This winter will be a balancing act for health systems like no other. Hospitals are coping with very high numbers of Covid-19 patients during what is traditionally a stressful time of year in health care. Staff must play catch up on service backlogs from care cancelled or postponed during the first wave, while preparing for vaccine programmes of enormous scale.
These combined pressures mean that health systems will face difficult choices over the coming months about how best to protect access to planned care. In July, we looked at what the NHS could learn from how other countries were resuming health services following the first wave of the pandemic. But what are health systems doing now to meet the dual challenge of winter and the latest wave, and how does England compare?
Here we discuss how different countries are balancing Covid and non-Covid capacity, with a focus on nations where Covid-19 hospitalisations are also high or increasing, such as Belgium, Denmark, France, Germany, the Netherlands and Spain.
A more tailored and coordinated approach to scaling back planned health care
The decision to restrict elective health services early in the pandemic came at a significant cost to patients with non-Covid health conditions, and one that systems are keen to avoid as they once more manage high levels of Covid-19 hospitalisations.
In the first wave, many systems experienced marked drop-offs in activity, including in urgent care and essential services that were intended to be protected, like screening programmes and treatment for chronic conditions. For example, France and the Netherlands reported worrying declines in the number of people accessing cancer services throughout the early waves of the pandemic, similar to the experience of the UK. This has driven significant care backlogs and concerns that some conditions may be caught or treated at more severe stages – or missed altogether.
In England, the number of patients waiting a year to start consultant-led treatment has reached its highest level in 12 years, and activity still hasn’t fully restored to meet demand. The challenge is shared even with countries that entered the crisis with more workforce capacity, such as Denmark and the Netherlands, where waiting lists have increased and rates of cancer screening and GP referrals still lag behind anticipated levels in certain areas.
While some countries have been forced once again to take a national decision to put elective services on hold going into winter, others have adopted more tailored responses. For instance, Spain and the US have developed national frameworks to help hospitals judge when to scale back elective procedures based on levels of Covid-19 occupancy. This can help ensure non-Covid services continue in areas with lower risk, and gives clear guidance on when and how to shift more resources towards the virus.
A more dynamic approach to planning has also been adopted here in England, and a blanket policy to step down elective care has so far been avoided. While some hospitals in more severely affected areas have scaled back elective procedures, decisions have been based on a number of contextual factors, such as the number of local cases, whether patients can be moved to Covid-free sites, the availability of critical care bed space, and staff absence levels.
Other systems have relied on greater local and regional coordination to help protect access to as much planned care as possible. This has been the case in the Netherlands, where regional and national government are coordinating transfers of Covid-19 patients to localities with fewer cases to redistribute capacity.
So far this hasn’t been completely straightforward, as some hospitals have been reluctant to take cases after concerns about their capacity to deal with rising infections in their own areas. Transfers of this kind are also happening to some extent in the NHS, but they are a significant challenge and a limited option as few regions have spare capacity, even among places with lower rates of the virus.
Focusing on community and primary care capacity – not just hospitals
Many health systems had a laser focus on hospitals in the early stage of the pandemic, and rushed to mobilise acute and intensive care resources and beds.
Building community and primary care capacity is important to free up hospitals for patients who need them most, while reducing transmission. Hospitals by their very nature are a higher risk environment for spread, and the number of Covid-19 infections occurring in hospital has been a particular concern in the UK.
Taking a whole-system view can also avoid blind spots like the kind we observed earlier in the pandemic, when some countries (like England) quickly discharged patients to care homes and other community services without adequate support. As more is known about how to manage and treat the virus, some countries are placing greater emphasis on primary and community care services as they plan for winter and another Covid wave.
This is the case in Ireland, where the government introduced a winter surge plan that expands community care for both Covid and non-Covid services, including through home support packages, and rehabilitation services to reduce pressures on hospitals and help GP practices maintain their usual care.
France has also rolled out new pathways focused on respiratory assistance in the home and the community, as well as proactive home visits for Covid-19 patients and other vulnerable populations. This is a shift from the early stages of the first wave, when patients were primarily managed in hospital.
Germany, despite having greater acute care capacity than nearly all of Europe, had a strategy since the first wave to only treat Covid-19 patients in hospital who couldn’t be managed at home or in outpatient or primary care settings. Regional physician associations set up new outpatient clinics and organised mobile teams to conduct home visits to manage patients with the virus and identify cases who required hospitalisation as quickly as possible. Germany has expanded this approach going into winter, by setting up more outpatient clinics for Covid-19 patients to free up GPs and other community care services to deliver more routine care.
In the NHS, primary and community care services have also been a critical part of the Covid response, which have implemented new service models to manage patients in the most appropriate setting. However, some argue that models like hospital-at-home should be scaled even further, and primary and community care services better prioritised to address the range of health challenges arising from the pandemic.
Responding to new demands
Alongside another wave and winter, new demands on services have surfaced that add to the complexity of balancing Covid and non-Covid care. For one, many people who have survived the virus are experiencing enduring physical and mental effects that require interdisciplinary support. These symptoms are wide-ranging, and include things like post-intensive care syndrome, post-viral fatigue and permanent organ damage.
To develop capacity, some countries like Denmark have taken the same approach as the NHS to devote designated one-stop clinics to assess, treat and study ‘long Covid’. But even with this added support, the varying degrees of severity mean that additional community care capacity may also be needed. This may be a challenge in the NHS without an expansion of the workforce, given underlying staffing pressures.
With the arrival of a vaccine looming large, health systems are also having to prepare national roll-out programmes that will require significant staff and resource coordination to distribute vaccines broadly, equitably and effectively. Many countries will be looking to establish vaccine centres – like those proposed here in the UK, Spain and Germany – which will require significant staffing at a time when the workforce is experiencing burnout and exhaustion.
This may again be a more acute challenge for the NHS given the staffing pressures it had going into the pandemic, although plans are in place to rapidly recruit and train new staff and volunteers to help administer the vaccine. Even with those additional resources, however, there is an expectation that GPs in the NHS will have to scale back usual activity to deliver the Covid vaccination programme, with further implications for backlogs and system recovery.
Common strategies but different results?
Different countries have had very different approaches for how to contain and mitigate the spread of Covid-19, both in terms of how best to test, trace and isolate cases, and whether and how to introduce lockdowns. However, when it comes to health system responses and how to meet the competing demands of Covid-19 and essential services, we see many common challenges and solutions.
But while the NHS may be pursuing similar strategies to balance winter pressures and Covid-19 as other health systems, we are also working in a very different context. Our ability to manage Covid-19 and winter while restoring services will likely be more constrained by the challenges with which we entered the crisis.
With a vaccine now approved, the choices made in the coming months will influence what system recovery will look like and the non-Covid health consequences of the pandemic in each country. It is crucial that we continue to learn from the collective experiences of a range of health systems to understand not only the effectiveness of different approaches to balance care, but how differences in implementation and context might yield different results.
Reed S (2020) “How are different countries balancing care during the latest Covid wave?”, Nuffield Trust comment.