Recovering from Covid-19: the international picture

We have seen distressing headlines about how Covid-19 has disrupted core NHS services. Has this been the experience of other countries?

The NHS has certainly not been alone in having to make difficult trade-offs and redirect resources in response to the pandemic.

Even the most well-equipped health systems have postponed or cancelled services that are less urgent – to free up capacity for surges in Covid-19 cases and to help keep rates of transmission as low as possible. Germany and the Netherlands, for instance, both went into the pandemic with more doctors, nurses and hospital beds than the UK, and have had less severe outbreaks of the virus, but still deferred elective care during the peak months of the crisis.

Although essential services have been maintained in many health systems, some countries have seen similarly worrying trends of people forgoing care as in the UK – raising concerns more globally about unmet need and the non-Covid health consequences of the pandemic. For example, experts in Germany, Belgium and Sweden have all reported drops in those countries in the numbers of patients presenting to emergency departments or receiving other critical services during the peak Covid period.

This has serious implications for people living with ongoing health conditions and for recovery in each country, and will add to the backlog of issues that health systems will have to address in the pandemic’s wake.

But of course, countries also entered this crisis with very different starting points, and have been impacted by the virus in different ways. It’s those differences that are likely to play out in system recovery – and influence how effectively and quickly health systems are able to resume care for everyone who needs it.

What might the NHS’s path to recovery look like compared to other health systems?

Despite the NHS pursuing many similar strategies to other countries in increasing capacity and in restarting elective care, it is likely to have a slower path to recovery given where it was at the start of the pandemic.

Even if the NHS had responded perfectly to contain and manage Covid-19, it’s plausible to say that recovery would have always been a challenge given the existing pressures on the health service.

The UK met Covid-19 with higher bed occupancy rates and fewer doctors, nurses and capital resources than most other health systems. Parts of the NHS have been working with older buildings and equipment, chronic workforce shortages, and very little slack to scale up activity in a crisis. This is different than in countries like Germany, which has three times as many beds and nearly twice as many nurses per person.

How many resources each country’s health system had at the start of the pandemic will be important when we consider the impact of infection control measures that the NHS and other health systems will now have to implement. Every country severely affected by the coronavirus will be challenged to deliver what it could do previously.

But those capacity concerns in the UK could mean it is more stretched than other countries in addressing the demand that’s built up over the pandemic – which could mean longer waiting times and have devastating consequences for some patients.  

What else might influence how well a system recovers?

The amount of beds, equipment and staff in each health system is only one determinant in system recovery. A host of other factors – many of which are harder to quantify – will also be key to understanding how resilient health systems have been.

These include practical things like testing and tracing capabilities, and availability of personal protective equipment. But they also include how well countries are able to coordinate and make effective decisions across different levels of government and sectors. Other factors, such as how well health systems are able to adapt and maintain any positive changes developed in response to the pandemic, will also matter.

The recovery of health systems will also not happen in a vacuum. Given the way the health and socioeconomic crises of the pandemic are converging, wider government responses to the pandemic will also be critical.

What are some common ways that health systems have built capacity to respond to Covid-19?

Even countries entering the pandemic with relatively greater capacity, such as Germany and the Netherlands, have had to find ways to increase staff and release acute and critical care beds and equipment to treat patients severely affected by the virus.

To quickly mobilise the workforce, a number of countries called upon the help of inactive health care personnel, as well as students close to graduation from medical, nursing and public health programmes. Countries also stretched their existing workforce by moving more staff from part-time to full-time roles, modifying work schedules, and upskilling staff into new roles. Such efforts have also been supported by simplifying registration and hiring processes.

To free up more acute care resources, common approaches have included converting existing wards and theatres into intensive care units, building temporary field hospitals or treatments centres in the community to help triage and manage cases, and adding resources from the private sector.

This all required rapid changes to how care is organised and delivered. It is critical that we learn what’s been positive about some of the system changes, and maintain them for the future.

Where have there been key differences?

A large number of health systems have created designated treatment or diagnostic centres as ‘Covid-19 only’ to further reduce transmission, but countries differ in their feasibility and need to do so.

In countries where this hasn’t happened, health centres have been reconfigured to make it possible to isolate potential cases into separate ‘zones’ or ‘circuits’, and prevent staff from working across different pathways to reduce exposure.

This is happening in Spain, where elective surgery is only being resumed in hospitals where Covid patients make up 5% of total capacity. There providers are also doing things like restructuring appointments, so that all pre-surgery assessments happen remotely or on the same day to avoid multiple visits.

A smaller number of countries have also found capacity by redistributing resources regionally to areas less overwhelmed by Covid-19. This has happened in France, Spain and Italy, where staff or patients were moved to redistribute capacity more evenly throughout their respective health systems. Doing so has been less practical in countries like the UK, where the virus has spread more widely across regions and localities.

Another key difference has been around staff pay. Covid-19 prompted a handful of countries (such as Germany, France and Canada) to increase wages or provide bonus payments to key health and care workers, particularly those in lower paid roles or those working in high-risk environments.

In many cases those uplifts were temporary, and only applied to the peak Covid months.

What are some of the main considerations for countries as they reopen services?  

Health systems are all in very different stages of resuming services, but there are some common decisions that many countries have to face. They include how best to manage infection control, which services to prioritise, and how much reserve capacity to maintain in the event of future outbreaks.

Countries have varied in their approach, and again the choices they make will in part be influenced by their existing resources going into the pandemic.

Reconfiguring health care facilities to reduce transmission and build in greater slack will place constraints on what health systems can deliver. The NHS entered the crisis with real pressures that are unlikely to go away any time soon, even with the recent £3 billion funding announcement.

The key thing is getting patients back through the system as quickly and as safely as they can, but as long as the NHS has to remain Covid-19 resilient then access will be reduced and people will unfortunately be left waiting longer.

*Sarah’s briefing, Resuming health services during the Covid-19 pandemic: What can the NHS learn from other countries? is published today.