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After the pandemic – the challenge that lies ahead

RCP registrar Professor Donal O’Donoghue looks at how the NHS has adapted in recent weeks to meet its greatest challenge, and at what lies ahead as plans to reboot and reshape the NHS take shape.

Read the letter from NHS Chief Executive Sir Simon Stevens and Chief Operating Officer Amanda Pritchard here.

It has been a Herculean effort.

In a matter of weeks the NHS has pivoted to respiratory support and critical care provision to manage the COVID-19 surge. Physicians from outpatient specialties have been redeployed to inpatient care, trainees have returned from out of program research, rotas have rapidly been redesigned and the esprit de corps has been a sight to behold.

At the same time hospital debts have been cancelled, the NHS financial model has been suspended and routine services have been delayed or deferred.

The SARS-CoV 2 virus remains prevalent in the community but the first peak of COVID-19 activity has been managed. The system has coped, albeit at huge cost. More than 100 healthcare workers have lost their lives doing their jobs, including many members of our RCP family and some groups have been hit particularly hard, including members of BAME communities.

In addition, there will be patients for whom lockdown is accompanied by pain and discomfort as a result of their treatment being delayed. For some the consequences of not being seen sooner will be serious, for example stroke, heart attack and cancer patients, and this will also place extra demands on the NHS later.

More positively, digital technology has been introduced at pace to support virtual consultations and team working. Social distancing and shielding have been the catalyst for a long-awaited transformation, which we in the RCP have previously played a leading role in promoting. We do not want to lose this progress in the coming months.

While the pandemic is far from over and likely to evolve into an epidemic disease until an effective vaccine becomes available, the NHS faces its greatest challenge: to reboot routine and specialist services in a way that is responsive to the needs of our 21st century population, availing of technology, with quality as the organising principle. The scale of this task should not be underestimated.

'Health Equity in England: The Marmot Review 10 Years On', published in February, described the widening gap resulting from the austerity years and the numbers of nurses, doctors and all healthcare professionals remain as low now as before the seismic shock of COVID-19. However, the NHS England Long-term Plan and the NHS People Plan describe a future system we can still aim for. The devolved administrations have similar goals. There is even talk of a national social care system.

Each medical specialty has been working on service transformation and new models of care over the past few years. New professions, including our physician associate colleagues, have emerged. Each locality has been working through governance and organisational arrangements to provide better health and care for their populations. Right Care and Getting it Right First Time have established new ways to triangulate information and demonstrate unwarranted variation. The RCP has produced reports on sustainability of health services, learning resources and guidance such as Never Too Busy To Learn and has shone a light on workforce planning, but focusing on the wellbeing of  trainees and consultants as well as the numbers.

We don’t start with a blank canvas. Over the next year or more, while the virus circulates, services will need to be configured as red or green. PPE will still be needed and systematic testing has to become the norm.

Meanwhile, trade deals with the rest of the world remain to be negotiated, while economic depression is considered likely. This will impact health services and, unless efforts on the scale of the COVID-19 response are made to support all services, inequalities will widen, increasing morbidity, mortality and health service demands.

Planning to reboot and reshape has started. Over the past three weeks, the RCP, working with its specialist societies, has responded to an NHS England request to identify time-dependent interventions and procedures.

This revealed what we already knew - outpatient coding is poor and medicine has a different complexity compared with surgery. It is also self-evident that urgent elective interventions are only one piece of the jigsaw of medical care. Diagnostics are required, premises are required, training must be sustained and professional teams, mentally and physically strong, are required to deliver safe and reliable evidence-based care, be that emergency, elective, urgent or long-term condition care. Given the magnitude of what has been asked of so many of them in recent times, ensuring that staff have been able to recover from the stress and pressure of being redeployed to deal with COVID-19 will be essential.

As we start this process, let’s not forget the importance of patient experience, quality of life, the role of carers and that mental health and well-being are closely linked to physical health; no decision about me without me, no health without mental health.

So, we face a daunting whole system complex and multi-layered ‘wicked’ problem. Working together as physicians, in partnership with other colleges and healthcare professionals, collaborating with patients and patient groups and influencing government policy, NHS and social care plans we can make the difference that we went to medical school to achieve.

There is no room full of physicians in a parallel world who are going to do this work on our behalf. The charitable objects of the RCP mean we must nurture and sustain outstanding physicians to improve the health of the nation. Let’s get started.