and to identify particular risk factors that we may be able to modify.

The symbolic things like putting rainbows on houses and clapping, those have come across as empty promises. It needs to be translated into something more concrete.

6. Do you have any sense of what you expect to see among healthcare workers as we move forward?

TG: What we'll see is largely dependent on how we look after our healthcare workers. There will be some inevitable attrition because it's been exhausting. Many gave it their all during emergency times, but they feel completely burnt out. We saw from our research that a lot of people experienced a sense of betrayal from the people that were meant to be looking after them. Managers, bosses, the heads of their organizations, and even at the national policy level and society. They felt let down. Things like not having access to appropriate PPE. When holidays were cancelled and everyone had planned to spend Christmas Day with families but instead they came into work. This was compounded by things like lack of appropriate pay or pay rises. All of those things led to a sense of “I'm not valued and nobody cares about me.” People felt deeply let down, betrayed, stigmatized, and at risk. If those issues aren't addressed now, then we'll continue to see people either working alongside a great deal of mental health difficulties or people will just leave their jobs.

A big challenge for healthcare systems is to think about how to make people feel properly protected and valued, and to provide psychosocial support, not just in emergency times, but in routine times. The symbolic things like putting rainbows on houses and clapping, those have come across as empty promises. It needs to be translated into something more concrete.

7. What do you think are the main mental health lessons from the pandemic?

TG: We saw that it exposed gaps that already existed. Where there was unmet need, waiting lists, low psychosocial support. This was not just in the UK but across the world. There were just not enough resources. That really emphasizes how important it is that we set up mental healthcare provision across settings, not just obviously in low resource settings. Prioritizing and integrating mental healthcare into the healthcare system and scaling it up. Relying solely on psychiatrists and clinical psychologists is not sufficient. We need to think about how to make it more accessible, how to reach people, and how to integrate it with physical healthcare.

8. What do you think will be the long-term effects of the pandemic on mental health?

TG: I think it's clear that there will be a mental health impact for people directly impacted by COVID, i.e., people who survived serious illness, people with long COVID, and those bereaved by COVID. And frontline healthcare workers, social care staff, teachers—these are people who dealt with the pandemic in real-time. Then there’s the broader and longer term impacts on society, such as poverty and economic insecurity. I'm very concerned about how those will impact mental health. COVID has deepened existing vulnerabilities. That’s my real concern.

9. How can we, as researchers, be better prepared for future pandemics?

TG: Something that struck me as we were busy trying to set up our study was the lack of cooperation and collaboration. Everyone was scrambling around trying to find like-minded people to set up large-scale studies. And there was a huge amount of duplication. People conducted similar but not identical research in an uncoordinated way, and we found that participants were asked multiple times to take part in studies while other groups remained completely understudied and under-researched, and we have no idea what was happening with them. We need more structures set up to facilitate coordinated, collaborative work with real knowledge sharing, data pooling, coordination and planning. As researchers, we put the lessons we’ve learnt into papers, but we need to think about how we connect with policymakers and planners and institutions to actually implement those lessons. Integrating institutions and governments locally and internationally is really critical.


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