‘Think yourself into a new way of acting’

They say it’s easier to “act your way into a new way of thinking” than it is to “think yourself into a new way of acting”. The urgency and enormity of the covid-19 pandemic has given the NHS no choice but to act – innovating radically and rapidly.

Experiments are underway in every part of the service, as patients, clinicians and managers adapt to the new world created by the emergence of a new infectious disease, and the transformative impact of the requirements of physical distancing.

The tables have turned

To take one striking example, the Health Foundation first funded an innovation project at Newham in 2010 on Skype-based consultations for people with diabetes. After 10 years of hard work from clinical and academic teams to scale these up and carefully build research evidence of benefits, these methods remained marginal, comprising a small fraction of all consultations, and zero in many specialties.

The tables have now turned in 10 weeks, as the equation on the relative advantage of remote consultations has been transformed by covid-19; for example, NHS England has stated that as many as 85 per cent of GP consultations are taking place remotely during the pandemic.

Further examples of swift adaptation include the creation of critical care capacity at the Nightingale hospitals, the expansion of the role and capacity of NHS 111, and the less visible but no less extensive reworking of pathways in NHS and social care providers, enabling rapid discharge of thousands of patients to create bed capacity.

Equally innovative approaches are now needed to address the questions arising from this pace of change, as the immediate crisis response shifts into a second phase, likely to continue until a vaccine or treatment is widely available.

Aside from more visible innovations, what other changes are taking place? What is their impact on quality? How can policymakers, clinicians, managers, and patients and the public come together to decide what should be sustained, and what discarded, often in the absence of definitive evidence?

Local innovations 

The challenge of even identifying and capturing the full range of changes is a significant one. Service innovations have taken place through widely distributed routes: through national bodies, where for example, the Health Foundation’s policy tracker records 95 major policy responses since the end of January, and NHSE has issued more than 50 sets of specialty-specific advice for treatment of non-covid patients.

Royal Colleges, speciality societies and professional networks have acted as critical conduits for changes to clinical practice and education. Yet more innovations are emerging locally, and are less visible, as staff have used their ingenuity to reduce risks of infection while still delivering care.

One step on this front is to create more distributed, agile means of capturing and sharing learning from local innovation, for which there is clearly great appetite; an online workshop offered by the Q Community (an initiative connecting people with improvement expertise across the UK and Ireland) on how to do this well registered its full capacity of 300 people within 24 hours.

Yet more innovations are emerging locally, and are less visible, as staff have used their ingenuity to reduce risks of infection while still delivering care

A second challenge is how to assess impact to inform decision-making on what’s working, what to adapt, and what to retain, in the absence of the usual carefully controlled management processes of planning, piloting, commissioning, evaluating and monitoring.

This starts with getting a better understanding of the acceptability of these changes. Public, patient and clinical attitudes to particular innovations will be key to what is sustained, and may shift with experience and given the increased risks of face-to-face consultation.

In polling of 2,000 UK adults in 2018, only around 63 per cent were willing to have a video consultation for minor ailments, 55 per cent for chronic conditions, and 43 per cent for emergency advice.

Rapidly moving changes

We also need to understand the impact on experience and outcomes; we know the spread of an innovation in itself doesn’t mean we can be sure of getting the same results everywhere, as quality of implementation and local context matter. Some innovations may also risk exacerbating existing inequalities.

So, while national research efforts are for now rightly prioritised on urgent public health and clinical questions, decision makers will also need rapid evidence of the impact of service changes, to understand their benefits and any unintended consequences. Emerging models here include the use of citizen science methods to gather perspectives from clinicians, safety experts and patients; THIS Institute at the University of Cambridge is running a prototype project on managing obstetric emergencies for covid-19 positive women.

Finally, leaders throughout the health and care system need help to make sense of the huge range of innovation and research underway, particularly at a time of relentless and intense operational pressure – to feel their way towards a more sustainable balance of acting and thinking.

In the absence of the usual events and conferences, new forums will be needed where policymakers, managers and clinicians can debate emerging evidence. System partners and knowledge brokers, social media influencers and professional communities will all play a critical role in making this evidence visible, interpreting it and ensuring it informs, and is informed by, the rapidly moving changes in the practice and experiences of clinicians, patients and the public.