What lessons can the NHS learn from COVID-19?
Much attention has been paid to the impact of COVID-19 on the NHS, with concerns about delayed diagnosis, increased waiting times and the appointments backlog dominating news reports. Drawing on her experiences of interacting with the NHS during the pandemic, Associate Director Maddy Farnworth sets out her reflections on lessons the health service could learn.
I’ve been working in health policy and communications for a while now, leaving me with a pretty thorough understanding of the complexities of NHS commissioning, funding flows and medicines reimbursement. However, like most people, my actual experience of interacting with the NHS as a patient or caregiver is limited.
For various reasons, I’ve interacted with the NHS more in the last few months than I ever have before. Luckily for me, I can see one of London’s largest teaching hospitals from my bedroom window. Unluckily, there’s been a global pandemic going on at the same time. In these interactions, I’ve viewed the NHS through a new lens: simultaneously wearing the hat of a policy wonk and a patient’s family member.
Much attention has been paid to the impact of COVID-19 on the NHS. With the health system placed under sudden and intense pressure, we saw unprecedented demand on intensive care units, rapid adoption of digital technology, and a renewed public adoration for our healthcare workers. But we also know that GP appointments fell by around 30%, GP urgent referrals for cancer fell by 62% and routine operations were cancelled. The full impact is still emerging, but the NHS faces an uphill battle to clear the huge backlog of unmet patient need.
The conversation is now shifting to how the NHS can recover, reset and move forward. From the NHS Confederation to the Health and Social Care Committee, the health policy world is clear that we can all learn from the pandemic. From my own experience, there are lessons for the NHS to consider as it rebuilds.
Managing demand on accident and emergency services
Pre-COVID, my interactions with A&E (usually for suspected broken limbs) were characterised by long waits, overcrowded waiting rooms, and severely overstretched staff. The pressures on A&E have long been well understood: the NHS had not met the four-hour standard at a national level in any year since 2013/14, and it had been missed in every month since July 2015.
By contrast, in three trips to A&E in the pandemic, care has been prompt and hospital admission completed well within the four hour target. In evidence given to the Health and Social Care Select Committee, the President of the Royal College of Emergency said the pandemic had effectively “cured” the issue of crowding in A&E departments.
At the start of the outbreak, the numbers of people attending A&E fall sharply to 52% below normal. By mid-May A&E visits had increased but were still 36% lower than expected for this time of year. A combination of changes to the way NHS care in delivered, and to patient behaviour, has helped to limit the demand on A&E services. Albeit unsophisticated, the hospital I visited had a nurse at the door of A&E triaging presenting patients. Calls to NHS 111 increased two-fold in March, and continue to be higher than at the same time last year,
Pilots to manage demand on A&E are being trialled throughout the NHS and evaluations should follow: a 111-first model is being implemented in Portsmouth. Evaluations of these pilot schemes must be undertaken, and there are, obviously, important considerations to ensure those patients needing A&E services are able to access them. Whatever system the NHS puts in place must ensure it does not leave behind hard-to-reach groups. However, the NHS should carefully consider patient triaging, in whatever form most effective, to support A&E departments during the next phase of the pandemic response, and beyond.
The challenges facing NHS data are not new. Nor, really, are they specific to the pandemic. Research from the Institute of Global Health Innovation in 2019 found NHS Trusts were using at least 21 different electronic medical record systems which are unable to effectively share information. You only have to whisper the words care.data and whole departments in NHS England start twitching.
However, it’s only when you’re confronted by the reality of what this means for someone’s hospital care that the impact of the fragmented healthcare journey really hits home. Relying on patients to provide an accurate medical history, or hospital doctors needing to read previous discharge summaries off an iPhone screen so a surgical team can make decisions about major operations, make an already stressful situation infinitely more so.
Even before the pandemic, the drive for the NHS to make better use of digital technology had already started, with the government placing clear strategic focus on integrating digital technology throughout system. However, COVID-19 has resulted in the rapid adoption of digital technology in the NHS, and there has been a surge in patient’s uptake of remote health services, like the NHS App, NHS login and e-prescription services. Undeniable progress has been made.
But, the underlying challenges around NHS digitisation still exist – like inadequate infrastructure, limited interoperability, and under-investment, as the National Audit Office recently reported. These challenges must be addressed, with urgency, to ensure the welcome progress is maintained.
The little things matter
Our health service went into the pandemic under significant pressure: with demand for care outstripping the service’s ability to meet performance targets, a growing, ageing population, and a capital maintenance backlog of £6.46 billion, a figure that increases year on year.
Some may question why I mention NHS estates, one of the least sexy areas of NHS policy. Beyond my somewhat inexplicable nerdy interest in the topic, the NHS estate is crucial. My brilliant former colleague and NHS knowledge hub Helen Buckingham sums it up perfectly: getting the estate right makes a difference to patients.
In amongst the stress of repeat hospital admissions, coupled with the added challenges of COVID-19, there were a few things that really stood out. Hospital WiFi provided a vital lifeline at a pretty awful time. Gardens and green space around the hospital site allowed the briefest glimmer of normality into an entirely abnormal time.
These are both estates issues, albeit small ones among a vast range of other, more important issues like broken MRI machines. In the NHS’s recovery from COVID-19, attention will rightly be paid to addressing the backlog of operations and appointments, minimising the impact of delayed diagnosis and ensuring the continued delivery of health and care services. But in doing so, the Government should ensure a multi-year NHS capital funding settlement, and not forget the vital role the small stuff can play.
The COVID-19 pandemic has, more than anything else, elevated an already positive perception of the NHS to god-like status – the weekly applause for front-line NHS staff proves this. If it was the NHS that won elections before the pandemic, I can only imagine what it will be like during the expected 2024 General Election Campaign. As the child of two doctors, the grandchild of a nurse, and a career built in health policy, I was already firmly one of the NHS’ biggest fans. My experiences in the last few months solidify this.
Perhaps the most surprising thing to emerge from the COVID-19 pandemic is the way in which NHS services have been transformed. The challenge now is to make sure the beneficial changes are identified and sustained for the benefit of all.