18 - A double edged sword

The COVID-19 pandemic has not only forced people to change their daily lives in ways that seemed almost unimaginable a few months ago, it has also transformed some parts of the NHS beyond recognition.

Some key Long Term Plan ambitions have been swiftly achieved, particularly around digital service delivery, where video GP consultations have become the norm for many patients. But elsewhere, a drop in A&E attendance has led to fears that many patients might be failing to seek help due to fears over contracting coronavirus in hospital. There are also concerns over the impact on elective procedures.
In this article, we will explore the impact of COVID-19 on the NHS so far and assess which aspects of the Long Term Plan have been accelerated and which are being significantly derailed during these unprecedented times.

Digital service delivery
According to the Plan, all patients in England will have access to online consultations by 2022-23 and the ‘right’ to switch to ‘digital first’ GP practices (where patients can easily access the advice, support and treatment they need using digital and online tools). A similar expansion of online consultations is envisaged in secondary care to meet the ambition of cutting a third of all hospital outpatient appointments within five years.
At the start of 2020, most GP work was still conducted face to face but since then there has been a seismic change. Indeed, one influential GP, Dr Clare Gerada (former Chair of the Royal College of General Practitioners [RCGP]), commented in March that social distancing had led primary care to adopt digital triaging as its primary way of working in just three weeks.
There has also been a marked increase in the use of other digital tools. For example, hundreds of thousands of people across the country have been turning to services such as the NHS App or the NHS 111 online service for advice on symptoms. Elsewhere, we’ve seen electronic patient records and other essential technology services installed within days at new field hospitals.
Also, nearly 700,000 people signed up in the first 24 hours of the launch of the COVID-19 Symptom Tracker app which enables people to record their symptoms and feeds data through to a centralised collection point.
With data key to achieving many Long Term Plan ambitions, it is possible that this tracker might prove to be a watershed that inspires the development of apps in other areas, such as blood glucose monitoring and spirometry.

Integrated care
Integrated care underpins many Long Term Plan ambitions, and, in some areas, we have seen significant progress in recent weeks with all players within integrated care systems (ICSs) coming together quickly to make decisions on resource and capacity.
To make way for coronavirus cases, many older patients have been transferred from acute wards to care homes, or their own homes where they are being looked after by district nurses. Since moving more care out of hospitals into the community is another key ambition of the Plan, this trend is likely to continue.
It is also possible that COVID-19 strategies could result in the management of long-term conditions being increasingly moved out of surgeries and more outpatients’ appointments conducted by specialists online in the future.
For example, in cancer care, the current pandemic is expected to create an increased demand for homecare support from chemotherapy nurses and allied healthcare professionals (HCPs) and a need for consultant services to be delivered in the patient’s home, to reduce the risk of infection posed by attending hospital appointments. This could include telephone or virtual appointments.
To cater for the increased number of people with complex needs being cared for at home, particularly older people, we might see rapid training for community nurses to help them acquire additional skills and ultimately become independent prescribers.
This could result in tiers of nurses being created in the community as is the case in hospitals and general practice. This corresponds with another aspect of the Long Term Plan because flexibility and mobility of nurses and allied HCPs was one of its aspirations.
Elsewhere, synergy with Long Term Plan ambitions has been seen in the sharing of resources, which was necessitated after a national incident was declared over coronavirus.
This enabled NHS England to command all NHS resources across England and NHS organisations were instructed not to stockpile medicines, devices or consumables. The move aligns with the Plan’s vision to move procurement away from individual hospitals to focus on the system as a whole.

The other side
While it appears that COVID-19 has been a catalyst for some positive change within the NHS, there is also concern that focusing too much attention on it will have unintended consequences and put some non-coronavirus patients at risk of significant harm or death, because they are missing vital appointments or not attending emergency departments.
NHS England was tasked with identifying risk groups and building an intervention plan after it emerged that visits to A&E had dropped by almost 50% during a three-week period up to Sunday 29 March. Subsequent data for April showed a drop of 56.6% in A&E attendances versus a year ago, while emergency admissions were down 39%.
This has fuelled fears that people with potentially serious symptoms, such as those that could indicate cancer or a heart attack, for example, are not seeking help for fear of contracting coronavirus in hospital.
The Long Term Plan makes it clear that early diagnosis and preventative strategies are key to improving outcomes in key disease areas. But if patients are not getting symptoms checked promptly, this could thwart efforts to drive improvements outlined in the plan.
The same principle applies in planned care, which has also been severely disrupted, prompting the Royal College of Surgeons to warn in April that the NHS would need a five-year strategy to deal with a “mountain” of an elective waiting list following the coronavirus outbreak. The elective waiting list already stood at 4.4 million patients before the outbreak.
To help manage care during the crisis, NHS England has issued a series of guides outlining how patients with conditions ranging from cardiology to diabetes and respiratory conditions should be treated and how services will be impacted during the coronavirus pandemic.
For example, in cancer, where the Long Term Plan has many ambitious targets, NHS services have changed beyond recognition in recent weeks. This is in line with the new guidance outlined in the Clinical guide for the management of non-coronavirus patients requiring acute treatment; Cancer, which explains how patients will be prioritised and indicates delays and treatment rationing for some patients.
The appointment of leaders to oversee swift clinical decision-making is a common feature in the new NHS guides. The ability to justify decision-making in specific cases could prove critical as specialist lawyers have recently warned that the NHS should expect a “huge number” of legal challenges relating to decisions made during the coronavirus pandemic.
The raft of concerns that have been emerging around non-coronavirus care have underlined a need to redress the balance and new NHS England guidance on resuming non-coronavirus services has been published. It is explicitly permissive in letting regions decide their own pace for reintroducing routine care, at least for the ‘transitional period’ of the next six to eight weeks, but how this will unfold remains to be seen.

Conclusion
So far, the impact of coronavirus on the Long Term Plan has proven to be a double-edged sword. How long it will take to tackle COVID-19 is, as yet, unknown, and so too is the true toll that NHS service disruption will have taken on non-coronavirus patients.
But, in the midst of this global tragedy, there is a growing certainty that some things have changed forever in the NHS, as coronavirus has shown how some of the Long Plan’s key aspirations can successfully work in practice.
When we finally emerge from the pandemic, it is possible that a new wave of NHS policy will be introduced that builds on key aspects of the Long Term Plan and cements some of the positive changes that have occurred. This provides a glimmer of hope that in the future, something positive will come from COVID-19’s lasting legacy.

A double-edged sword