This is a summary of a presentation made at a webinar held by St Mary’s University Twickenham on the 28th September 2020. The other presenter was Rt Hon Sir Norman Lamb, and the debate was chaired by the Rt Hon Jenny Willott. The talk looked at changes in the workforce and transparency of decision making that are needed post-COVID-19.
SARS-CoV-2 (COVID-19) has had a massive impact on society, both in this country and around the world, with around 42,000 deaths in the UK (as on 28/9/20). As a result of COVID-19 we have all experienced restrictions, including lockdowns, that have impacted everyone. The world that we eventually emerge to will be different from that we left in March.
One area where the impact has been particular large is of course the NHS. COVID-19 has led to structural changes, for example a rebalancing of power from individual providers, such as NHS Trusts, towards systems run at a regional level. It has also produced changes in the way it works. Most of these changes were already happening, what the pandemic has done is accelerate them.
There has also been a big impact on the public perception of health. This has included a realisation of massive inequalities in health, a result of socioeconomic disparities and embedded racial discrimination.
There has been a massive outpouring of support for the NHS, as Nigel Lawson said some time ago it is the closest thing we have to a national religion in the UK. This was seen in the Thursday ‘Clap for Carers’ as well as the massive increase in people applying to work for the NHS (this year applications for nursing degrees were up 15%).
There has been the beginning of a debate on personal responsibility for health, and we need to build on that so that people understand and accept how the choices that they make impact on their health.
We have seen changes in the NHS, that would normally take more than 5 years, happen within 5 weeks. These include remote consultation, structural reorganisation, and a willingness to embrace innovation.
Indirect effects of COVID-19
But going forward we are faced with some massive problems. These include the indirect impact of COVID-19. Some expert observers predict that more people will die because of COVID-19 than of COVID-19. This is very difficult to estimate, but a bundle of studies suggest that excess cancer deaths will be between 3000 and 10 000, though some are more pessimistic with a worse case scenario of 35 000 excess deaths. During lockdown deaths relating to heart attacks rose 40%, and the BHF estimates that there have been over 3600 excess deaths from heart and circulatory disorders. This number may increase over time due to the long-term consequences of late diagnosis and so inadequate treatment early in the disease. These numbers are all estimates but demonstrate the indirect impact of COVID-19 on health, over time, may be as great, if not greater, than the direct impact.
One area where this is especially critical is in mental health. It is almost impossible to forecast what the short- and long-term impact of the anxiety and stress caused both by fear, social dislocation and the economic downturn will be. There will also be impacts on NHS staff and patients who have recovered after months in ICU and who have PTSD. The Centre for Mental Health has estimated ½ million additional cases of mental health following COVID.
Then there is the impact of the inevitable economic downturn. This will stress the NHS by increasing health inequalities, increasing the health needs and also reducing the funding available for health.
In the short term we are also facing a loss in confidence of people in the ability of ‘those in power’ to deliver the changes – which may impact on necessary behavioural changes.
Need to decide on the change we want
We need to deliberately think about what we change in response to COVID-19. There are things that we have changed during the crisis that are good, and we need to continue. Other things were the right thing to do in an emergency but which we need to stop and revert to normal. There are some things we have stopped doing that we need to restart, and other things that we have stopped doing and will not restart.
So, there is an opportunity there. We need to make a decision as to what we want the NHS to be, and look to a future with a better, more sustainable, health service.
In the brief time I have I will only touch on some aspects, in particular workforce and transparency.
What we need to do when looking at this change is put the patient at the centre of our thinking. We need to think about what support they need to maintain their health and wellbeing. We also need to think about what is important to them in their health (healthcare is often too focussed on what is important for people, rather than to people).
The factor that most limits this are people who work in healthcare. Getting enough of the people with the right skills in the right teams is critical. The shortage of people is going to be the greatest limitation. The current government has a manifesto commitment to increase the number of nurses by 50 000 in the term of the Parliament – which is ambitious given the current numbers (around 290 000). But many commentators think that will not be sufficient as healthcare demands rise.
There is no doubt we need to have a work force that is larger, but they also need to work in new ways that improve care and are more efficient. There are several changes that are needed.
Teams and siloes
Crossing disciplinary siloes. This includes the professional siloes – now there is a often a rigid demarcation between professions such as nurses, doctors, physiotherapists and psychologists. There are also boundaries between medical disciplines. These siloes can be inefficient and reduce patient care. For example, a patient may be visited at home by a specialised nurse who will decide on the care needed, but will then instruct a health visitor or more junior person to carry out a procedure – such as change a catheter. This is neither efficient nor good care.
There is increasing emphasis on working in teams, with the specialist in a team providing training to others so that they are empowered to support the patients. One mental health trust I visited recently was educating clinical psychologists during their doctoral studies to teach other members of the team, including nurses, doctors, healthcare assistants, to provide the simple straightforward psychological support. The expert psychologist’s role is for complex cases and to support and train other members of the team.
During the COVID-19 pandemic circumstances have forced similar team working. The result of so many patients being ventilated is that there were many patients on hospital wards who had tracheostomies. These are normally cared for by specialised teams, on specialised wards, but this was not possible. During the height of the pandemic most acute hospitals in the major centres set up specialised tracheostomy care teams consisting of physiotherapists, dieticians, speech and language therapists, specialised nurses and (remote) consultant care. The teams were trained to go around hospital teaching ward nurses how to provide routine care for these patients, to provide support when things were complex, to do daily reviews and make critical decisions.
There has also been increased emphasis on distributed leadership, where people who would normally be thought of as ‘lower’ in the conventional hierarchy are given control. An example of this is in ICU which are traditionally very doctor led. Patients with COVID-19 in ICU will often benefit from proning, being placed on their front. This is a very difficult procedure to do on sick patients and proning teams have 6 staff to ensure patient safety. In many centres the procedure is led by a physiotherapist, with the anaesthetist in the team being responsible for maintaining the air supply to the patient but not leading the process. This is a small example of how patient care can be best provided if people change the conventional hierarchies.
Attracting and retaining staff
The need to bring people into the healthcare system means that we will need to look at improving access to the health professions. There are large parts of the population that are not sufficiently attracted to work in healthcare. This is an ongoing issue, but there is considerable work to improve pathways not only so people can be recruited to associate roles and then progress (for example from nursing associates to nurses and physician associates to doctors), but also so people can move between professions.
It is also important to make sure the NHS is good place to work so that it retains staff. This may be a particular issue in large cities where the high cost of living is balanced by the social advantages of urban life. This balance may be altered as a result of restrictions caused by the pandemic.
Technology can help There is also a need for medical professionals to use technology to enhance the care that they give. This is an area of considerable interest, and technology including wearable technology, remote sensors, as well as artificial intelligence and intelligent use of big data, can make healthcare workers more efficient. One example is Technology Integrated Health Management, developed by Surrey and Borders Partnership NHS Trust and academic partners. These are monitors that can be used for people with dementia and can monitor vital signs and movement. Machine learning allows those responsible for care to be alerted to unusual behaviours, such as agitation. This is now being rolled out across Surrey.
This is going to require us to rethink out medical professions. Health Education England has just published a report on the Future Doctor Programme, which talks about how the medical profession will change. It suggests that doctors of the future will have their patients front and centre, that they will need to be more generalist than present, that they will need to lead and collaborate in multidisciplinary teams, that they will need to focus on the health needs of the population, not just individuals, and that they will use research and innovative technology to improve care.
The final area I want to touch on is improving decision making and making it more transparent. The backlog of procedures since March has meant that surgeons and other clinicians have had to prioritise patients. This is inevitable. However, in the past this has been difficult to do in a way that is just and equitable and considers the particular needs of a patient, the only thing that was considered was waiting times. One response developed in Imperial College Healthcare Trust and now being adopted widely has been to develop a harm matrix, which provides a framework for assessing the potential harm to patients as a result of delay. This allows rational prioritisation, which considers the individual needs, rather than using universal waiting targets that inevitably distort provision and reduce the overall benefit to patients.
Covid-19 has had a massive impact on the NHS. The challenges continue. However, the response has been to drive change – much of which was already happening. What we need to do is to envisage what we want the future to be, so that we can build an NHS that is resilient, efficient and equitable and places the health of patients and populations at the heart of what it does. The workforce will be critical for this – and we need to ensure that those that work in the NHS are equipped with the skills and attitudes needed for a new way of caring.
Declaration of Interests
Organisations that Andrew is associated with can be found on his website (ajtg.co.uk). Of relevance to this presentation; he is Chair of Imperial College Health Partners and on the Board of Health Education England, the Health Research Authority and Surrey and Borders Partnership NHS Foundation Trust. This talk was given in a personal capacity.
An executive coach and consultant. Andrew has been held senior roles in universities. His interests include medical research and innovation, education, leadership and research ethics.
Web page: ajtg.co.uk
Blog page: andrewgeorgeblog.com
© 2020, Andrew George, all rights reserved
Published 29 September 2020