How many of the changes in NHS practice will continue after this crisis is over? (2)

I write these posts whilst looking over the Thames in South London. If the O2 wasn’t in the way I could just catch a glimpse of the Excel conference centre – the one that has being repurposed as the new Nightingale hospital.

Richard Lee, COO at St Johns Ambulance said recently that in a few weeks there would be 500 St John’s volunteers working 2 x 12 hour split shifts there. The volunteers will be paired with the nurses on site, tending to patients and ensuring they are as comfortable as possible. The news was treated with universal approbation and relief that the NHS can call on such skilled and committed people to work with them.

Which brings me neatly to the topic I want to discuss today,

Do some tasks really need highly skilled personnel to perform them? Or could someone with fewer skills do them?

During every winter over the last few years there have been crises in nearly every A&E department in the country. At such times the St John’s Ambulance Service have had volunteers able step in and help many of those overstretched departments. If that had happened on any scale, many NHS staff and the “Save the NHS” lobby would have denounced it as a fall in standards.

Now it’s a ‘good thing’. And it will reduce the pain and distress of thousands of patients.

This follows – some weeks ago – a letter to all doctors asking them to be flexible about their specialist skills and use the more generic skills that may be needed in this crisis. I suspect that this week, as patient need really hits, there will not be many doctors who will refuse to do something because it is not a part of their specialism. They will correctly feel that their generic skills could help patients – and that they can learn from others how to do this.

It’s not that there is anything wrong with specialisms – nor very enhanced and specific skills. They have saved many lives and will continue to do so in the future. But all medics and all clinicians have a core set of important skills that can be deployed to work with patients who have the virus. They also know when to call on those with higher skills when necessary, but given the shortage, only when essential.

I follow many articles in the Spectator. On 28th March their health correspondent Max Pemberton, a psychiatrist working in London, wrote with pride and amazement about how quickly the NHS had moved onto ‘a war footing’.  “By the time I came in the next morning….(the morning after the lockdown announcement)… managers had been up all night, had already started to implement profound changes to the way in which hospital and services were run, and this continued over the following days

What makes these comments all the more remarkable is that Max Permberton is no sentimental NHS cheerleader. As his article goes on,  “Decisions that used to take months or even years because of endless form filling and meetings now take place in less time than it takes to boil a kettle… Services have been reconfigured and reorganised involving difficult and uncomfortable decisions about having to redeploy staff… Red tape is now non-existent. It’s nothing short of extraordinary.”

These words demonstrate the thrill for him of being part of an organisation that is meeting this enormous national risk by taking risks itself. This thrill has been echoed by many clinicians I have spoken to. Whilst they love working for the NHS, they have been wearied by the very slow pace of change – even in the face of very obvious need. It takes ages.

Around the country new relationships between hospitals have been implemented in days. Some of these changes bear a striking resemblance to proposed service reconfigurations that have taken decades NOT to be implemented.

When old NHS hands meet it only takes a few drinks to get them telling very painful and funny war stories about decades of their lives that have been wasted failing to make inter-hospital changes.

Well not in the last few weeks.

For 10 years, one of the main set of reforms that the NHS has been trying to develop has been “integrating” services. Some of this has been very ambitious – not just linking NHS services and social care, but housing and education.  Very few places have managed the full alphabet of A-Z integration but many have linked A to B, M to N or Y to Z. This has been achieved by very different professionals having respect for each other’s very different skills. Diabeticians with 20% of their patients suffering with dementia have learned to respect the skill of social care staff specialising in dementia. The GP has learned to trust the skills of the paramedic. And the orthopaedic surgeon has learned the importance of the physiotherapist.

There has been progress. But it been very slow and very hard work.

Now, not in a decade but in just a few days, within the hospital sector – including (as in Max Pemberton’s piece) mental health hospitals, institutions have been completely repurposed.

How has this happened and will it continue?

Change doesn’t usually take place because risk causes everyone a lot of anxiety. People are afraid that the new – by disturbing the present – will lead to changes that may reduce safety.

That worry about safety is twofold – it’s a worry about how change will impact upon patient safety but it’s also about how it will impact upon individual cultural and psychological safety. “I’ve been doing it this way for a while. I feel safe in doing it this way – changing that means I do not feel safe”.

But now there is a bigger and obvious risk. If we don’t change the NHS will be overwhelmed by virus patients. And agreement about that risk is NOT simply a feeling within the NHS, it is shared by the nation.  For most clinicians the NHS not changing is viewed as a bigger risk than changing.

Personally I think the balance of risk for the public is greater if we don’t implement integrated care. But for a decade we have failed to make that case to the NHS – and more importantly to the public.

This crisis has been met by rapid change to protect patients. In the future integrated care will be too.