Getting the NHS back on its feet – redrafting the social contract

Miles Watson

As the NHS emerges from the COVID-19 crisis, an open and honest public conversation is needed to set expectations about what it can, and cannot, deliver.

In a recent contribution to the Health and Social Care Committee’s hearing about the COVID-19 pandemic, Nigel Edwards, the Chief Executive of the Nuffield Trust think tank said that, in the next phase of the crisis, the NHS will operate more akin to a middle income country’s health service, but in a country where the population is used to a high income country’s health service.

The next few months will require a careful redrafting of the social contract upon which the NHS is built: healthcare leaders need clear, honest and realistic communication about what the service can and cannot do; and the public, which has demonstrated its love and appreciation for the NHS throughout this crisis, need to re-engage with it in a measured and patient way.  This mutual exercise in expectation management will be critical in protecting the NHS as it recovers and looks to return to something resembling business as usual in an era that remains very unusual.

The reformulating of the provider-patient relationship will necessarily take place against the backdrop of some fundamental challenges in the system:


The capacity crunch – Hospitals

Until a viable vaccine is developed and distributed, COVID-19 will remain, to a greater or lesser extent, at large in the population.  As long as it does, hospitals will need to be calibrated to efficiently process these patients, whilst protecting non-COVID-19 admissions.  Already, hospitals are working on a green, amber and red zone basis, whereby patients are triaged to certain areas based on the likelihood (confirmed by testing) of whether they have the virus.  This takes capacity – physical capacity in hospital buildings as much as human capacity to work on each zone and be responsible for maintaining rigorous hygiene standards.  The knock-on effect of such a recalibration will result in longer waits in A&E and ambulatory care and a slower pace to the hustle and bustle that we come to expect from a hospital.  Like water draining slowly through a blocked-up sink, it takes time for patients and clinicians to navigate around a COVID-19 firewalled hospital.


Holding back the tide no longer – Primary care

At the start of the crisis, primary care clinicians worked hard to reduce the flow of patients into hospitals that were managing the surge of urgent COVID-19 admissions.  This meant discouraging patients to present physically to surgeries if they had suspected COVID-19 and advising to self-isolate.  It also meant ‘holding back’ referrals into secondary care, a decision designed to protect the patient from unnecessarily entering hospitals where there was inherent risk of exposure to the virus.  These approaches were effective, but a double-edged sword.  GPs, through innovative virtual triage were able to prioritise need, but fewer patients overall presented to GPs with issues that they would do normally – for example with suspected cancer symptoms.  Hospital resources were freed up to firefight, but patients in need of routine secondary care procedures such as hip ops or scans were not progressed at the normal rate.  Approximately 1.6 million people entered a new care pathway pre-crisis, but as the crisis took hold, many of those pathways had to be paused, and there are now predictions that 10 million people will be on waiting lists by the end of the year.


What next for ‘our heroes’? – Staff

Put yourself in the shoes of an NHS frontline worker and what you may have had to confront over the past couple of months: increased workload on COVID-19 wards; adapting to an inconsistent supply of PPE equipment; retraining to learn respiratory care skills; re-entering the health service post-retirement; struggling to access testing for yourself; or being struck down by the virus itself.  The human impact of all these factors, and many more, cannot be stressed enough.  The NHS workforce will likely be exhausted, traumatised and shaken by the efforts it has put in over the past few months.  Staff, who have pivoted to work on or support the COVID-19 efforts will slowly transition away back to their day jobs, and the pressures and strains that those entail, but the system will be alert to the expected second peak of the virus.


A lot is expected from the NHS: first-class care; world-renowned research; and a service that is free and accessible to all.  A lot is promised of it too.  This crisis has shown that the NHS is capable of delivering on these promises, but in doing so has taken a battering that will take time to recover from.  The recovery is underway, and we are beginning to see the health service returning to a degree of normality.  But, as we are told so often, these are not normal times.  The scaled-back recovering NHS that users experience over the next few months will be dramatically different from what was seen before.  As the NHS emerges from an unprecedented crisis, the social contract that underpins it needs to be updated to reflect the new realities.  This means that healthcare communicators, from the Government minister conducting the daily press briefing to the neighbourhood GP practice manager, will need to set public expectations accordingly and the public – we, should be prepared.