As the Covid-19 crisis moves to its next phase, the conversation is already turning to restarting elective care, and the lives taken indirectly in shutting these essential services. However, with ongoing pressures exacerbated by the impacts of the virus, now is a unique opportunity to innovate healthcare provision – not simply to go back to a system which was already struggling to cope.
Public goodwill towards the NHS has never been higher. If the weekly clapping (accompanied by cheering, pan-banging and bell-ringing) doesn’t show this, the speed at which 750,000 citizens volunteered is surely a strong indicator. The idea of awarding the NHS the George Cross is neither unwelcome nor surprising.
This goodwill is not misplaced; the NHS has stood up to the test of the Coronavirus with aplomb. To take just one example: by April 3rd, the necessary workforce, equipment, and space for over 2,500 additional adult critical care beds was found – an increase of over 50 per cent on pre-virus UK levels (and this excludes the Nightingale hospitals). This precious resource has provided headroom throughout the crisis, with over two thousand beds reported as available during the peak.
However, once the crisis is over and the media has moved on (following in the footsteps of Brexit coverage), what next for the NHS?
The pressures faced are as stark as ever, and the macro-trends are concerning. The UK population age 65 and over is due to grow 45 per cent by 2050; the average health spend of this additional 5.7 million people will be over four times as much as those aged 0-64. The potential impact on public health expenditure is enormous under any scenario, and that’s before considering the social care implications of our ageing population.
Covid-19 adds long-term pressures both directly and indirectly. Of the thousands of intensive care survivors, up to 45 per cent may require rehabilitation support. In parallel, projections show up to two million people becoming unemployed following the crisis, with serious implications for physical and mental health. We will also need to contend with the backlog of elective care not provided during the pandemic.
Given existing, predicted and Coronavirus-related pressures, we cannot simply insist that the NHS goes back to its old practices; we need our non-virus healthcare services to resume, but in a different way. However, if we really want change in our healthcare services, we need to do more than talk about “transformation”; we need to truly shift the mindset of politicians, professionals, and the public to NHS services.
During Covid-19, service innovation suddenly became possible at break-neck speed. For years, the NHS has been calling for a greater prevalence of remote consultations, allowing patients to be seen quicker and without the risk of attending hospitals; where these had previously been resisted, they have now become commonplace. The NHS App – launched and rapidly expanded under the tech-loving leadership of Matt Hancock – saw a 111 per cent increase in registrations in March 2020. Patients have embraced new service models; this shift needs to stick long after the Coronavirus is over.
The causes of this recent rush towards remote care are clear: closed services, constricted travel, and concern of contracting the virus in healthcare environments. However, as these drivers subside, we need to consider what was stopping people from shifting to them pre-virus.
A core issue of remote GP consultations is that residents can still only register with one practice at a time – which means that signing up to an app-based service such as Babylon cuts you off from face-to-face GP care completely.
However, an app can’t measure blood pressure, take samples, or listen to your chest (at least not yet). Surely the most effective model for an individual’s care would be a hybrid one, in which remote appointments could be used where possible, with the back-up option of requesting a visit to a local surgery; this is not an option under the current restrictions. The one-registration rule was created to allow for a single location of health records, but now that technology allows people to hold their own records – readily accessible on their mobiles – it’s time we scrapped it.
Whereas remote GP services are readily available but not necessarily taken up by patients, remote hospital outpatient services are often not even available as an option. Many hospitals have started to implement new models such as telephone or video appointments and community clinics, but the pace of change pre-COVID was frustratingly slow.
In 2019, the Shelford Group of leading hospital trusts wrote that change should be driven, in part, at regional and national levels. Whilst many hospitals have created innovative solutions, it is prohibitively expensive to expect each organisation to invest individually in the development and implementation of these schemes. The national Outpatients Transformation Programme – still yet to be formally established – must be an NHS priority, either to provide much-needed support to existing partnerships or to lighten the load by sharing best practice and cost.
Funding and resources will need to both enable and follow these new structures. Critically, there will be a large infrastructure cost. The ‘NHS England Med Tech Funding Mandate’ makes organisations responsible for investing in innovation expected to deliver same-year savings, but central funding schemes must be increased and made more readily accessible for major investments.
Implementing new technologies will require a workforce with additional skills and an open conversation between professionals and politicians to tackle our existing workforce shortage.
It will also require a shift in where the workforce sits. The benefits of at-home consultations will only be maximised if follow-up care can also be done in the community or even better in the home as well. In February 2020 just 21.1 per cent of nurses and health visitors worked in the community – down from 24.2 per cent in February 2010. A lack of community nurses contributes to the centralisation of care into hospital settings. We must act to reverse this trend.
Finally, we cannot expect all models to work first time round – successful entrepreneurs often have failures amongst their successes, and we need to give the NHS room to take risks as it improves. One anaesthetist summed up much of the issue in describing the need for “permission” (and a common understanding of it) to try new ways of doing things, and the average tenure of an NHS Trust CEO is just three years – not enough time to implement a major transformation. Politicians need to provide professionals with the air-cover to innovate.
Of course, these are just some of the changes needed to help our NHS services to survive. To truly alleviate the pressure, we need to improve public health, and Boris Johnson is absolutely right to be launching a national anti-obesity drive. However, whilst we’re starting on that journey – which will surely be decades-long – we must continue to protect our NHS past Covid-19 by ensuring it is free to make the step-change towards sustainability it desperately needs.
