12 – Known unknowns – managing health services in the next phase of the pandemic

by Richard Sloggett

Reports that say that something hasn’t happened are always interesting to me, because as we know, there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know.’ Donald Rumsfeld, 2002

For NHS policymakers the Rumsfeldian concept of ‘known unknowns’ is one that will currently feel familiar.

Much thinking is going into how to switch on a national healthcare system that has been in large part suspended and disrupted during the pandemic response.

A great deal of attention so far has focused on the ‘how’. How to get patients back into the system for operations, to catch up on missed cancer appointments, to detect undiagnosed disease and perhaps most importantly to prevent COVID 19 from spreading in healthcare settings between patients.

There is little doubt that in recent weeks the NHS has undergone one of the most radical shifts in its history. Millions of appointments made digital, field hospitals built in days, normal payment systems frozen, the changes have been far reaching and fundamental. And so far, they have seen a system that has been able to cope with everything the pandemic has thrown at it.

But, and it is a rather significant but, what public health needs is the service is going to have to address in the coming phase? The ability to change service pathways and delivery methods is one thing, but such moves need to reflect and line-up with the needs of the population. And that need burden has changed over the last few weeks. Some of these needs will be physical, some mental, some clear, some hidden, some new, some old.

So what could this new need look like?

Broadly it falls into five categories (with various subcategories). The categories are not mutually exclusive, but give a sense of the immense difficulty the NHS faces in meeting what is coming.

The first category is COVID 19 related patients.

These will be patients being treated for the virus and where most focus has rightly been in recent weeks. There will also be those recovering from the virus. Thankfully for many the recovery process appears to be fairly swift, but the long term implications of the virus are to be determined, will vary and could require ongoing support for some – particularly in the community.

The second category is non-COVID related patients who had pre-existing long term conditions that require regular management (eg diabetes, arthritis).

In particular the switch of outpatient appointments and primary care to a ‘digital first’ model has been rightly applauded. But the impact of this on individual patients and patient outcomes is uncertain. Where have digital models worked and where have they been less effective? The push will rightly be to ‘lock-in’ the lockdown gains on digital health; but this needs to be based on evidence. A patient and clinically led evaluation would help answer these questions and ensure the right lessons are learnt.

The third category is patients waiting for planned care. Waiting lists were already at record highs and, with predictions that they could rise to above 7 million after the pandemic, how will patients get the treatment they need? Will further use of private sector capacity be used, as indeed it has during the pandemic? How will care be prioritised/rationed/paid for? This will require tough choices and difficult public communication.

The fourth category is missed conditions such as cancers not caught or minor strokes missed. Here the system has both a catch-up challenge as well as a capacity crunch. In terms of the former how patients can be safely screened for services may require new community care based support, diagnostics and pathways, alongside publicised plans for COVID free hubs.

The fifth category is the wider impact of COVID 19. This is by far the hardest to quantify and indeed such effects will have a much longer term impact than the virus itself.

The health needs in this category could include those who have lost a relative/family member/friend to the virus, those made unemployed following the economic impact of the virus, vulnerable groups who have had support disrupted during the pandemic, groups who want to avoid any interactions with healthcare settings, those suffering domestic abuse and (of critical importance) to the system healthcare staff suffering burnout and exhaustion.

An interesting element of this fifth category is that it is not all negative. Attendances at A&E for minor injuries for example have dramatically reduced. How to maintain such behavioural changes in accessing healthcare through and beyond the pandemic presents an opportunity to support a faster NHS recovery. To do this effectively will require a strong and clear patient and public engagement strategy, such as that advocated by National Voices.

The NHS has stood up to the first phase of facing what was an unknown virus As it enters the second it faces a complicated set of known unknowns that will test it much further still.


Richard Sloggett is Senior Fellow and Health and Social Care Lead at the think tank Policy Exchange. He was previously Special Adviser to the Secretary of State for Health and Social Care.