The future of the NHS: ‘peering into the fog’

In this article, Sir David Dalton talks to Jamie Foster, partner in our Health team, on his views of the impact of COVID-19 on the NHS, and the future for healthcare after the crisis. The key points of their discussion are recorded here:

A lot has been asked of the NHS – it has risen to the challenge of Phase 1 of the crisis and in so doing it has revealed fragilities and yet so much energy, innovation and kindness have also been shown. The NHS’ real test will be whether it can learn from its experiences and be more agile, adaptive and receptive to change.

Headlines

• Staff morale and public emotion for the NHS will change – a new vision must be created, with staff and public supported to develop new operating models and processes to maintain commitment.
• Social care risks implosion: the crisis provides the opportunity for a new consensus for a long-term settlement and a different relationship between the NHS and care sectors.
• Enormous (short term) backlogs will need to be dealt with – waiting times; estate; debt; and time owed to staff, each with costs and consequences.
• Fragility of the supply chain and inadequacies of procurement practices have been exposed, but there are huge opportunities for new relationships with industry and for building manufacturing capability.
• The rapid adoption and deployment of digital technologies must continue and change the means of delivery of healthcare.
• New service models must be pursued which assure rapid access for infectious patients, while protecting non-urgent surgery and cancer care; and which also support cohesive primary care.
• Staffing flexibility, erosion of demarcations and automated substitutes will change the workforce profile, with the potential for greater efficiency.
• Conditions are being created for better governance and collective decision making – new group models could feature to co-ordinate at scale: organising improvement and delivering better care at lower cost.

A key message is that the experience of the last eight weeks is just the first phase – it has had purpose, with amazing staff response and public support. Phase 2 over the next 18 months will be different. Changes have been pursued in Phase 1 which would otherwise have been unthinkable or certainly difficult to implement. The backdrop of an economic crisis means requirements for greater productivity and agility. Staff fatigue and public frustration all mean that plans must be developed now and action taken to build on to the momentum of Phase 1. Consideration must be given not only to restoring services but also to catalysing opportunities for transformative change.

Transformative themes for health and care will likely include:

• understanding demand, capacity modelling and utilisation;
• service models, delivery modes and configurations, including building capacity;
• collective decision making arrangements enabling decisions at scale across a system;
• workforce changes and staff resilience;
• innovative ways of working, including digital;
• relationships with primary care and social care;
• relationship with public (demand management and control of access);
• supply chain and distribution;

Accelerated support is necessary to consider and prioritise these issues. A key requirement is for rapid exploration of the experience of Phase 1, to create the will and ideas to produce plans capable of reliable implementation. Creating conditions for change to be effective is essential and will require leadership to have the right mindset and behaviours which, at all times, should be supportive and respectful of both staff and the public to give their ideas for change and improvement.

Further exploration

Government’s unprecedented spending has secured, in the short term, income for citizens and vital infrastructure and services. ‘Protect our NHS’ is at the heart of the government’s message with frontline staff responding superbly and being held in reverence, as demonstrated by a weekly applause across the nation.

Intensity of public emotion will surely wane and be replaced by post-Phase 1 frustrations, namely that more must be done. It may be hard for government to convince people that there is not a ‘money tree’ to shake.  Staff morale and fatigue is at serious risk as they realise 18-24 months’ longevity of the crisis. The requirements for greater productivity and efficiency will be inevitable, requiring new means of staff support and engagement.

The NHS will soon need to address some major challenges:

• A backlog of waiting times and waiting lists. Already standing in excess of 6 million, the highest figure for 15 years and with concerning issues of health inequalities.
• Backlog of estate maintenance, with real concerns about the fragility of engineering and building fabric.
• Backlog of historic debt, with limited understanding of how a debt write-off will really work.
• Backlog of staff annual leave and time owed, and the consequences of physical and mental exhaustion.

The crisis has highlighted key dependency on social care and revealing its current inadequacies and fragility. Yet the crisis may create the space for a new political consensus to emerge for a long-term settlement to ensure its resilience for the next generation. New relationships between NHS and the care sector are required to prevent fragmentation and to assure standards of care, including cohorting of infected patients. Other opportunities include providing supportive career structures for care staff, greater co-ordination of transfers and discharges, and common data capture and reporting.

Challenge on NHS procurement practice has exposed fragility of supply chain, for example ‘just-in-time’ pull arrangements. A new equilibrium, including on-shoring manufacture and higher stock holding must be agreed.  Trusts will wish to consider organising the means of manufacture and distribution of key equipment. There are huge opportunities to build on the collaboration and agility of our universities, manufacturers and NHS customers, driving new arrangements for innovation and adoption. This energy must not be lost.

Transformative digital changes must be designed into new operating systems including, primary care activity delivered online, video triage, remote specialist assessments, home testing and remote monitoring by smartphones must be locked into operating systems. The key issue is creating the supportive conditions, mindset and behaviours for continued change management to work. The public must be helped to interact differently with the NHS, including fewer attendances at surgeries and clinics and less use of the car parks.

Change service models: new service models need to be agreed, for example enabling the delivery of cancer care and surgical activity to be separated from ‘hot’ acute receiving centres for infected patients, expansion and redesign of critical care facilities with agile staffing and remote monitoring, improved primary care networking and supporting the care sector across larger geographies. Building on relationships with the independent sector will remain important.

Workforce flexibility: redesigned operating models enable a redesign of the workforce contribution, for example home working; digital support; skill mix blending; retraining into roles which past demarcations may not have permitted. Must recognise the likelihood of the economic position requiring even greater productivity, flexibility and agility. Great care is required to work with the ideas of staff and not push change from the top.

Governance must be different: current centralised command through local ‘cells’, ICS’ and regions has been effective with organisations accepting a level of control that would have been resisted. High recognition of the value of collaboration and collective decision-making which are making a difference. What takes their place?  Likely that the ICS level will be given new powers and responsibilities. New governance forms of collective decision-making will be required, this could include pooling of sovereignty across multiple organisations for defined decision-making, possibly through new group-style structures and developing standardised operating models to assure care is delivered to a consistently high standard across the system, at a lower cost.

This article was authored by Sir David Dalton.

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