On the frontline: NHS 24's 'crucial' role in fighting COVID-19

When Angiolina Foster presses the home button on her iPad and sees the image of her newborn grandson’s tiny feet, for a moment she can lose herself in their perfection.

That brief interlude, where the purest form of innocence is captured so succinctly, provides her with the strength she needs to be able to face the challenges of the day.

And for Foster, there are many, many challenges.

As chief executive of NHS 24, she now finds herself at the helm of the country’s main access point for anyone requiring a COVID-19 assessment.

Having gone from Scotland’s out-of-hours telehealth and telecare service before the pandemic, NHS 24 is now the first port-of-call at all times of the day for those concerned they may have the virus, which has required a massive – and incredibly swift – overhaul of the way the service operates.

Foster and her teams have had to increase staffing levels by 45 per cent to cope with the new demands on its 111 phone service, which also still has to deal with all the usual calls and health assessments on top of the coronavirus queries.

Foster says NHS 24’s role is “crucial” in Scotland’s response to the pandemic.

“As of three weeks ago, we are now the main access point for everybody in Scotland for COVID assessment from a primary care perspective,” she explains. “Before the pandemic, the 111 number was principally for out-of-hours urgent care when GP surgeries were closed, so evenings, overnight, weekends and so forth. As of the 23rd of March, we’re doing in-hours COVID assessment.

“We were already Scotland’s national digital health and care service, so you can imagine by the nature of this virus, all of our digital services and products are now more important than ever.”

Foster says that in the week commencing 30 March, there were 726,000 visits to the COVID-19 section of NHS Inform, Scotland’s national health information service and a key part of NHS 24’s services. Within that site, there is a coronavirus self-help guide where people can assess their symptoms and 98,000 of those self-help guides were completed in that same week alone.

The total number of visits to the NHS Inform website that week was 1.8 million – which includes the COVID-19 specific hits – which equates to around double the number of visits the site would usually receive.

“That gives you a sense of how important all our digital products are,” says Foster.

With such a dramatic rise in usage and monumental change in the way the service works, how has NHS 24 coped?

“With some difficulty is the honest answer,” Foster admits. “Because, of course, our staffing models were quite correctly heavily weighted on the out-of-hours side and we had far fewer pairs of hands available on the in-hours period to begin with.

“So, a lot of extremely rapid footwork by our human resources colleagues to do rapid recruitment. Very fast footwork from our training colleagues to induct and train new recruits into the system and, again, flexibility from existing staff to step up into new hours and so forth.

“The other thing is that, in truth, for the first week of the operation, people had to wait, members of the public had to wait longer than usual to get into the service as we wrestled with the supply and demand challenge, but we are in a more balanced place. That said, we don’t know where the curve is going to go, so we are continuing to increase our staffing resource so that we will be ready for further surges in demand.”

At the same time, NHS 24 is also increasing its mental health services, expanding staffing capacity in this area by 56 per cent.

Up until 30 March, the mental health hub was running for just four nights a week, but since then has been operating every night, from 6pm to 2am.

There has, therefore, been a big jump in the number of people using the service and the increased staffing levels will enable the mental health hub to be available 24/7.

Foster says that while she doesn’t yet have any “structured data” on the number of mental health service users calling as a result of anxiety over the virus, anecdotally, staff have been telling her that COVID-19 is a factor for many people who are using the phoneline at the moment.

But it’s not just the mental health of the Scottish public that Foster has to worry about; it’s that of her own staff too.

They need a clear sense of calm and a sense of a plan and a sense of direction, and they need to know that you are supporting them

With this in mind, I ask her how she sees her own role during this crisis.

“My role at the moment, it’s such an interesting one, because what do people need from people like me at times like this? They need a clear sense of calm and a sense of a plan and a sense of direction, and they need to know that you are supporting them, not just as professionals delivering a service, but also as human beings who are dealing both with their professional responsibilities and with a bunch of family roles and, very likely, concerns.

“I think my role is to provide as much stability as is achievable in these remarkable times to make sure I get the resources that my people need to rise to the challenges of this, and to make sure that I maintain an environment for them that lets them do what they do best, which is to provide that compassionate expert care to the people of Scotland 24/7.

“That’s why I think, particularly at the moment, this is not just about operational management, it’s not just about the standard ingredients of planning and delivery. This is absolutely about recognising our humanity and supporting each other as human beings and so it’s very much that dual role that I think people need from me at the moment.”

Is this how she would normally lead, when not in the midst of a global pandemic?

Foster laughs. “Clearly by its nature, that’s a question you’d really have to check in with my colleagues on, but my honest answer is, I really hope that it is and certainly that is how I try to be.

“I have always tried to recognise that even the most complex piece of operational delivery is fundamentally achieved by the quality of the human interactions and the relationships that underpin the operation.

“I think that is a correct observation in any service environment, but it is particularly true of a care environment where I am asking my people to provide caring, compassionate, expert services and therefore they need to feel cared for.”

This pandemic has the potential to make us feel anxious, and it’s taking away from us some of the things that make us human

I don’t canvass the opinions of her colleagues – I’m sure they have more important things to do right now – but I do get the impression that Foster’s sense of compassion and responsibility is genuine.

It feels like an awful lot of pressure, particularly during these unprecedented times when emotions and anxieties are heightened, so I wonder how she manages her own resilience so that she is able to lead by example.

 “Let me confess that I think when I was a younger, less experienced person, I used to treat myself like an indestructible machine,” she admits. “And I’m now longer in the tooth and, I like to think, wiser. And I realised that that’s foolish and that I am not an indestructible machine. And, more to the point and to [answer] your question, my people need to see me looking after myself.

“I’m lucky in that I absolutely love my job and that does sound a bit corny, but it makes a heck of a difference. It’s a long day at work if you’re miserable. My job is massively motivating and rewarding. And I think most of my colleagues feel similarly that they have a real sense of purpose in what we do.

“At a more practical level, I’m finding that because this pandemic has the potential to make us feel anxious, and it’s taking away from us some of the things that make us human, you might say…touch, hugs are rationed. You know, how horrible a world is it where hugs are suddenly rationed? I think because of the nature of the conditions that the virus is creating for all of us, all the more important that we understand on our own behalf, what brings us comfort and joy.

“So, where does beauty and joy sit for each of us? For me, I am turning to music and nature, which have always been a real source of stamina and resilience for me and at the moment nature, in effect, means my garden. I love climbing mountains, but that’s not on the agenda at the moment. So, when I can, I’m taking care to spot to the buds that are appearing on the trees in my garden. And things that are beginning to come into blossom and I’m making sure I spot the birds hopping about in the garden and all the signs of life that are appearing.

“I think I’m encouraging people to make sure they know where they find the beauty and joy at the moment and make sure that they keep space in their life for that. And the last thing I would say is I think, as everybody is doing, we’re connecting with family as best we can just now through whatever means possible and keeping those connections going, I think, will be very, very important to all of us.”

Foster tells me that family is incredibly important to her, and as someone with Italian heritage – hence the unusual spelling of her first name – she is finding the world where “hugs are suddenly rationed” a tough one.

“My mother was second generation Italian, so my grandparents were economic immigrants from Tuscany,” she says.

“I have two sisters. I’m the middle of the three of us. I’ve got a son and a daughter, and my daughter, incidentally, at the moment is working in the care home sector.

“My son is married and has two beautiful little boys, so I’m a granny. To come back to your question about my own resilience, my screensaver on my iPad at the moment is a close-up picture of my youngest grandson’s newborn feet. That perfection of a newborn’s feet is quite uplifting, so seeing that many times a day at the moment is all part of my resilience.

“Family is hugely important and because of that Italian heritage, we’re a very tactile family, so it’s hard just now not to be able to be tactile with my family.”

Foster tells me about the death of her parents, who both had Alzheimer’s disease, three years ago and says she simply “hasn’t got the words” to describe the pain of families who can’t be with their ill or elderly loved ones at the moment.

“I think there is a double human pain in this, which is, by its nature, meaning that some people who would normally not have died alone – by alone, I don’t mean without care, I mean without family by them – someone who might otherwise have died in the arms of a loved one, they are dying without that presence and comfort. That’s one cruelty, and then on to that is layered the cruelty of a virtual funeral of some kind, which feels to me....well I haven’t got the words for it to be honest.

None of us really knows the path that this is going to take

“I was very fortunate in that I had both my mother and my father into their 90s. We lost them in 2017, so they’re not part of my worry list as it were, but my heart goes out to people who have relatives with dementia at the moment because it’s hard enough for people with dementia to feel calm and comforted. There is an anxiety that comes with certain stages of dementia at the best of times, so for people with that condition to now be deprived of frequent visits from family, again, I’m a little lost for the language to describe how difficult that must be for those family members and for the individuals themselves.

“The professional care home sector and for the care profession, I think they have phenomenal challenges within a care home environment, so I absolutely applaud everything they’re doing at the moment.”

Foster hopes that the care sector will benefit from “permanent and valuable lessons” learned from this crisis once it has passed.

“None of us really knows the path that this is going to take in the UK or in Scotland more specifically,” she says. “However, my hope is that the more permanent and valuable lessons that we will take into the post- COVID world of health and care will be the one of absolute inter-dependency between the NHS and the care sector and the need for really strong mutual respect and understanding between the two.”