A new normal by James Underhay, with Helen Blanchard

Time to reset and restart

The recent communication from NHS Chief Executive, Sir Simon Stevens to NHS leaders clearly sets out the Government’s view that we are now moving into ‘Phase 2’ of the NHS Covid-19 response. The NHS has now been asked to focus on re-energising non-Covid services, including cancer treatment, urgent and routine surgery, cardiovascular, heart attack and stroke treatment, as well as a wide range of other clinical services which have been suspended during the pandemic.

The priority to ‘Protect the NHS’ has, for now, been realised with some encouraging signs of containment and confidence in our capacity to cope.

The timing of Phase 2 is not surprising given the national suspension of many services and growing concerns that patients across the country are missing out on urgent treatment. The potential risks or future harm that this may bring are obvious.

Cancer Research UK are reporting that as many as 2,700 patients per week are not being diagnosed with cancer, as a result of fewer GP referrals, and a reduction in screening services.

The Royal College of Surgeons are describing the backlog of routine surgical treatments as ‘gigantic’, with as many as 700,000 treatments per month being cancelled. The financial cost of delivering these services, is estimated by NHS England to be in the region of £1bn a month, with a growing backlog to contend with.

The Challenge ahead

So, what does recovery look like, how do we resume ‘normal service’? Just turning back the clock, returning to the former operating model is probably not what we need. Looking to the future, we will have an ongoing requirement for Coronavirus related capacity perhaps for the next 12 to 18 months. This needs to be delivered alongside traditional healthcare and clinical services.

The challenge now for the NHS is to rapidly rethink and redesign what and how it can deliver services in this new environment. We have witnessed the pace at which the NHS can change, with incredible flexibility, local decision making and strong clinical oversight. How can we now cement and build upon these new ways of working to meet some of the greatest challenges the service has faced.

Protecting our most Critical Assets

What now for NHS leaders and their heroic workforce? Having expended Herculean efforts, the NHS and partners have delivered its largest mobilisation ever. The pace and commitment in establishing and delivering critical care capacity across the country has been unparalleled. This transformation has almost certainly prevented the system overload witnessed in other parts of the world. Now, they must briefly draw breath before embarking on the restart of dormant services, while also to trying to quantify and plan for the mammoth backlog of cancelled services and current unmet demand.

If we are to successfully move forward at pace, we must recognise and acknowledge that the pressure on staff across health and care has been unprecedented. NHS and Care workers have reported some of the most harrowing experiences of their careers. Employers now need to ensure that staff are cared for and supported, including support for their mental and physical wellbeing.

The recent survey of nurses carried out by the Nursing Times found 33% of respondents reported a ‘bad or very bad’ state of mental health. 87% of respondents felt more stressed at work, citing insufficient PPE, catching the virus and the health of family and friends.

As a minimum, employers need to ensure that sufficient, appropriate and high-quality PPE is readily available for all staff working at risk. Accounts of workers saying they are ‘afraid’ or ’terrified’ of going to or being at work cannot persist.

Planning for the Future

So, we are planning for a future that is long on challenges and which is likely to be short on resources. What is needed is that we

    • Get the most clinically urgent services back on stream
    • Understand and prioritise the backlog, and ensure those patients with priority needs are identified and treated quickly
    • Establish robust supply chains to secure the PPE, medicines and equipment needed by more effectively capturing and managing demand – to provide safe care for COVID patients and to ensure staff safety
    • Capture the lessons learnt over the past two months
    • Provide continued support for our staff, with provision of both practical and emotional support made available

Whatever the future post-Covid-19 will hold, the need to design and deliver change – and therefore control the purse strings – around service users and providers will not change. And the need for Local Authorities to continue to be responsive will be a constant.

James has significant operational and strategic experience gained across a number of organisations in both the private, public sectors including a time as Deputy Chief Executive Officer of the South Central Ambulance Service. James is available at: james.underhay@the4oc.com

System-level Solutions and Leadership

To date it feels as though STPs and ICSs have made slow progress, dogged by concerns about financial and clinical risk, and sometimes by the vested interests of member organisations and the heavy hand of history. If ever there was a time to consider breaking down organisational boundaries this may be it.

We need to consider capacity planning at a more aggregate level where this is safer or more efficient, for example some hospitals could be designated surgical centres, focussing on the surgical backlog, whilst others continue to provide care for patients with COVID-19.

The coming weeks and months will require strong leadership, tough decision making and rapid action. The scale of change required requires real leadership, and a culture that supports innovation and allows learning together with the occasional failures that will inevitably follow. The current ‘command and control’ NHS structure does not lend itself to this approach and it is to be hoped that the local organisations which have delivered such a strong response to COVID-19 will be given the freedom to lead the recovery effort without undue central interference.

Priority Setting

What do we stop doing? At organisational level, a methodology for reassessing priorities and planning future projects needs to be developed and deployed. It may be that existing plans are no longer relevant or perhaps have been overtaken in response to the pandemic. NHS leaders need to have clear direction, working to a common set of principles and objectives, shared amongst partner organisations and within each local system.

Helen is a very experienced and skilled senior health service manager with 18 years NHS experience, including at Executive Director level in the acute sector. Helen is available at: helen@the4oc.com

Programme Management

Robust modelling, planning and programme management will be critical over the coming weeks and months to ensure that urgent needs of the public are being met. At system level, strong programme management needs to be in place, with effective governance and a continuation of the kind of rapid decision making that has been necessary during the past two months.

This does not mean swallowing the PRINCE 2 manual whole (please don’t!), setting up a mini-industry of overly complex programme management tasks, but instead a focus on setting clear priorities, action plans and simple, readily understood monitoring of progress will help.

Managing our People

Displaced staff working outside of their normal settings, and those who have recently returned to the NHS, need to be carefully managed. Their roles considered in balancing the need to maintain surge capacity against returning other clinical services to normal. Health leaders and workforce planners will have a challenging role in determining organisational priorities against the broader needs of their local system. Staff will also need to take leave, rest and recuperate and this must be reflected in capacity planning.

Building on and Developing New Ways of doing things

While the last few months have seen significant development and delivery of urgent care capacity in responding to the crisis, other significant achievements have also been delivered.

Given the requirements of social distancing, we have witnessed unprecedented growth and acceleration of digital consultations in Primary and Community Care. Sensible data sharing across organisations has been accelerated without the endless delays previously caused by the heavy hand of (often incorrectly applied) Information Governance. Not only must we ensure we maintain the good progress we have made, we must learn lessons from what and how we have done this and replicate these in the future.

The Challenge remains significant but …

Finally, we cannot ignore the fact that prior to the pandemic, our NHS was challenged financially, had limited capacity with significant unmet demand and was trying to come to terms with an unclear and at times poorly executed transformation. Performance targets across many metrics had not been achieved, for months and in some case years.

As we return to our new normality, these conditions will continue to prevail. While the national euphoria we currently share for our NHS colleagues is heart-warming, we must not underestimate the significant challenges ahead.