“Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning”
The NHS has come through the first phase substantially intact, but with considerable losses, and a mixed performance at best, as ably outlined by Cyclefree in a previous header.
Moving to the next phase is a challenge across all the domains of economics and society, but my thoughts turn to the next phase for the NHS. The NHS has a central role in British Politics, whether Labour’s “24 hours to save the NHS”, the Brexiteers “£350 million pounds per week for the NHS” or the Conservatives “forty “new” hospitals and 50 000 “new” nurses”. The NHS remains political catnip for voters, and there is little reason for that to be less so at the next General Election. Indeed every reason for it to be a central issue once more, alongside the related Social Care services.
Peak coronavirus seems to have passed, and though the stress has been significant, there has been enough reserve capacity mobilised to avoid the overloading that was feared. This has not been without cost, as many elective services have been suspended since mid March. There are concerns that many other conditions are going untreated as a result. The next phase is to restore these services, and to recover the position pre-deluge or better. There are several interconnected issues that make this a quagmire.
Command and Control Centrally:
It is quite striking how at the first whiff of gunpowder the policy of the last 30 years of localised commissioning and increased independence of providers vapourised. Since March the NHS has had a top down system more centralised than ever in its history. Decision making descends from Whitehall, and while some of these decisions may well have been mistaken or reckless, others have been more successful. Even Mr Corbyn must have raised a quizzical eyebrow at the requisitioning of the Private Hospitals, and effective abolition of private medical practice in the UK for the first time in history.
How long will this centralised system continue? Or will services be restored to local organisational control, with all the risks of fragmentation and loss of political control?
The Continuing need for a significant workload of Coronavirus Patients:
My own hunch is that rather than a large second wave that the virus situation will shift from a pandemic pattern to an endemic one. I suspect significant ongoing numbers of new cases for many months to come, perhaps around 100 Covid-19 inpatients per million population for the rest of the year. Even if the numbers are less than this there will be a need to have such reserve capacity as to be able to cope with a second wave, should one occur.
This necessitates the separation of all patients into Covid and non-Covid streams, whether in one site or more, with testing early in the patient pathway in order to direct patients accordingly, and duplication of staff and equipment. In particular, there will be a long term need for more than baseline Intensive Care (ICU). This either denies that capacity directly or indirectly for other services, with anaesthetists and theatre staff running overflow ICU at the expense of those facilities being used for elective surgery.
NHS PPE supplies seem adequate at last (though supplies remain tight, and protocols less protective than other lands), but still are an issue in Social Care. Other supplies are now becoming more of an issue, particularly some pharmaceuticals used in ICU and also in anaesthesia, and of haemofiltration equipment for renal failure.
Much elective surgery is an “Aerosol Generating Procedure” (AGP) that is high risk of transmitting the virus to staff, and also contaminating the operating room environment. Currently this requires respiratory masks, full length gowns, and much longer case turnaround time due to donning, doffing and extra cleaning between cases. This includes all general anaesthesia, and all dentistry. Not only is this uncomfortable and gruelling for staff, expanding the amount of surgery exhausts precious PPE and pharmaceutical stocks.
Social Distancing and related measures:
UK hospitals are designed for high throughput and occupancy. Corridors are narrow, lifts are small, offices and examination rooms crowded and most wards are designed with bays of six patients rather than the single rooms common abroad. Waiting rooms are intimate and diagnostic units such as outpatients and emergency departments can not work at full capacity while maintaining a 2 metre distance. Architecturally UK Hospitals are amongst the worst places for social distancing, and are by their very nature full of the highest risk population. Patients are in large part right to be wary.
Necessity is the Mother of Invention:
Rather like the retail and business sector, healthcare is experiencing a decade of change compressed into a few weeks. There has been a vast increase in the proportion of telephone and video consultations, up from 10% to 85% in General Practice. The implications on quality of care and accuracy of diagnosis are yet to be explored, but much General Practice will continue in this style. There are also areas within Secondary care where this can be used. There has also been a renewed interest in the generic skills of hospital staff, with anaesthetists and theatre nurses running ICU, and orthopedic juniors looking after respiratory patients.
There will be further innovations too, and better more reliable testing may reduce the need for PPE, by screening admissions a week or so in advance (though these may need multiple swabs and isolation over the week). Some of the 40 new hospitals may need to be redesigned to accommodate a greater ability for social distancing.
The Perfect Storm:
The combination of a 3-4 month suspension of elective surgery, reduced availability of operating theatre space and reduced throughput on operating lists will greatly lengthen surgical and diagnostics waiting lists. I suspect this productivity will drop by 50% or more for the duration of the coronavirus, so likely to be for 12-24 months. Within a year patients waiting over a year for treatment in England and Scotland will be common, they are already in Northern Ireland and Wales. Within 2 years we will see some patients waiting 24 months. Non surgical specialities including mental health will be similarly affected, though these get less media attention.
Seven day working and evening working may help to some degree, but the numbers of personnel and need for all support services to be functioning over these extended days will be limiting factors. The private hospitals will not be able to take up the slack as exactly the same issues of reduced theatre productivity, supplies and social distancing apply. These are international issues so international recruitment presents no magic solution.
Even if the virus is solved by vaccination or miracle in 2021 we are going to have an enormous backlog of waiting lists that will still be present at the next General Election, and a hotter political potato than ever. Not least because clinical outcomes will worsen from the delay.
The Chancellor of the Exchequer will not be able to find the savings he needs for deficit recovery in the Health sector, and the failure to deliver the 40 hospitals and 50,000 nurses will prey on his mind too. That £350 million per week extra is going to be needed not for expansion, but simply for political survival, particularly for placating the newly acquired older, more working class Tory electorate.
This perhaps explains why, despite a comfortable majority and massive poll lead at present, Betfair exchange has for next GE, Con most seats at 1.8 and Con Majority odds against at 2.92. No overall majority looks reasonable value at the current 2.62.
Foxy is a PB regular, and a Hospital Doctor in both NHS and Private Practice.