The consequences of Covid-19 for the NHS

The new coronavirus that arrived in the UK in January 2020 has triggered changes in the NHS which will be difficult to reverse, at least in the short to medium term. Crises lead to change when three conditions are met: there must be a latent desire for change, plus capacity to change, which pre-date the crisis; the crisis needs to reinforce the arguments for change, and even pre-figure new ways of working; and a political alliance is needed to turn the possibility of change into reality. If we think of the NHS in its pre-pandemic state in these terms,  we might spot some changes that may become permanent. 

The NHS has a centralised  ‘command-and-control’ management style within a huge institution made up of intertwined and sometimes competing bodies. Some of these management actions may prefigure or bring about future changes. They include:

  • Commissioning NHS England took over commissioning services from Clinical Commissioning Groups (CCGs), which had anyway failed to transform the ways in which the NHS worked over the preceding decade. There was latent desire for change and the crisis required the NHS centre to work around CCGs. It seems unlikely that the CCG form of commissioning will be restored. 
  • General Practice The NHS increasingly dictates the terms under which the public contact their GPs, encouraging doctor-patient communication via video consultations and email. The technologies for virtual consultations that took the commercial provider Babylon years to establish in two cities have become established across general practice in weeks. General practitioners are beginning to look like doctors working in a salaried service, instead of being sub-contractors. There is growing interest in a salaried option, especially among younger GPs5. Here there has been a growing sense in general practice that it could not go on in its present form, and NHS England agrees, although it does not anticipate a sudden change.
  • Spare capacity and labour direction Not only has the NHS taken up direction of professional labour, encouraging forward movement of specialists into A&E departments and seconding nurses to work in field hospitals, but it is also mobilising ‘returners’ from among the recently retired. Volunteers have also come forward in large numbers to provide temporary support for isolated people staying at home without family support. Managers in the NHS will want new, flexible ways of working to remain but some professionals may want to return to the status quo ante; both camps will search for political alliances.

New capacity was created by conversion of existing premises into infectious disease wards with ventilation capacity, and by construction of large field hospitals like the 4,000-bed Nightingale Hospital in London. The NHS bought almost all spare capacity (in terms of beds and staff) in the commercial medical sector. These acquisitions may not be permanent but there will be a backlog of postponed surgery and cancer treatments to work through, and spare capacity in theatres and beds will help this.  The need for slack in the system has been acknowledged for a decade but now there is publically visible spare capacity which may prove difficult for politicians to close.

  • Integrated health & social care  By contrast, the NHS has failed, despite decades of talking, to reach agreement with local government social services, and so is still handicapped in transfers of mostly older people with multiple problems out of hospitals into community settings. Retired social workers are not being called back into action. 

This historic mismatch may yet change, but it will probably do so slowly. There are accounts of some Integrated Care Organisations (which depend on collaboration between local government and the NHS) developing quickly because managers who would often act as brakes to progress are absent, dealing with Covid-19 planning. Others report that the NHS and local government operate with same distrust and disregard for each other as usual. 

This is a deeply entrenched problem that successive governments have promised to uproot, but nothing much has happened. One suggestion that may offer employment opportunities during the coming recession is the formation of a community health worker service staffed by young people who have gone through a crash training programme. And smaller changes may also make a difference. How different the NHS response to Covid-19 might have been if Advance Care Plans were in place for vulnerable older people like those living in care homes. Such plans should contain the option for us to decline ventilation, just as we may decline resuscitation. The NHS knows what to do but government has prevented change; it will probably work around the problem, but avoid trying to solve it

  • Market mechanisms The government has abolished payment by results and payment by performance in the NHS, and suspended payments for target achievement in general practice. It has also written off the debts that hospital and community trusts have run up with the Department of Health, a “hair cut” that has been talked about for two years. These are blows to the marketisation of the NHS, and will re-inforce the existing enthusiasm for direct control of the NHS from the centre. The NHS is beginning to look like a service that is clinically-led rather than target-driven. The supply failures suggest that it is time for the NHS to grow its own PPE and diagnostic testing kit manufacturers, in-house. A long-standing policy of marketisation may well be rolled back further when the full benefits of command and control management become evident
  • Public engagement & case mix Constant encouragement to relieve pressure on the NHS seems to have had an effect; attendances at A&E departments fell by one third in March 2020, the biggest fall being among young adults.  With hospitals being depicted as dangerous, infectious places, potential A&E users are understandably avoiding them. Supplier-induced demand may also be reduced, as doctors and nurses prioritise those with infections and pay less attention to others, reducing follow-up or onward referral to outpatient clinics of patients who do not have Covid-19. Use of health services (often confused with ‘demand’) has risen relentlessly, but Covid-19 has stopped this. The public will want normal services to resume. There may be a latent desire to change but not the capacity; Covid-19 is a disruptor that causes an emergency mobilization but not long-term changes in behaviour.   

These are only the most salient of examples of possible long-term changes in the NHS being initiated by short-term responses to Covid-19. Not all changes will take root. But overall the old order of the NHS will be shaken.

Steve Iliffe

3 Replies to “The consequences of Covid-19 for the NHS”

  1. Congratulations Steve on your fascinating analysis.
    Surely the next step must be the creation of a blueprint for the future structure, management and funding of healthcare and social care which seeks to incorporate the lessons learned from the pandemic as well as tackling the long standing problems of health and social care delivery that have been evident for many years but have been ignored by successive governments. In short we need a big vision for the future.
    A key element of the blueprint must be a mechanism for preventing the government of the day meddling for ill informed and ill judged political reasons as has been the practice for the last forty plus years. This could present very difficult constitutional problems that need to be thought through.
    In my time as Chair of the Socialist Health Association twenty odd years ago we spent a lot of time trying to develop a blueprint that addressed some of the problems as we then perceived them but it got no further than an early draft or two. Some organisation such as the SHA working with others such as the Kings Fund needs to work on such a blueprint now as a matter of urgency. My fear is that when the pandemic is history – hopefully later this year – everything will return more or less to the status quo ante and the momentum for change will evaporate. Paul Walker

  2. Many thanks Steve for a very thought provoking blog. My reflections are as follows:
    -You mention that a crisis leads to change when certain conditions are met, and I wonder if tackling health inequalities will meet these conditions. There was a latent desire for change, there is capacity to change ( but we can see financial resources are going to be even more stretched as a result of the pandemic) and certainly the crisis has reinforced the arguments for change, including the deep concern of the impact of the crisis on our BAME communities. As Jennifer Dixon of the Health Foundation said on the 25th February 2020, commenting on the Marmot Review 10 Years On, “..the plea is for the Government to develop an explicit strategy to reduce health inequalities: to join the dots on existing efforts, coordinate scale and boost action, set some manageable targets to reduce health gaps, and publicly report performance against them.”
    -I wondered whether you could explain further your statements under “Commissioning”, that “NHS England took over commissioning from CCGs..” and “It seems unlikely that the CCG form of commissioning will be restored”. NHS England might often, under normal circumstances carry out tender processes anyway, where products or services are to be made available and are to be drawn-down by many public bodies, such as NHS Trusts, and where the latter would be the contracting party with the chosen supplier(s). Further, CCGs appear still to be much needed for the co-commissioning of GP services and also services like acute and community health services using NHS Standard Contracts. Furthermore, during the crisis, commissioning decisions continue to be made by CCGs including giving notice to terminate substantial health service contracts and to put in place their strategies to achieve better integration.
    -In relation to General Practice, it would be interesting to hear more about how GPs can help more radically in integration going forward. How best to utilise PCNs or whether Local Resilience Forums could play a part or the possibility of GPs playing a greater triage and pivot point role for both the care and health sectors to enhance integration.
    -In relation to spare capacity, your reference to the Nightingale Hospitals and buying spare capacity from the commercial sector made me think ( bizarrely perhaps) of how the Crown bought extra services from the Cinque Ports and Ancient Towns before the regular establishment of a Royal Navy. The arrangement was that, in exchange for charters freeing them from tolls, dues and other burdens, the Ports of Hastings, Romney, Hythe, Dover and Sandwich would provide so many ships, men and boys for service at sea during the space of 15 days in any one year. For services in excess of 15 days they were permitted to put in a bill for overtime. It just made me think of the Government these days agreeing with owners, landlords etc, to make facilities or capacity available for a certain amount of time every year. If the capacity is not used for real emergencies it could be used to replicate emergencies and conduct preparedness exercises, to absolutely make sure we have the skills to convert and manage facilities like the Nightingales, on an ongoing basis, and to do it fast.
    -In relation to integrated health and social care, it is interesting that you mention advance care plans. I think these are very prevalent in personal health budgets but of course the take-up of these has been relatively small. The Department of Health and Social Care is very keen that CCGs scale up on these budgets. On integration more generally I do recall that Matt Hancock said in one of the Downing Street briefings that he did want to sort integration and its funding and he was going to get on in this Parliament to try and achieve that.
    -Finally in relation to market mechanisms, I wonder if the Government is going to, in particular, dwell on the word “accountability” after this crisis. If the Government has been accountable to the press and the public for the day to day pandemic response, even though for example NHS Trusts, Councils and Care Homes are separate legal bodies, it may want to look and think more about the ongoing operational requirements that providers should be subject to, like further controls and checks of readiness and preparedness for emergencies.
    Steve, I said your blog was thought provoking, and I am sorry I may got rather carried away in my response.
    Best Wishes

  3. I like Paul Walker’s ideas about a new blueprint for the NHS, but does the failure of previous efforts to produce blueprints mean that this engineering model – in which the blueprint shows us where everything fits – may not be the best way to understand the NHS. Perhaps a more organic systems model might be a better fit?
    Chris Brophy’s comments are challenging. Is the current polarisation of wealth correctable by attention to poverty, or even to Marmot’s gradient of inequality? Marmot’s work on inequality is powerful, but has it had an impact on policy and practice?
    I may have succumbed uncritically to the general feeling in the NHS that CCGs are on the way out. This may be wishful thinking, but the Covid-19 crisis has demonstrated the power of centralised decision-making and action, which has moved resources around, abolished Trust debts, built field hospitals and postponed elective work. Maybe the old (post 2012) system will reassert itself. As for general practice, the collectivisation processes that have been going on for decades are now accelerating. Whilst most GPs want to get on with the job (as long as they can influence the job description) and don’t have great ambitions, some will find a career path within PCNs and ICSs where they can be innovative and collaborative.

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