The coronavirus pandemic has brought great change across our society, including in health and social care services.
There are of course terrible consequences – loss of life, illness and bereaved families, as well as the closing down of normal social discourse. There will be economic consequences – some businesses will not survive, those in the gig economy are the hardest hit and many people will lose their jobs. This will lead to more inequality, more poverty and more ill health in the long run. The political response to the economic downturn could be more austerity which will have longer term consequences for the health of the nation.
A great disruptor can shift the status quo quickly – some of the current changes in the health and social care systems may or may not persist at the end of the crisis. Some of the longer term and seemingly intractable problems in the system have been brought to light.
The parlous state of social care is obvious – there has been a mobilisation of local community volunteers to look out for older people and those who are vulnerable. Could some of this community action persist?
The importance of the Care Home sector has also been on the agenda –with recognition of the poor staffing levels, and poor pay of the care workers who in the recent past have been designated as “unskilled”. They are caring for very vulnerable people in difficult circumstances with poor support from the wider system (such as the current lack of Personal Protective Equipment).
It has also been clear that the medical support of the vulnerable residents is often poor. There has been a lack of Advance Care Planning, which should be routinely done for all residents –but in a sensitive thoughtful and personalised way, involving the person if possible and their families. Before the crisis about 10% of emergency hospital admissions were care home residents, most of whom died soon after admission –a hospital admission may not have been in their best interests and have caused additional distress.
But the sudden crass imposition of blanket Do Not Resuscitate Orders for all residents in a care home by some GPs , with instructions that care home residents should not be admitted to hospital caused rightful outrage and a fear of people being denied appropriate treatment. Those discussions should have taken place before, and be part of the routine care of people in care homes. This involves thinking about each individual’s best interest and how much intervention will be appropriate – and welcome. Maybe more thought will be given to this in the future?
The NHS has created extra capacity by buying beds from the private sector, by creating field hospitals at great speed and designating existing areas into COVID 19 treatment areas. Patients have also been discharged at speed from hospital – delayed discharges are often the norm, when people need support at home. The intractable problems of working well across social care, community health services, private sector, residential care and voluntary sector have been partially overcome, at least for the moment. More funding has been put in, less bureaucratic hoops have had to be jumped through – can those lessons be learnt for the future? The underlying crisis in social care MUST be addressed, not kicked into the long grass as usual.
There has been flexibility of roles, with a redeployment of medical and nursing staff from specialist units, to deal with the emergency case load and the need for intensive care. General medical and nursing skills have been applied to the presenting patients. The system has been trying to achieve more generalism and less super-specialisation for some time, with a need for more senior staff to be at the front line when patients present to hospital. How much resistance will there be to this continuing in the future, as professional interests come to the fore again?
The NHS has moved to a “command and control” footing, with local commissioning side-lined. Will local Clinical commissioning groups survive? The suspension of market mechanism payment regimes and target achievement in General practice, alongside the writing off of the debts in hospital and community trusts means that the NHS is looking less like an internal market. Will there be a renewed drive for market solutions, with private contractors being brought in – or has that moment now passed?
General practice has rapidly adopted new ways of working with video and telephone consultations being the norm. This was resisted by a lot of the profession in the recent past yet is now widespread. This way of accessing general practice is obviously not suitable for everyone (there are concerns about people with mental health problems in particular) and there will be a need for physical intervention with some patients, but this new way of working could also apply to Hospital outpatient consultations.
There has been a 30% reduction in A and E attendances – we don’t yet know exactly why, but some people are avoiding what they see as a dangerous place. There may be less trauma (less traffic on the road), and people may be dealing with self-limiting illness at home, or getting telephone advice. There has also been some concern that people who really need treatment have not been accessing it. Whether the relentless rise in A and E attendances seen year on year will recommence after the crisis remains to be seen.
Many staff in the NHS and local authorities have been working from home, using digital technology to meet with colleagues. Some of this redesign in jobs could continue, with much more working from home, leading to reductions in road traffic density, in commuter stress, and in air pollution; the crisis may affect climate change for the better.
There will be many changes in our society after such a shakeup –some consequences will not be predicted, some will be really bad news –others may be for the good in the long run. We need to be thinking carefully when we eventually begin to come out of this crisis. “Business as usual” may not be possible –and may not be desirable.
Linda Patterson 21st April 2020