Politics

Coronavirus: the crisis the NHS needed?

The health service will emerge stronger and better prepared to face the next pandemic

June 02, 2020
Photo:  Yui Mok/PA Archive/PA Images
Photo: Yui Mok/PA Archive/PA Images

Before coronavirus knocked the world off its axis, many healthcare systems, including the NHS, were facing major difficulties. These included rapidly rising levels of non-communicable diseases (for example, the care of diabetes now accounts for 10 per cent of NHS expenditure), co-morbidity—the majority of people over the age of 75 have three or more significant chronic illnesses—and an ageing population, with more than five million over-75s in the UK. At the end of 2019, the NHS had serious problems. A recruitment, retention and morale crisis across the service meant that hospital duty rotas were riddled with gaps, general practices were closing down, and waiting times in accident and emergency departments and for hospital outpatients were escalating. Little wonder that one of the first slogans to emerge in the crisis was “Protect the NHS.”

In the event, the response by health service and care workers at every level, accompanied by an astonishing level of public support, has been little short of miraculous. The professional and public reaction to coronavirus demonstrated the depth and strength of support for the NHS, although this has scarcely been matched by the fumbling management of the crisis at the highest levels of government and health sciences. Frontline NHS staff deserved better. The carnage in care homes is a tragedy of its own.

However, the pandemic has undoubtedly jolted the NHS into adopting and developing new ways of working which are likely to become embedded, with considerable benefits for the service in the future. It will be astonishing if the post-mortems on the pandemic do not reveal the need for major organisational and policy changes.

First, technology. The New York Times described the adoption of telemedicine in the UK as “10 years of change in one week.” The NHS, chronically averse to adopting new technologies, suddenly found that technological alternatives to face-to-face GP consultations or outpatient visits are not only feasible, they may be preferred by patients and have advantages over traditional ways of working. Before coronavirus, only a minority of GP appointments and very few hospital appointments were conducted by telephone or video link: this has now become routine. Screen time cannot substitute for physical contact and examination in certain cases, but savings of travel time, time off work, waiting room delays and the associated costs of all these are considerable. Medical Royal Colleges and university departments have produced detailed guidance on conducting Covid-19 and non-Covid-19 video consultations to maximise diagnostic accuracy and minimise the disadvantage of dealing with disembodied patients.

Disquiet about the credentials of some providers, such as Babylon Health, may have deterred NHS clinicians and managers from widespread adoption of direct, smartphone access to primary care, but this will undoubtedly change because of the coronavirus crisis. The disengagement of general practice and primary care from clinical support in the care home sector has been starkly highlighted: TECS (telemedicine-enabled care services), with remote monitoring and digital assistants, and wearable or in-room sensors to measure and transmit important physical signs, such as temperature, blood pressure and pulse rate, are likely to become routine. Linking these measurements to computer-generated measures of illness severity, such as the National Early Warning Scores, could lead to better clinical support and greater patient safety.

The care home disaster had been waiting to happen for some years. The Dilnot Commission in 2011, the Barker Commission in 2014 and the Economic Affairs Committee of the House of Lords have all advocated an integrated approach to health and social care, recognising the delicate reciprocity between them. On 4th July, 2019 the committee published its report “Social care funding: time to end a national scandal,” in which it urged an immediate £8bn investment in social care and the provision of free personal care for five years. This now looks a bargain. Readmission to hospital of elderly people within 28 days of discharge, often because of poor community support, is calculated to cost upwards of £2.5bn per annum. Despite changing its name in 2018, the Department of Health and Social Care has not lived up to expectations or to its responsibilities in ensuring that full attention is paid to care outside hospital. Proclaiming plans to build 40 new hospitals will always trump an announcement about improving services for incontinence, pressure sores and malnutrition in the elderly. In future the DHSC really must do what it says on the tin. Hospital and community care, including care homes, need to be seen as interdependent components of a single system which requires central oversight and coordination.

These rapid changes in the delivery of healthcare are being fuelled by even more rapid changes in the way in which the results of medical research are disseminated. Delays built into the traditional peer review publication system are being reduced by very rapid review or pre-review publication of preprints, which have been accepted in the physical and biological sciences for many years, and provide an opportunity for authors to respond to comments from multiple sources before being finalised for publication. This growth of open access and sharing will accelerate moves towards open science envisaged by Plan S, an initiative for open access publishing supported by an international consortium of research funders. Extraordinarily rapid drug and vaccine development, and unprecedented collaborative efforts involving academia and big pharma, could set new standards for clinical research in the future.

Covid-19 is a catastrophe, but there are many reasons to believe that systems of healthcare in many countries, including the NHS, will emerge stronger, more effective, efficient, and agile, capable of meeting their populations’ growing needs and able to react more effectively to the next national health crisis.

Roger Jones is emeritus professor of general practice, King's College London, and writes about primary health care and health policy