The writer is a senior fellow at Harvard University and an adviser to the UK Department of Health and Social Care
Now that the UK has passed the first peak of deaths from Covid-19, we have learnt a lot about ourselves — and about the National Health Service. The NHS has discovered that it can move with astonishing speed to build new hospitals, reduce bureaucracy, redeploy staff into different roles and forge partnerships which must be preserved after the crisis.
“We mustn’t go back after this,” one hospital chief executive recently told me, echoing the feelings of many in the system. The crisis has exposed what a knife-edge the UK was already on, with huge vacancies in nursing and social care and too few critical care beds. But it also shows that turf battles and bureaucracy are the enemy of both patients and staff — and that we can break free of both.
It is impossible to overstate what has happened in the past two months. Dentists have retrained as respiratory nurses. Healthcare assistants have stepped up to do the work of senior nurses. Local councils have redeployed administrative staff to care homes. Dedicated frontline staff have worked long hours in hot protective gear or — even worse — without it. Budgetary wrangles about who pays when discharging patients from hospitals to care homes, that used to result in elderly folk “bed-blocking”, are resolved overnight. This is unprecedented in a sprawling system of fiefdoms.
Rather than being a national service, the NHS is a ramshackle lifeboat held together with dotted lines and goodwill. Around 700 organisations including acute hospitals, mental health trusts, clinical commissioning groups, GP surgeries, statutory agencies, and regulators wrestle for control. At least eight different sets of people were involved in trying to develop Covid-19 testing — including Public Health England, the Cabinet Office and private laboratories. Things only speeded up when the government put one person in charge: John Newton.
In a pandemic, you need a system with clear lines of responsibility and accountability. In the past six weeks, the 210 clinical commissioning groups, which purchase healthcare, have effectively been nationalised, with NHS chief executive Simon Stevens taking control. In place of the old blame game between commissioners and providers, we see pragmatic co-operation.
In London, the NHS regional director holds daily “gold command” calls with hospitals to enable them to share capacity and to avoid the tragedies seen in northern Italy where individual hospitals were overwhelmed.
In Greater Manchester, local councils and hospitals have created a central procurement system for personal protective equipment. “Hospitals are lending to social care, and we pay the hospitals back,” says Andy Burnham, the region’s mayor. His staff, he says, are “doing deals on airport runways”.
The shortages of PPE and testing are enormously frustrating. But for some staff, the chance to find pragmatic solutions is liberating. “Hospital trust leaders feel they’ve been given permission to get on with things in a way they haven’t been before,” says Chris Hopson, chief executive of NHS Providers.
Systems which give staff more autonomy, and remove unnecessary paperwork burdens, provide better outcomes. They are more attractive places to work. In the Netherlands, nurses have come out of retirement to work in self-managed teams, with better outcomes and higher satisfaction ratings for a million patients.
The rules being rewritten or ignored include those in the 2012 Health and Social Care Act which encourage competition. Right now, collaboration is the order of the day, including with the private sector. Trying to enforce competition did little to break down the mutual disdain between the public and private sectors. Funnily enough, this pandemic has probably done more: through new partnerships between the NHS and private hospitals, tech companies, manufacturers and the pharmaceutical industry.
Virtual consultations are one example. GPs are now doing around 90 per cent of consultations on the phone or online; that’s too many but it’s revolutionary. Until now, the NHS has suffered from clunky technology which wastes time. You can fetch up unconscious in your local hospital and be treated as though you’ve dropped in from another planet, because they can’t get your medical records from the GP. You can wait weeks in dread for a diagnosis, only to find they’ve lost your test results. Nurses spend hours ringing care homes to discharge elderly people, rather than tending to patients. All this must change; suddenly it seems possible.
It would be naive to ignore the fact that some progress has been achieved by the Treasury’s blank cheque. The public will be ready to pay higher taxes for the NHS after this crisis: that money must also extend to social care. But progress has also been made by unleashing ingenuity and co-operation.
The battle against Covid-19 is by no means over. Doctors and nurses are breathing a sigh of relief at having weathered the first storm; the Nightingale hospitals are mostly empty. But while death rates are lower than expected, more survivors are sicker, requiring longer hospital stays. Staff must also turn their attention to all the other people who have stayed away from A&E or had their treatment interrupted.
This is a long game: but one legacy must be a joined-up NHS, sustained not merely by heroic staff but by systems that properly support their efforts.
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