What will the next six months bring for the NHS? HSJ has spoken to the service’s most senior figures and makes the following predictions.
The testing programme
The test and trace system is meant to provide a three-week warning to the NHS that a spike in coronavirus cases might be on its way.
It cannot do so at the moment – but it might be able to do so by July. It is the tracing part of the system that is particularly challenging, but for planning purposes the NHS just needs the theoretically simpler testing programme to reach sufficient scale.
As the testing infrastructure grows in size and effectiveness, NHS England will feel more confident in releasing capacity it reserved (in case of a surge in the virus) for non-covid services. This “release” will mean the return of services “displaced” because of the coronavirus response, as well as the ability to use staff and buildings more flexibly to meet non-covid demand as it re-emerges.
As confidence grows, NHSE is likely to be more content to let regional and local systems make their own decisions about when to free up capacity.
However, expect this capacity release to be a slow and gradual process – the centre does not want the NHS to be ramping services back up only to slow them down a few weeks later because the capacity is needed to deal with a rise in coronavirus cases.
This caution means that so-called “phase three” of the NHS’s coronavirus response is likely to begin next month rather than this one. NHS acute hospitals may be operating at 50 per cent capacity for some time.
The NHS is about to enter a new era in which infection control measures will assume much greater significance.
Operating a health system in the midst of a pandemic requires ways of working which will impact very differently on specific services. For example, activities which have previously able to maintain high activity levels – such as cataract surgery or endoscopy – will find their models severely challenged by the need for more regular “deep cleaning” or donning and doffing protecting equipment after each patient.
But every service, role, individual and organisation will be affected – to a greater or lesser degree – by the need to keep the virus at bay.
This also means the NHS is going to have to take social distancing more seriously.
NHS staff will be subject to the same isolation rules as the general public if they come into contact with a carrier outside a clinical setting, including within hospitals, as health and social care secretary Matt Hancock stressed on Friday.
This matters because, in general, NHS staff are not catching covid from patients, but from each other. This is a result of social areas not designed for distancing, fatigue and, in some cases, exceptionalism. The recent case of a 12 strong orthopaedic team now all in isolation after their decision to hold a face to face meeting, and the subsequent testing positive for covid of one of their number, is the kind of behaviour the NHS can ill afford.
Messages about the importance of social distancing even at the risk of pissing off knackered and stressed NHS staff will need to get louder, as they did when masks were made compulsory in non-clinical areas of hospitals last week. At the same time a forensic audit of how the social areas of healthcare facilities can allow social distancing needs to become a priority for every chief executive.
Switching the default
The NHS has been debating “moving care out of hospitals” for decades. Now it has an urgent incentive to achieve that goal. Faced with doing work in the community and/or virtually – or not doing it at all – the service has finally begun to move at pace. The same is true of the previously tortuous attempts to create hot and cold (separating emergency and elective-only) acute sites.
The fact the NHS will be living with covid for, very probably, at least the next 12 months means those parts of the service that have resisted such moves – for good reasons or bad – are now having to join the enthusiasts in making the shift.
The realignment to community and virtual delivery may be aided by changes in patient behaviour. Demand in the future is likely to look quite different than before the pandemic.
Within emergency care it is minor cases that are being displaced at a rate of 14 to one when compared to major ones. This, of course, is exactly what countless initiatives have tried – and usually failed – to achieve. Some of this workload is bound to return, but even a sustained 10 per cent decrease in minor attendances would give the NHS the breathing space to bed in robust alternatives.
The centre remains sceptical about warnings of the elective waiting list ballooning to seven million plus. Elective referrals are also significantly lower than pre-pandemic. They too will increase, but there should be no assumption the pattern or scale of referrals be the same – especially once again if alternative community/virtual solutions become widely used.
Money, still no object
For once, the availability of cash is not a constraint on capacity (although capital still is). The NHS continues to draw down from the chancellor’s blank cheque.
However, this is not proving as painful for the Treasury as might be expected. Lower activity levels elsewhere in the service means much of the covid-related work has been “netted off” against savings elsewhere.
But the true financial cost of covid for the NHS is yet to come: More difficult conversations will come as both elective and emergency non-covid demand step-up, but more stringent infection control measures means it cannot be met without much more staffing and space.
All the while the pandemic will rumble on. There is particular concern that winter will be a pinch point for demand, capacity, and cost.
There are about 6,000 covid positive patients in English hospitals. The centre believes this number is likely to level out at around 5,000 and there are, of course, many thousands of recovering coronavirus patients who provide a whole new patient cohort with expensive, continuing healthcare needs.
Reform rolls on
Before coronavirus arrived to re-arrange our world, the health policy community were starting to get excited about the proposed legislation that would formalise the arrival of integrated care in the NHS. There is still hope at the top of the NHS shop that the government can be persuaded this is right thing to do and autumn the right time to do it.
Whatever happens – one thing is clear. It is over for clinical commissioning groups. Brave defences have been made of their role in the pandemic, but the truth is they were largely left on the side lines.
NHS England took their powers when a level four emergency was declared. Do not expect them to give them back. Instead power will flow to new leadership “cell” teams like those which have been created in London and Manchester to deal with covid and the fallout. They consist mostly of the leaders of integrated care systems but, the centre would like to think, with a newfound buy-in from top foundation trust leaders who have seen the collaboration light during the crisis.
Primary care networks too look likely to become even more important as enhanced community models are fast tracked.
It will be intriguing to see whether the events of the past three months mean the government develop an appetite for further reform.
While the NHS has enhanced its reputation at the top of government, by responding quickly, public health and the care home sector have not. There is a particularly pressing need for action on social care. Who knows how this most unpredictable of governments will seek to answer these questions, but its instinct appears to be to double down on the NHS whenever it can.
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