During the peak of the Covid-19 outbreak in April, the NHS took extraordinary measures to avoid the horrendous scenes of overcrowding and chaos seen in Italy. Planned care was cancelled, patients discharged, students and retirees recruited, and whole new hospitals built. Now, with the disease under some control, it might seem reasonable to expect a return to normal service.
Unfortunately, three major obstacles mean that business as usual is not coming back any time soon.
First, the ever-present danger of the disease re-emerging will mean slowing down basic processes and treatments. Without a quick and reliable test, patients needing planned surgery will have to be swabbed and required to self-isolate before planned investigation or treatment, with a further test immediately before. A 20-minute test is being trialled, but even this will slow down the pace at which the system can operate.
Restarting planned care will require a great deal more protective equipment, which is needed any time that a patient without a confirmed negative test is seen. Yet its supply has been beset with problems. The NHS will need to have confidence this will change before booking people for treatment — that is, if those patients can be persuaded to come.
For those requiring help in an emergency, staff will need to assume they are Covid-19 positive, requiring enhanced PPE and extra time for cleaning beds, imaging equipment and operating theatres between patients.
Second, living with Covid-19 will have profound implications on the availability of staff. Staff in high-risk categories may need to be removed from frontline duties, further exacerbating the shortages that predated the pandemic. For those that remain, the changes they will have to make to their daily work will be onerous — from changing in and out of PPE, to administering tests, to changing daily practices like multiple site visits or ward rounds — all with the effect of reducing the amount of work they can do in any one day.
These changes do not just apply to hospital staff. In many services like dentistry, optometry and much general practice, direct physical contact between the patient and the professional is needed. Dental practices could face financial ruin as they have to don full PPE and clean rooms between patients. GP surgeries have made great strides in introducing more virtual treatment and consultations, but these are not a panacea: there are limits to what can be done virtually and some patients will want a return to face-to-face contact with their family doctor.
Third, the building and design of many English hospitals makes them woefully unprepared for the kind of infection prevention and control needed in the coming months. The NHS has large numbers of older hospital buildings, which include shared accommodation and narrow corridors. That will make segregating coronavirus and non-coronavirus patients very difficult. Many hospitals do not have waiting areas that allow for social distancing, particularly A&E departments, which were significantly overcrowded before the outbreak. Even if these difficulties can be overcome, through increased investment, the NHS will need to hold on to some of its surge capacity for a possible second wave.
All of these factors, set alongside the staff shortages we already had, and the drying up of international recruitment, are likely to have unpalatable results: long waits for treatment, rationing of care, burnt out and bogged-down staff, and an angry and confused public, increasingly impatient with the health service they have sacrificed so much to protect.
Politicians need to prioritise getting new types of test introduced as soon as they are found to work. But they shouldn’t be tempted to claim that they will solve every problem before we have the evidence. If it turns out otherwise, that could turn sympathy for the NHS into disappointment.
It is time to tell it straight: we will be asking the health service to go above and beyond in dealing with coronavirus for many months to come. As long as that is the case, there will be no return to normal service any time soon.
This blog was originally published in the Times Red Box on 2 June and is reproduced with permission.
Edwards N (2020) “Covid-19: the NHS not returning to normal any time soon”, Nuffield Trust comment.