The Integrator: Going back to normal?

In some ways, the coronavirus response has put health and care transformation into fast forward. Those who spend their time trying to shift service models and ways of working, or change policy, are now seeing it happen in spades before their eyes. In very difficult circumstances, of course, for many.

Shortly, people will need to disentangle what’s good in all that’s happening from the bad, and start dealing with it all via a recovery and reform plan. Work is already underway to do the disentangling, and to shape the conclusions, even though much could still change and a lot is, in fact, unknown.

Digital and phone access to general practice has spread rapidly along, crucially, with a move to what is known as “total triage”, apparently with few of the usual concerns or objections. Clare Gerada is among those hoping and believing the changes will stay, but with proper provision for people who might not benefit from the shift. Similar may well apply to outpatients, though there is less evidence available here so far. Relaxed governance and better data flow has helped and we have seen the problems where it does not — will more public and professionals accept freer use of health data once the crisis has passed?

Discharge and community support

Many are happy about the huge acceleration of discharge from hospital. In places not yet seriously hit by coronavirus, it has brought acute bed occupancy down to levels very rarely seen before — said to be in the 60-70 per cent range. Ninety per cent is normal for this time of year, and the NHSE’s planning objective just over a month ago (then seen as highly ambitious) was to try to keep occupancy to 92 per cent next winter by opening more beds. 

Some of the speeding of discharge is due to government dismantling the funding and administrative barriers, by saying it will pay for care on a no-questions-asked basis — and this is surely an unalloyed good for the services and their users.

We can’t go back to normal on care funding and rules, not least because of the huge recovery job to do after the first covid-19 peak.

But there is a grey area too: the acceleration in discharge has in part relied on a major shift in risk calculations, with abnormal and very clear backing from regulators, royal colleges and the like. It is now perceived as far safer to get people out of hospital. Some will say, ”let’s keep it — this has been the unrecognised truth for years”. Others will see the risks. Mass discharge has also required a huge effort of community and care resource. Some will argue, “great”, but others will point out the other priorities which have been neglected.

There’s also the question of where discharged individuals are being cared for. Will they be empowered, with the right support, or not? Hotels are being converted into mass accommodation and there is talk of huge intermediate care barns to rival the Excel Nightingale.

The real test of the aftercare system will come as the acute stage of this first peak passes, and large numbers of people start to flow out of critical care and towards rehabilitation and longer-term care. And how well are vulnerable “shielded” people who need it being supported?

Self-care and emergency attendance

On the sudden leap in people’s interest and protection of their own health, Paul Corrigan writes: “This crisis shows that the NHS needs the public — all of them — to play a much bigger role in taking care of their own health. The reality is that we (and not GPs) are our own primary health carers (in the sense of being our own first responders)… Along with so many others it’s now very likely that relationship will change forever.”

That self-care realisation is linked to the huge drop in emergency department attendances. This drop, along with emergency admissions falling by a fifth in March, is perhaps the most dramatic spectacle of what covid-19 is doing to healthcare. It prompts polarised reactions. 

There is a spectrum of likely reasons from those not getting ill via better hand washing, skipping nights out, or people safely staying away with self-limiting illness (good) through to children becoming severely ill when they really need urgent treatment (bad), via heart complaints — some of which will be urgent — and cancers going undiagnosed. We don’t know the balance yet.

In terms of structure and relationships, covid-19 may have shown us a lot of the best but some of the worst. There has been some rapid operational cooperation under threat and local NHS organisations and systems have rapidly developed responses, not waiting for national orders. Local government and social care have stepped forward — though not without severe tensions — to help the NHS with discharge. A few feel the role of councils and, the third sector and volunteering — as well as wider community support such as local businesses — vindicates the collaborative partnership approach the health service has been pursuing in recent years.

Others see dithering and fragmentation in preparations and delivery. The finger of blame has so far mostly been pointed at the centre, such as on testing, but at regional and local level the lack of absolute decision making hierarchy is, for some, also now showing its weakness. The centre invoked command-and-control powers early on in the crisis; local commissioning groups have felt cut out; payment by results is suspended. There will be those who see damaging micromanagement in those changes, and others arguing to keep this approach for the long-term.