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.