Ruth Boaden and Joy Furnival outline how the health and care system can continue to work effectively post COVID-19.
One of the remarkable aspects of response to COVID-19 has been the magnificent joint efforts from across health and care to respond to the crisis together. All parts of the NHS, social services, public health, primary care practices, and the voluntary and private sectors, have collaborated and worked across boundaries with a single shared aim - to serve and protect patients and populations.
In our view it is essential that for all organisations to continue to work together effectively in the future, they consider the whole system and we suggest that consideration of people, place, partnership, processes and power can enable this.
As our health and social care system recovers from COVID-19, we must focus on the holistic needs of people requiring care, rather than a fragmented restoration of health services that prioritise clinical emergencies and which may leave gaps in the support available for the total health and care needs of the population.
As non COVID-19 health services are now likely to resume in staggered and different ways, the challenge for health and care will be how to focus on the multiple and complex needs of individuals when restoring service by service.
The potential impact of this for those with multiple morbidities, or those who already experience health inequality, is enormous. At the same time the pandemic has created - and will continue to create - demand for new care services, such as the long-term mental health and rehabilitation for those affected by COVID-19.
We need to align recovery activity in a place that makes sense to the people and builds on how response to COVID-19 has worked, rather than following administrative boundaries for the NHS or any other organisation.
Much activity during the COVID-19 response has been driven by central government and enacted in a place-based context by a range of organisations, supported by Local Resilience Forums and their members, including those from health and care.
However the lack of alignment between NHS structures and others is now bringing its own challenges, especially in terms of working with local authorities, from metropolitan districts and boroughs through to county councils and district councils. Effective partnerships for recovery need to develop at place level and may be best co-ordinated by local authorities rather than NHS organisations.
We need to consider recovery of the whole system and work in partnership. Effective recovery requires a systemic approach that is inclusive of the priorities and challenges for community-based and social and care services alongside those of hospitals.
Following a time where there has been a huge emphasis on the acute hospital sector, it will require leaders from community health services, social care and general practice - as well as other parts of local government and those that use their services - to be brought into the heart of design and prioritisation decisions about health and care provision. We must listen to the experience of staff and service users in partnership to ensure recovery.
These mechanisms are already in place or being developed through Integrated Care Systems, and COVID-19 might be the ‘push’ that is required to make these partnerships come together more quickly. Health services cannot recover on their own and should exploit the emergent structures and learning from the pandemic response.
In a monumental effort of redesign, many new and adapted processes have been established very quickly during the COVID-19 response. Nevertheless, it is clear some processes have not worked well, such as those in supply chains for personal protective equipment.
Data to assess and measure new and adapted processes, to understand whether these changes have been improvements, has been infrequent and challenging to collect for the out-of-hospital sector. A key challenge for the system recovery phase is therefore to ensure that adequate assessment and data is in place to learn about and evaluate, adapt, adopt, and/or resume new or old processes. We need to consider all processes within and across organisations, evaluating where they have worked and retaining them, and questioning the reintroduction of others.
We need to ensure that the power of all parts of the health and care system is recognised and can be exercised, and consider the longer-term consequences of decisions for society as a whole rather than only for the convenience of the NHS.
However, will the newly reconfigured services best meet the needs of diverse local populations, and will population health be better served in these new forms? Will services need to revert to their previous configuration or will health and care institutions even want to change services back if needed? And how will the public and other local and regional stakeholders be involved in such changes?
Choices about who is treated - and who isn’t - given the limits of space, equipment, supplies and staffing must be made transparently and consistently. These choices are also likely to be different for different populations.
Previously this would have been done through Clinical Commissioning Groups, although they had their power significantly reduced when emergency orders were imposed allowing NHS England to direct local commissioning powers. Where is the power of the local population going to be exercised now?
Recovery is not only an NHS, or a hospital, or a health issue, nor even a health and ‘social care’ issue. It is something for the whole system and which must include people who live and work in places and communities.
And it is imperative that all parts of the system work in partnership, building on the way in which response to COVID-19 has broken down barriers and enabled new and improved processes.
Dr Joy Furnival is a Senior Lecturer in Healthcare Management.
Ruth Boaden is a Professor at Alliance Manchester Business School.