Published 21 May 2020
Three months ago, I travelled for three hours from home to meet the transformation leads of a hospital. They met me in the coffee shop where we dithered about shaking hands before spending three hours in a meeting discussing outpatient video consultations. They became a pilot for the NHSIE programme in October 2019 and up to February had delivered three consultations using the platform. Patient feedback had been recorded on three anonymised post-it notes that I still have in my notebook.
A lot has changed in the last three months. For now, living with Covid-19, or the risk of its return is the new normal for health and social care.
This means continuing to operate with massive amounts of uncertainty: who has it; how best to treat; who is at highest risk; how best to manage alongside other services; will there be a second wave; what will government policy be; will the economy be able to support the full range of NHS services; how will staffing be affected; will there be a vaccine; etc.
Data have helped navigate this uncertain environment. When combined with purpose and a clear objective (‘minimise mortality’), decision making has been faster than considered possible. One former colleague who holds a senior role in a central NHS organisation commented: “Decisions that previously took six weeks are now being made in one week.”
Social care successfully supported the NHS to create capacity in preparation for a surge in Covid-19 demand, but it has exposed underlying imbalances. These range from funding to quality and oversight. Ultimately these contributed to a substantial increase in care home mortality – caused by Covid-19 infections and reduced usage of health services.
Primary care and technologies, such as video consultations for outpatients, also need to help keep people out of NHS estate
Protect NHS capacity
Going forward social care needs to continue to help protect NHS capacity – especially while there is a fear of ‘missing’ emergency demand (i.e. the people not admitted to hospital for stroke in April) returning at the same time as the second wave of Covid-19. There should be greater parity between the two.
Primary care and technologies, such as video consultations for outpatients, also need to help keep people out of NHS estate (where safe) – this will help with the recovery and will be strongly supported by clinicians and the public.
Even if social care, primary care and technology are collectively successful in protecting emergency capacity, it is unlikely that planned operations will resume in full for some time. When they do return, the delay will guarantee no non-urgent treatment within 18 weeks. A drop in operational productivity from new infection control requirements means that it will be almost impossible to recover the pre-Covid-19 performance, let alone deliver improvements.
the success of the NHS sits in a broader ecosystem of private and public organisations
The independent sector must play a role in helping to provide capacity for some of this planned activity. But it will also suffer from a drop in productivity. This will lead to prioritisation of cases that may evolve into a form of rationing. So that this is based on need, more diagnostics and virtual consultations will be required.
As the new landscape evolves, it is more apparent that the success of the NHS sits in a broader ecosystem of private and public organisations. The continued challenges with testing and PPE remain to highlight the challenges involved. It is, of course, less visible where these arrangements work; medicines supply has been uninterrupted as national bodies worked with industry to bring stock in and distribute it efficiently. The economic model to support these partnerships and ongoing cooperation will be important.
Health security will now be on a par with national defence – as many lives were at stake from Covid-19 as from a nuclear attack in central London. So, guaranteeing and protecting supply chains will be critical. It is unclear how these may fit with the industrial strategy, but presumably Covid-19 could result in the government shifting more supply to the UK and taking controlling shares of organisations, rather than merely relying on their goodwill.
Resources and staff
Funding this service will become even more important. Given the focus on capacity, it seems unlikely that activity-based funding will continue in its current form. With the prospect of increased economic uncertainty and challenges it would seem prudent to link any increases in NHS funding to GDP – perhaps with greater focus on the role of the individual in their own health and wellbeing.
The most valued part of the response over the last few weeks has been the staff. The national pride in the NHS has increased, and this is reflected in satisfaction survey feedback from several trusts. Combined with higher unemployment in other sectors and the opportunity for more flexible working arrangements, potentially permitted by technology, the NHS may have become a much more attractive place to work than it has been for years.
With thanks to Gary Owens, Kelly Lin, Jack Wagstaff and others for their insight and input.