By Accountable Care Journal-
To begin with, let me thank all of you currently supporting services, be it in the NHS directly, social care or in services that keep us safe during this stressful time.
In such unprecedented times, when the full effects of the Covid-19 pandemic are evolving around us, it is obvious that the capacity of the NHS and social care will be significantly challenged, and quite possibly overwhelmed. We are learning to our cost, but not total surprise, that the ability to absorb large numbers of very ill patients in respiratory failure is inadequate. This is primarily due to two principal factors, the relatively low numbers and asymmetrical distribution of critical care beds across the UK, and a lack of trained staff to cope with such a surge inactivity.
Recent announcements to bolster the service, which include; rapid training in respiratory care for hospital staff; increasing the manufacture of respirators; pleas for 70,000 clinicians recently retired to return to the ‘front line,’ are all helpful. The response so far has been good. The shortage of trained critical care nurses has been highlighted in the changing ratio from the expected parity position of 1:1 to upward of 1:6, nurse: patients. The opening up of a 4000- bed field "Nightingale" hospital at the Excel centre signals the scale of the situation.
Public health measures are even more important in attempting to reduce infection rates and to smooth down the peaks in demand through social behaviour adaptations. However, international evidence is variable on this, as it seems to have been less effective in Italy than South Korea or China. This is a rapidly changing scenario and one where the normal rules of procurement and deployment are being either ditched or rapidly updated.
The remarkable public response, both in limiting their movements and in a declaration of support through volunteering at scale, is heartening.
Mortality and case numbers are rising in a frighteningly similar fashion to the sinister rehearsal in Italy, Spain and Iran. The US is not far behind and perhaps even less well prepared. We have all been taken unawares.
We are all getting used to words and phrases such as ‘unprecedented’, ‘apocalyptic’, ‘war-like situation’.
This virus respects no one, neither prince nor pauper. We have also seen a rapid reappraisal of societies' priorities. No longer the growth and isolation agenda, be it at national or Trust level, instead, more one of coming together prioritising and looking out for each other.
Most have acted spontaneously, distancing and isolating themselves, but this hasn’t been enough and most governments, including our own, have moved to restrict and compel behaviour change. This we have all accepted with humility and in the hope of abating what seems the inexorable rise in cases most notably highlighted in the work from Imperial College and Johns Hopkins universities.
The often-conflicting data sets and predictions must frustrate policymakers, but we are lucky to have a world-class scientific community supporting the Department of Health and Social Care and NHS England.
Prior to the current outbreak, there was already a recognition that the current workforce lacked the capacity to cope with the changing demographic, both in the UK and internationally. The NHS 'people plan' which was to address this has been postponed until the end of the year. It seems a somewhat hopeful document at present.
Covid-19 has opened up opportunities for new ways of working. The focus on acute care being separate from elective and prevention may make us think again about how services are delivered and commissioned. At present, this means longer waiting times for routine surgery and more worryingly cancer cases. This can only be temporary but we may end up with networked hospitals on large population footprints delivering hot and cold sites for care becoming the new norm.
We are also witnessing the rapid redeployment of staff from their traditional roles to supporting critical or respiratory care colleagues, everyone plays their part. Acute hospitals are changing the way they work and acting collegiately.
Perhaps the most significant change will be in how we deliver services locally and the increased use of digital health such as remote consultations via video/telephone, remote monitoring and testing, and, as important, self-care and accessing algorithm-based advice for self-limiting or chronic disease.
This must be the time for digital health to come ‘of age’?
Lastly, the role of the independent, NGO and voluntary sectors needs to be re-evaluated. The move to mobilise the bed base in large private providers for non-Covid-19 illness and procedures should act as a stimulus to joint planning and working in the future. Specialist NGOs offering respite for patients unaffected by the virus but who require help which the NHS will struggle to deliver, all a play their part.
What I think we are seeing, which is probably long overdue, is a reappraisal of what a health and social care system should and can deliver. It will also entail a fundamental look at the skills and talents we need to lead and deliver care. I expect a major overhaul of education and training both pre and post-licensing of clinicians.
NHS and social care staff are working above and beyond, by necessity as well as volition.
As more people contract the illness or have to self-isolate, and without effective testing programmes, the ability of the NHS to cope will be further challenged. The recent recruitment of volunteers, returners and those towards the end of their training will take time to have an effect.
The strains will begin to tell and mental health issues will develop. A nurse in Italy blamed herself for spreading the disease and committed suicide. Tragedies will continue to happen. We have all heard of the first two doctors in the UK to succumb to the illness. Chief Executive of NHS England Simon Stevens' recent letter outlining the NHS response to the crisis made special emphasis on looking after staff. This needs constant attention and vigilance.
So, what else can we do?
1. Test! Test! Test! Trace and isolate; States the WHO
Testing to date is to demonstrate exposure to and presence of the viral RNA signifying infection. It has been reserved for those thought to have the illness. Of those tested to date <10 per cent of cases are positive. We are not sure of our denominator and most estimates put those who have been exposed to the virus in the millions. We simply don’t know.
We have failed to test and trace, a long-held maxim of stemming an outbreak. This will be revisited as a post hoc analysis but is largely a result of a political decision rather than a change of emphasis by public health staff. Countries that have successfully limited the infection have tested heavily.
As time goes on, and if we successfully mitigate, many clinicians will have been infected and recover. The much-anticipated antibody test to confer past infection will be important as it will allow a boost to the workforce. We are uncertain if this conveys complete immunity.
2. Secure those most at risk
Isolating completely those at highest risk. The isolation by social distancing of the general population, and more importantly the quarantining of the most at risk 1.5 million citizens for up to 12 weeks, is a bold decision. Puesy in his paper Coronovirus; the hammer and the dance, sees this as the hammering down phase allowing for ‘time’ to plan and abate an inevitable second peak later in the year. This allows time to test, trace and isolate appropriately.
Public policy may become ambiguous, contrary or even contradictory as the evidence suggests different strategies depending on time and geography. The South West of England has a different trajectory than London.
What else to buy us time?
This won’t be the last we hear of Covid-19, nor the last of its ilk. We need to learn the lessons of SARS and this outbreak. Countries that had learned from SARS have limited spread more successfully than Europe and the US.
In the interim, we need to use the great international goodwill to develop vaccines, potential pharma interventions and better ways of escalating risk when a pre-pandemic is recognised. We might also reflect on the origins of the disease and look at basic animal husbandry and welfare.
So is the cavalry arriving?
Yes, more trained staff but not enough; yes, more drugs and insights into the virus including complex genomic evaluation and mutations; yes, on international cooperation; yes, on novel interventions but not enough in time; yes, on technology and how we use telehealth in a wider setting
Once we have managed up the first wave we must make immediate provision for the next. Anticipating a move to BAU will be well over a year away, let’s make some bold decisions on catching up. Some suggestions:
- Shorten nurse training programmes by 12 months and designate all 2nd-year courses as complete
- All doctors in the final year of speciality training to be awarded their licence, suspend final endpoint assessments and allow them to practice on a ‘green plate’ for a year with their local educational supervisor agreeing full licensure then
- Increase medical school places by 3,000 per year as of September 2020 (many international students will be absent and there is capacity in the new schools)
- Fast track new technologies, especially those that promote communicating at distance and where novel drugs can be monitored in true ‘real-world conditions’
- Under the new emergency powers act use the opportunity to agree shared data systems across the NHS/social care and agree a system provider avoiding a procurement exercise. Offer Google/IBM (other) a clear trajectory and use of data but with a long-term contract that is affordable and sustainable
- Data predicts where things are going well and where they’re not – we need to embrace it
- Use the crisis to define future social care funding and revise the decision on essential skillsets for future immigration policy.
- Commission the private sector to catch up on all elective surgery within 18/12 months
- Develop improved and more streamlined working with the 3rd sector for routine use as a provider organisation
- Free tablets and WIFI for every household with an isolated citizen at risk. Use charities like sliver line to help set up what’s important
- Reduce the regulatory load, self-assessment should be the norm with peer review. Abandon appraisal as part of revalidation
- Look for a new charter for staff and how they are dealt with, emphasising their essential roles as supporting a complex society
Lastly, I undertake reviews of excess mortality in acute care. Even in non-pandemic times, hospitals are at capacity and barely cope.
Our greatest clinical and operational issues surround the care of the elderly frail or patients with multisystem disease. Our system is geared towards individual specialities. This starts with unconscious (and perhaps conscious) bias in our clinical and medical schools. It is exacerbated during training programmes and through the rewards-based systems of payment that pervade the service.
We’re seeing who are the true unsung heroes of clinical care during this outbreak, we need to recalibrate what the health service is for and it’s not exclusively for specialisms.
We have discovered that in a crisis leadership reveals itself and that left unfettered people will innovate and do the right thing. The centre should set the ground rules, good local leadership can do the rest.
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