From reaction to reform: preparing health services for the next COVID challenge

By on 15/12/2020
Service transformation: in Birmingham, social enterprise Badger Group doubled its clinical workforce to operate a drive-through care facility for patients with COVID symptoms. Credit: Badger Group

The pandemic has driven rapid reforms to healthcare as officials maintained service delivery while protecting patients and staff. But exhausted workforces now face new demands: at a GGF webinar, health leaders from the USA and UK discussed the lessons learned so far, and set out today’s priorities

Healthcare services have undergone rapid change during the pandemic, including a shift to remote delivery of primary care, system-wide collaboration to source and share essential supplies, and major service reforms to separate COVID patients from others. And now they face new challenges – particularly around delivering mass vaccination campaigns, and restarting elective treatments that slowed or halted during the pandemic.

As health policymakers and strategists consider how to address these needs while dealing with rising infection rates, a recent Global Government Forum webinar brought together USA and UK leaders from trade unionism, healthcare management and digital services. They discussed what we’ve learned about how to deal with COVID-19, and the lessons to apply as national health and care services deal with the evolving demands of the global pandemic.

Iain O’Neil, director of digital transformation at NHSX – the UK Department of Health & Social Care’s (DHSC’s) digital technology agency – first highlighted the impressive changes in service delivery. “At the start of the year, somewhere around 3% of doctors could do video consultations, and now 99% of them have the capability,” he said. NHSX has supported healthcare staff with logistical challenges such as installing new equipment in heavily infection-controlled environments, he added, which in itself is a new way of working.

The height of the first wave “was a very interesting time: everybody wanted help to do whatever they could,” he said. But as NHSX worked to both support service transformation and help launch new services – providing food deliveries for those who were shielding, for example – it ran out of capacity. “There was a wave of offers coming in, and we didn’t really have the infrastructure to deal with them,” he commented.

Data provides a picture

Speaking from the USA, Heidi Steinecker, deputy director of the California Department of Public Health, explained that the state put better use of data at the heart of its response to COVID-19. California was the first US state to ask all its healthcare facilities to provide regular data updates, she said, enabling it track to the virus’s progression through local populations and – through the application of predictive analytics technologies – forecast which areas might come under pressure next.

Heidi W. Steinecker, deputy director, Center for Health Care Quality, California Department of Public Health, USA

The data enabled the state to set up an early warning system that, monitoring all incoming data in real time, flagged up facilities that were at high risk of a local spike in infections. A mobile app system was created to support infection control surveys, and weekly testing was introduced for all health care staff working with the most vulnerable patients. Forewarned, state leaders could then move resources such as healthcare staff and PPE supplies to deal with emerging hotspots, she explained.

California’s digital efforts resulted in a much lower death rate than other comparable states such as New York and Florida, Steinecker said: “California was really innovative in using technology to mitigate outbreaks, and that will be something we keep post-pandemic.”

The power of partnerships

Partnerships with local health providers and other public bodies were also key to slowing the virus’s spread and preparing health services in California. On a two-week trip to some of the hardest-hit counties in the state – many of them lying along the border with Mexico – Steinecker met with local leaders, visited intensive care units, and asked how state leaders could help.

“I think that really set the tone for them to feel supported, but not feeling like we were taking over their work or their processes,” she recalled. Though data, phone calls and qualitative information were also important, she added, in-person visits clearly demonstrated that the state was willing and able to help. Meanwhile, Steinecker’s department worked with the state’s Department of Agriculture to find solutions to the rapid spread of the illness among migrant farm workers in the most rural counties – some of the hardest-hit locations.

If the state worked well with local actors, though, Steinecker would clearly have welcomed a more supportive line from the White House. “We’ve had a lot of mixed messages on a national level here, which really caused some severe issues with compliance with mask-wearing, compliance with social distancing,” she commented. “There were a lot of things that we couldn’t control at a state level”. Within the state’s areas of responsibilities, though, “our California state leadership was definitely very science-based”.

The capacity to plan

Jon Restell, chief executive, Managers in Partnership, UK

As the crisis continues and evolves, different issues are starting to emerge. Many health workers are exhausted and some traumatised, commented Jon Restell, chief executive of Managers in Partnership: a trade union for UK health and care managers. The pandemic, after all, arrived after a long period of constrained health budgets and big social care cuts: “We’re dealing with a workforce that was already experiencing widespread shortages, not just in clinical roles, but in key back office roles like tech and IT,” he said.

It could be 3-5 years before the NHS fully recovers from the pandemic, he continued, noting that pent-up demand for elective treatments, the long-term impact of COVID infections and the harms caused by lockdowns – including worsening mental health – will place extra demands on health services. In this environment, he argued, it’s important that health leaders fund and protect the roles required to manage and deliver reforms: “To keep things moving in a positive direction is going to be really difficult to achieve, because people’s focus is very likely to be on survival rather than transformation.”

Restell added that many managers fear that staff will leave the service or take early retirement, worsening staff shortages. Central health leaders should act quickly to support staff wellbeing and mental health, he said – aiming to short-circuit policymaking processes so that people receive help within months rather than years. Measures such as giving staff greater flexibility to work from home or part-time, redeploy into new fields or take “flexible retirement” could help here, he noted.

National leaders could also help take the pressure off by maintaining the light-touch approach to regulation adopted during the pandemic, Restell continued. Deprioritising compliance and reporting work has allowed managers to spend more time with frontline staff and patients, he said, noting that “we’re still in a crisis, so let’s keep some of that crisis mode going.”

Tools for the job

To help healthcare providers improve service delivery models, commented Indi Singh – director of IT transformation at PA Consulting, the event’s knowledge partner – local leaders can deploy digital and data tools to strengthen activities such as modelling demand and managing patient journeys. When, for example, acute care providers have a clear picture of where demand lies and how it’s evolving, then “you can start thinking about your patient flow in between your wards and across your hospital,” he said.

Iain O’Neil, director of digital Transformation, NHSX, UK

Singh, who joined PA Consulting after a 14-year stint in DHSC and NHS digital roles, stressed the need for more sustainable investment in end-to-end services – improving patient pathways and handovers between service providers. This in turn may require changes to the split between healthcare providers’ capital and revenue budgets, he said: “We need to think about the move away from capital funding coming down nationally to revenue-based funding that can create investment around sustainable services.”

The UK’s nascent ‘integrated care systems’ (ICSs) – through which local authorities and NHS bodies are working at the regional level to streamline patient care – also need investment, Singh argued. PA carries out digital maturity assessments of ICSs, he added, and “it is really clear that the operating model isn’t mature yet.”

The pandemic has improved collaboration at the ICS level and produced lots of examples of transferrable best practice, said Singh: he cited an app created in North-West England to forecast demand and help providers plan their response. It’s important that these lessons are transmitted across the sector, he argued, and delivery bodies given direct assistance to introduce new services. And to support these changes, he added, it will be important to address a lack of clarity over responsibility for funding investments. Too often “we haven’t seen the reuse of services that are really good – that wipe their own face economically,” he commented. “Because people aren’t clear who the payer is, no one really moves on it.”

Supporting system change

Progress here is crucial: as Restell pointed out, the future policy and funding framework must cover not just acute healthcare, but the entire health and care system as well as other relevant public services. “A focus simply on the acute sector or simply on pandemic management is not going to deliver opportunities for transformation,” he said.

In some cases, Singh argued, national government should step in to fund systems that benefit patients and ICS bodies. And, supporting Restell’s point about staff overstretch, he noted that many health providers “simply do not have the resource” to simultaneously provide services and “do the transformation work and the forward-thinking, both in terms of the capacity in the workforce they have, but also in the capability.” Help with funds and skills will be required from the centre, he suggested: “Blueprints are great, but what we have to recognize is they’re going to need hands on-support around implementation and the introduction of some of those new technologies.”

Indi Singh, director – IT Transformation, PA Consulting

This issue of staff overstretch is also an issue for California’s central staff, commented Steinecker: those delivering the state’s digital and data solutions have been on call day and night, seven days a week, and are as burnt-out as clinical staff. Her agency has found solutions, she added, in “building sustainable structures of staff behind the existing staff so that they feel like they can truly get a break: making sure that they know that when they are offline, they’re completely offline and have someone else that they can trust to hand work over to.” Work is also underway to build up the next generation of healthcare workers, she added, with community colleges and nursing schools gearing up to boost workforces during 2021.

The next big challenge

Looking ahead to mass vaccination, Steinecker highlighted the lessons learned so far during the pandemic. “This is about working with systems, sharing resources across departments at all levels. And that includes workforce, technology, making sure that we have equity when we’re looking at access to vaccines, and to health care during the second surge,” she said. One early priority for vaccination is to immunise health workforces, noted Restell, emphasising the need to build staff confidence in the vaccines’ safety in order to maximise takeup.

For Steinecker, another key lesson is that California will need as much control as possible over the supply chains and delivery networks underpinning the vaccination campaign. Earlier in the pandemic, she said, the state struggled to procure testing kits: its solution was to build its own end-to-end testing service. “We created our own lab in California – everything from the swab to the chemical assays [for quality testing] – so that we could completely control the entire manufacturing process of our tests,” she said. “That’s probably the biggest lesson that we took back: we need to be self-dependent” – so that when the vaccines come through, California controls the system for distributing and delivering them.

So local and regional health providers need support from the centre to maintain the pace of transformation in an over-stretched system, putting in place the staff time, skills and funding to plan ahead and reform services. But it’s important, concluded O’Neill, that the centre listen carefully to frontline professionals – understanding their priorities, and providing assistance that supports their goals rather than over-riding them. “Don’t sit in the centre and try and second-guess what they need, because you’ll probably miss it by a country mile,” he said. “And then you’ll be in an even worse position.”

The Global Government Forum webinar ‘Reshaping health and care services’ was held on 1 December 2020, with the support of PA Consulting. You can watch the 75-minute event below, download the slides here or find our more about the panellists via our events page.

About Catherine Early

Catherine is a journalist and editor specialising in government policy and regulation. She writes predominantly about environmental issues and has held permanent roles at the Environmentalist (now known as Transform), the ENDS Report, Planning magazine and Windpower Monthly, and has also written for the Guardian, the Ecologist and China Dialogue. She was a finalist in the Guardian’s International Development Journalism competition 2009, and was part of the team that won PPA Business Magazine of the Year 2011 for Windpower Monthly. She also won an outstanding content award at Haymarket Media Group’s employee awards for data-led stories in Planning magazine. She holds a 2:1 honours degree in English language and literature from Birmingham University.

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