In the space of a few months, COVID-19 has changed health and care services beyond measure. Credit is due to millions of health and care staff, support workers and volunteers who have responded to the needs of those directly affected by the virus and maintained essential non-COVID-19 services.
On 22 April, the Health and Social Care Secretary told the House of Commons that the pandemic had reached its peak, and talked of his intention to ‘gradually reopen’ the NHS as soon as it was safe to do so. Patients, carers, staff and the public will want clarity about what services this applies to, and what resources will be needed to do this.
But much is still unclear about this pandemic. Although numbers of people dying in hospital with COVID-19 are declining steadily, the situation in care homes is only now stabilising. There remain many uncertainties about COVID-19, including the degree of infection within the community, the duration of any immunity, the impact of easing social distancing measures on the reproduction rate of the virus, and the readiness of test, trace and isolate measures. Further waves of infection are therefore possible and critical care capacity needs to be able to rapidly expand again.
It is also not clear how many services have been suspended. To release capacity for the critical care of COVID-19 patients, many services have been stopped, reduced, and/or switched to telephone or video. Those face-to-face services that have continued have often been split into services for COVID-19 infected patients (confirmed and possible) and services for non-COVID-19 patients. There has been some national guidance – which types of surgery should continue or which patients should be identified as vulnerable – but for the most part, judgements about who gets services and how, have been made locally.
In social care, staff have worked extremely hard to keep the people they care for safe, but seven local authorities have triggered emergency powers under the Coronavirus Act to scale back their legal duties to provide care, faced with unmanageable increases in demand and workforce shortages. Given the ongoing and forecast staff shortages, it is also critical that any plan for health and social care builds explicitly on the latest data on workforce capacity and makes reducing these shortages a central priority.
Fully understanding the impact of these changes on patients and users will be a slow process, as national data take time to emerge. In March, A&E attendances were 29% lower than in March 2019. GP appointments also fell by 30% during March. Polling suggests that patients may be worried about contracting the virus, or burdening services. There are no data for social care.
In our view, there are five important challenges that will need to be addressed by leaders in government and the health and care system.
1. How and when will appropriate infection prevention and control measures be available for all settings delivering care, and what impact will these have on capacity to reopen?
A reliable supply of PPE and testing needs to be in place for all parts of the health and care system. This is a pre-requisite to expand services. Many providers of home and residential care are still unable to protect their users and staff from cross-infection: testing and PPE must be prioritised for social care until there is confidence that the care home epidemic is contained.
All health and care settings where close contact is needed pose a potential risk for both staff and patients. This should decline over time, but ‘COVID-free’ services still need infection prevention and control measures. Expanding services therefore requires an expansion of PPE, additional space, additional staff and additional time for cleaning equipment and facilities. This applies not just to hospital care, but any face-to-face care, including general practice, community services, mental health services, dentistry and social care.
This will severely affect the productivity of services until the infection has been brought under control in the community or a rapid and reliable test is more readily available. It will mean continued reliance on the independent sector for elective care, longer waiting times, and additional pressure on the workforce. Any productivity gains from remote, non-face-to-face services will not offset this. The very real possibility of a second peak in COVID-19 and the usual winter pressures will need to be factored in.
2. How will the system understand the full extent of unmet need?
Responding to COVID-19 has meant unavoidable prioritisation of services and the need for this is not going to go away for a long time. There will be an increase in need. In the short term, the system will not be able to meet this. Although the guidance has aimed to protect services for the most vulnerable, people may have deteriorated, including those waiting for hospital treatment which has been postponed. Those who have physical and psychological complications from serious COVID-19 disease will require many months of support. It is likely that mental ill-health will increase everywhere as a result of the measures taken to contain the pandemic, but the scale of this is currently unknown. The pandemic has not landed evenly across the population: it has taken a greater toll on older people, on men, on poorer communities, and on black and minority ethnic groups. The health, social and economic fallout from social distancing is also uneven. These inequalities should frame any discussions about the resumption of NHS and care services. Local organisations will need help to collect and analyse data on rising levels of need and be able to draw on all sources of local data.
3. How will the public’s fear of using NHS and social care services be reduced?
Given the high levels of compliance with social distancing and the steep reductions in use of emergency services, it is reasonable to assume that many sections of the public are very worried about easing the lockdown, particularly in areas badly hit by the virus. Persistent fear of infection could mean people will be reluctant to use services even if they are open. Reopening the NHS and social care for normal business will be complex. Some people have chosen to stay away from services even when they need them: a nuanced and carefully targeted public information campaign may be required to assure the public that the NHS and social care are safe and ready to provide the care people need.
4. What is the strategy for looking after and growing the workforce?
Even if capacity can be released by scaling back the emergency COVID-19 response, staff who have worked to manage the pandemic will need time to recover. Staff caring for COVID- 19 patients in the NHS and social care have experienced high levels of stress and exhaustion and they will need access to the full range of mental health and well-being support. Staff will need evidence that adequate protection against the virus is in place before services are reopened, and reassurance targeted at those who have had bad experiences with PPE shortages. All of this needs to be factored in to any plans to expand services. Both the NHS and social care entered the pandemic with large-scale workforce shortages. The very welcome contributions from students, returning health professionals and volunteers will not have offset these. The stresses of the last few months may also lead people to bring forward their intention to retire. International recruitment, a key plank of workforce expansion plans, is likely to be disrupted over the short or medium term because of the pandemic.
5. Can the system improve as it recovers?
The pandemic hit a health and care system with underlying weaknesses: a severely underfunded social care sector and many under-resourced health services. These will still need to be tackled alongside the backlog of demand. At the same time, across the country the crisis has brought innovation, cooperation and an appetite to permanently change the way services work. Reconfiguring services will be easier in some areas than others – and will be harder in rural areas – but cannot happen without the active participation of all local partners: local government, the NHS, the voluntary and community sector, and the independent sector. National leadership has shown how quickly resource allocation, regulation and other system rules can be changed during the crisis. This willingness needs to continue. Necessity has driven some of the fastest innovations, such as rapid discharge from hospital and digital consultations, but patients and the public will need to be involved in conversations about what should be kept, as well as any large-scale changes to services.
The overall conclusion is that there has been a shock of unknown proportions to health and care services and that the pandemic is still a major threat. The bulk of NHS and social care services cannot simply be ‘switched back on’ to their pre-COVID-19 state in February 2020. Some patients, users and carers will suffer and many professionals across the health and care system will have to make painful choices for many months to come.
The Health Foundation, The King's Fund and the Nuffield Trust.