Health system recovery from Covid-19: International lessons for the NHS

As we move into the third year of the Covid-19 pandemic, the challenges confronting the NHS in recovering from its consequences are considerable. Elective services were scaled down during the worst of the crisis to meet the needs of acute and Covid-19-related care. Over 6 million patients are now waiting for treatment – a number that has grown by about 38% since the start of the crisis. More patients may not yet be accounted for as they have been unable to access primary, community or mental health services to have their health concerns addressed.

NHS England and NHS Improvement have set the ambitious goal of delivering around 30% more elective activity by 2024/25 than before the pandemic. Yet services must do so with persistent staffing shortages and health professionals still coping with the cumulative stress of the pandemic. Policy-makers and system leaders are tasked with clearing backlogs as quickly as possible, while simultaneously strengthening services so that they are more prepared and resilient for the future.

But the pandemic has left even the most well-equipped health systems vulnerable. Countries around the globe are confronting the challenge of how to recover from the legacies of the pandemic, providing an important opportunity to learn from other countries grappling with common challenges and asking similar questions about what a disaster-proof health system would look like.

This report uses interviews with medical directors, academics and policy-makers across 16 different countries alongside a structured policy analysis of each of those countries to understand how each has approached system recovery. The conclusions provide key learning and emerging lessons for the NHS on recovery and resilience as it delivers its own elective recovery strategy, as well as informing wider international learning.

Key findings

• The Covid-19 pandemic has created challenges for health systems of an unprecedented scale: not a single health system studied was sufficiently prepared to avoid disruptions to care that Covid-19 has caused. The pandemic has created an important opportunity to reflect and learn from long-standing health system challenges that the crisis has magnified and are impacting health systems’ ability to recover from its consequences.
• Health systems are pursuing a range of common strategies to quickly catch up on care backlogs and reform services to better prepare for future shocks. These include outsourcing care to private hospitals, extending clinical hours of care, scaling up remote and home-based services, separating planned and unplanned care, and implementing new staffing models to make best use of the available workforce. To enhance future resilience, countries are making significant investments in the workforce in order to recruit and retain staff in key areas, as well as in health care infrastructure to modernise facilities and expand capacity in acute and ambulatory care.
• The Covid-19 pandemic has typically reinforced health system priorities and ambitions rather than changed them, and has created a narrow window of opportunity to build broader system capacity. In many of the countries studied, the pandemic has served as a catalyst to advance system reforms to address long-standing structural weaknesses and priorities, but which have previously lacked political will or funding. We see this in the large-scale shifts to virtual care delivery and more flexible staffing models that are being sustained in many systems. It is also apparent in the way many systems are prioritising primary, community and long-term care capacity as part of recovery and resilience plans. The focus on non-acute health services reflects the interconnected nature of health system recovery, and how efforts to catch up on elective care will be futile if primary care, community care and long-term care are not also strengthened.
• The extent of the recovery challenge varies between and within countries and is a product of multiple factors, many of which are outside the health system’s direct control. These include public health measures, policy actions, and population behaviour, which have all influenced each country’s response to Covid-19 and the health and economic consequences that now must be addressed. The waiting lists that countries had going into the pandemic, how effectively countries have been able to contain Covid-19 cases, and how well systems protected access to routine and planned activity, will all inform how quickly countries are able to catch up on care backlogs and what is required to rebuild and strengthen future resilience. And even within countries, the effects of the pandemic have not been felt evenly, which will contribute to the different challenges health systems face in recovery, and will be a key consideration for countries as they seek to reduce backlogs or they risk entrenching inequities further.
• While the NHS is implementing similar strategies to other countries to clear care backlogs, its path to recovery may be longer than many other systems. The UK entered the crisis with higher bed occupancy rates and fewer doctors, nurses, beds and capital assets than most other high-income health systems, while experiencing higher rates of excess deaths during the pandemic relative to many countries. Waiting lists were rising in the NHS before the pandemic started, indicative of the challenges health services already faced in keeping pace with the demands placed on them. Countries with greater pre-existing capacity and that have more effectively contained coronavirus are likely to be in a better position to cope with care backlogs arising from the pandemic and recover from its consequences.
• Despite these different starting points, health systems face common challenges in rebuilding from the pandemic. In all countries studied, health systems are grappling with several unknowns and risks that may undermine recovery and future resilience. These include lagging rates of referrals and lower volumes of diagnostic and screening tests, which make the true nature of care backlogs unknown and risk patients presenting later with more advanced forms of illness. Workforce shortages are one of the most intractable challenges to recovery across countries – a constraint that is shared even in countries with higher numbers of staff per population than the UK. Many countries must balance the need for measures that reduce waiting times and backlogs in the short term with those which build workforce future resilience in the longer term, and avoid actions which could increase burn out or lead to more staff leaving the profession.

You can also watch the Summit Series session where the authors discussed this report below. You'll need to login or register for the Summit Series to access the video.