What issues do we face in resetting, restoring and rebuilding clinical services in the COVID-19 era?

On 30 January 2020 (a date that now seems an age ago), the UK’s NHS declared a level 4 critical incident in response to the emerging global COVID-19 pandemic. On 17 March, the NHS Chief Executive Sir Simon Stevens and Chief Operating Officer Amanda Pritchard wrote to NHS Trust Chief Executives, instructing them to enact steps to maximise critical care capacity, prepare for the anticipated increase in hospital admissions and increase staff availability to support patient-facing roles.

The instructions included a number of operational elements:

• the postponement of non-urgent elective surgery and other clinical activity
• accessing capacity in the independent sector
• support for remote working for staff at increased risk
• support for remote consultations and provision of advice and guidance for outpatient and primary care
• support for clinicians to work beyond their usual boundaries and specialties
• a move to block contract payments ‘on account’ with suspension of volume-based ‘payment by result’ tariffs and the underlying
• financial architecture and processes.

The pace and scale of the NHS response to the COVID-19 challenge was remarkable: testimony to the structures and processes of the organisation, and to the skills and attributes of those working within it. To many, it showed what could be achieved given the right conditions for change.

We now face a different challenge: how to reset, restore and rebuild clinical services paused over the last 6 months. Do we return to what we had, or is there an opportunity to achieve something better?

THE ‘NEW NORMAL’ IN CLINICAL ENDOCRINOLOGY

In keeping with many other specialist clinical services, endocrinology in the UK has evolved around local and regional requirements through processes that have been partly strategic, partly organic.

Some services are based in specialist centres, others within smaller hospitals that balance a range of generalist and specialist services. Some regions have well-established and functional clinical networks, while in others services remain in silos.

Nationally, we see variation in pathways, performance, matching of demand and training outcomes: variation we have looked to address over time with a range of success.

As in any large, complex system, effecting change within the NHS can be a slow process of small, iterative steps. We are now presented with a bigger, strategic opportunity and we have an ally in change: the NHS leadership.

In a letter to NHS Chief Executives on 29 April 2020, Sir Simon Stevens highlighted the opportunities to ‘lock in’ beneficial changes brought about during the COVID-19 response. A number of themes covering ‘lessons learned’ were emphasised as being key going forward:

• flexibility
• enhanced local system working
• clinical leadership
• remote working
• rapid scaling of new technology-enabled service delivery.

As we restore endocrinology services to the ‘new normal’ within this broader context, we have a window of opportunity to embed change at pace and scale, such that we go back to something better. What should be the vision for that change?

CHANGE IN HEALTH SERVICE DELIVERY: THE BROAD VIEW

A number of national groups have set out broad principles for resetting healthcare delivery as we emerge from the COVID-19 peak. There is significant common ground.

The Royal College of Physicians has set out nine priorities in resetting and relaunching services. A key principle is building in long term improvements, with specific reference to reducing health inequalities and improving access:

• supporting integration: redesign through co-production with primary care, social care and patients
• increasing the workforce
• encouraging protected time for quality improvement, service redesign and research
• supporting education development
• securing a new deal for international workers
• enhancing person-centred care
• enabling access and involvement in research for all
• making social care sustainable
• harnessing the potential of digital health.

The Health Foundation too has emphasised four key principles underpinning service restoration and reform:

• understanding and addressing the full extent of unmet need
• reassuring the public about using services
• looking after and growing the workforce
• improving, not just recovering, services.

ENDOCRINOLOGY

The Specialist Endocrinology CRG and Society for Endocrinology have been working on a range of initiatives.

A Specialist Endocrinology CRG consultation exercise on the future of clinical services reported in May 2020. The exercise identified strategic principles and specific operational elements capturing positive learning from the COVID-19 response that we recommended should be ‘locked into’ the reset and rebuild.

1. Over-arching principles:

• enhanced support for remote consultations
• wider engagement with primary and community care
• co-design of care pathways with primary and community care
• enhancing visibility of local clinical networks
• improving access to endocrinology MDTs.

2. Improving delivery of specialist care:

• clearer recognition of specialist centres.

3. Enhancing efficiency of outpatient services:

• providing advice and guidance as an alternative to referral for outpatient review
• assessment and triage of referral as standard practice in managing referrals
• development of ‘confer before refer’ systems with primary care
• supporting ‘direct to test’ pathways.

4. Improving access:

• developing and supporting patient group education via video technology
• development and implementation of patient-initiated follow-up.

5. Training in endocrinology:

• further development of allied health professional and clinical nurse specialist roles
• development and support of e-learning platforms.

To further inform and guide adaptation in service delivery, the Society for Endocrinology is supporting a working group exploring the future of endocrinology. This will include representation from patient groups and the Association of British Clinical Diabetologists, who have recently gone through a similar process to review services in diabetes. We look forward to seeing the output in the near future. Alignment, inclusion and a co- operative approach across the system will be important determinants of success.

OBSTACLES AND CHALLENGES

While there is genuine excitement about the opportunities, it’s important we recognise the scale of the challenge ahead. Reset and restore will not be straightforward.

After the usual drop in referrals from primary to secondary care over the Christmas–New Year period in 2019/2020, weekly referrals peaked at 385,503 in the week beginning 20 January 2020. There was a subsequent sharp fall. By mid-April 2020, routine referrals had decreased by 90% overall. Urgent and ‘2-week’ pathway referrals fell by 78 and 67% respectively. This shift reflected both decreased presentation of patients to primary care as we ‘locked down’ and reduced onward referral. While referrals have started to increase again, there is limited ability to ‘bounce back’ within the system.

The public remain wary; there is fatigue within a depleted clinical workforce – many of whom were redeployed to other roles; and making hospitals safe for both patients and staff has reduced capacity for traditional ways of working. In the short term, we risk a logjam as new incoming work meets that which was postponed from March–June, at a time when capacity is still limited. We cannot simply stop and reconfigure: the logjam will simply get bigger.

New ways of working with technology are both refreshing and challenging. ‘Remote by default’ will be the standard for outpatient consultations going forward, as we aim to deliver 80% of appointments non-face-to-face. While there are positives to this approach, there are some uncertainties. Subsequent face-to-face consultations may be required for a proportion of patients seen remotely and, although consultations may require less physical infrastructure, access to testing and laboratory data can be limiting. Those services with a functional electronic patient record (EPR) will be more adaptable than others. Institutions wishing to engage in EPR platforms now will find themselves approaching a large financial investment at a time of significant constraint. Maturity and capacity of the NHS digital infrastructure may limit the pace and scale at which we can engage and respond.

As well as clinicians, healthcare commissioners and managers have an important role to play in resetting and restoring services. Financial structures and accounting processes may need modification to reflect changes in mode of consultation and outcomes. Activity constraints (payment by result) versus block contracts need key reconsideration following service restarts. The real challenge may be for commissioners and managers to support clinical teams in doing the right thing: responsive funding packages being co-designed to support clinical innovation.

IN CONCLUSION

A pragmatic, balanced approach is needed to what lies ahead. While there are some ‘low hanging fruit’, it is crucial to establish the vision and principles behind the need for change, while building in the processes that will enable further progress over time. We need to ensure those processes are dynamic and agile, as we still face some uncertainty over when and how our clinical services will be asked to respond again. There is much to do. Get involved.

STEVE BALL
Society for Endocrinology Representative, Specialised Endocrinology CRG