How the NHS can get back on track after covid

As the covid pandemic begins to fade the NHS will face the challenging task of catching up on elective work while also coping with ongoing demand for emergency care.

It will not be doing that from a good starting point: before the pandemic hit in March, the NHS was already failing to keep up with the volume of elective referrals, with rising waiting lists which have been compounded by cancellations in the early weeks of this year.

And the NHS will largely have to tackle this backlog – and deal with both elective referrals and emergency attendances – with the resources it currently has, both financial and staffing. How to make the best use of existing staff and facilities – and driving up productivity – was the key issue debated at an HSJ webinar sponsored by Four Eyes Insight and Prism Improvement.

Panellist Nigel Edwards, chief executive of the Nuffield Trust, laid bare the magnitude of the task ahead. Comparing March to December last year with the same months in 2019, there were 4.5 million fewer GP referrals and close to 6 million fewer referral to treatment “clock starts,” as well as extraordinary drops in diagnostics – especially endoscopy. This was reflected across individual specialties, with orthopaedics particularly hit with nearly 140,000 fewer inpatient procedures and 192,000 fewer day cases, for example.

“There is a mountain to climb in hospital activity,” he said, adding there would also be pressure on some services from long covid.

However, the impact on staff of working through the epidemic could also be important, he said. In the Far East, an additional 8 per cent of staff who worked through the SARS epidemic had left afterwards due to stress. And there was evidence that about 40 per cent of ICU staff had some form of PTSD.

A new paradigm

But the NHS won’t be going back to its old way of working, said Saffron Cordery, deputy chief executive of NHS Providers. There had been a transformatory element to the pandemic which needed to be grasped, she said: “I don’t think business as usual can be the phrase we should adopt. It’s got to be something else, a new paradigm, a new way of operating in the NHS.”

Staffing across the NHS and social care was fragile before the pandemic and now needed a firebreak. “They are fundamentally exhausted and on the point of being broken after dealing with a pandemic for 12 months,” she said.

Former health secretary Stephen Dorrell – who now chairs Four Eyes Insight – summed the position up as “this is not just going back to some familiar model. This has to be the core starting point.”

Remote consultations would continue and could make the NHS more accessible

Hospitals faced two types of unmet demand – those on waiting lists for planned care and the less visible demand of those people who had not been referred – while also seeing capacity affected by the needs of infection control, he added.

“The idea that as a hospital manager you can address those three problems by saying what you need to do is a bit of performance management would be the surest mechanism for making certain the system collapses,” he said. Managers needed to deliver a solution which made the NHS a more attractive place to work and reignited the passion staff had shown over the last 12 months, he said.

So what is the alternative to returning to old ways of working? Ms Cordery said there were many ways the NHS should change post-pandemic – one obvious one was that people no longer expected to automatically have a face-to-face consultation. Remote consultations would continue and could make the NHS more accessible.

“The nature of what we see as priorities is changing,” she said. There would be fundamentals which would not change – such as treating people with life-threatening conditions. But there could be questions such as how to organise waiting lists – what priority should be given to working age adults who had conditions which prevented them working, for instance – and how to approach health promotion, prevention and health inequalities.

However, the real issue for the NHS was capacity, said Mr Edwards, and there were no easy answers to this as there wasn’t a “big set of things in the arsenal” to boost capacity. There was some scope for “industrialisation” of elective care but staffing and capital investment were constraints. There was scope to improve productivity although this had not been easy in the past.

He asked whether a “hard conversation” was needed about what the role of the independent sector – especially those organisations with charitable status – should play in clearing the backlog.

Set the priorities

And he suggested that priorities needed to be thought about – what was the priority of someone waiting for a diagnostic procedure compared with someone accessing emergency department for something self-limiting?

However, he pointed out there were many downsides from delaying elective care. Long waiting times for treatment and people not getting treated merely moved pressure to general practice. “There is a whole downstream problem in the rest of the NHS if we try to overly ration elective treatment. The problem does not go away, it just moves,” he said. Delays in treatment could just add to costs, he added: “I think we are going to have to invest. I don’t think there is a way round it.”

But Mr Dorrell said he could see “crocuses of hope.” “We have been surprised by how quickly things changed in the health services,” he said, citing general practice as an example.

“In hospital services, I remain persuaded that there is an opportunity for us to improve the quality of care we deliver and the environment which people work in,” he said. Unwarranted variation between organisations meant there were opportunities in areas such as theatre productivity.

“Every trust faces an immediate issue with its planned care waiting list. Looking at where there are opportunities in the people waiting and the way they are treated when they come into the trust that is an important element in improved management.”

Care pathways could also be adjusted to reflect the changed infection control needs of covid, he said.

Emergency care could also need a new approach. “We have to look at why people present at the emergency department and we have to deal with the root cause of those presentations,” he added.

And Ms Cordery could also see reasons for optimism, although she warned there could be a slower pace of recovery than in usual times as infection control procedures would be a limitation.

“I do think there are little kernels of gold in what we have experienced over the last period that have altered our relationship with the NHS. It may be a temporary alteration and over time what we have experienced falls away and the public’s relationship with the NHS changes again. We can have different kind of conversations with patients and the public about the services they receive,” she said.

There were things which should be “locked in” – such as staff not feeling they needed to seek permission to make changes and the flexibility which had been shown. “If we lose that we have lost a real prize in terms of what might come out of a terrible situation,” she said.

This webinar was broadcast live on Wednesday 24 February at 10.30am. The free webinar can now be watched here.