COVID-19 has had a marked impact on planned health care services in terms of activity, demand and patient confidence. Referrals from primary care to elective services plummeted as lockdown was introduced with very few patients going to primary care services, and even fewer being referred. At the same time and in order to reduce patient movement, and free up clinicians for what at the time was uncertain acute demand, all but urgent planned care activity ceased. Over the last few months hospitals have gradually resumed activity increasingly taking advantages of video consultation platforms such as “attend anywhere”. Increasing delivered capacity to anything like pre-COVID-19 levels has and continues to be a tough battle, with ever changing and developing Infection, Prevention and Control guidelines, staff sickness, safeguarding and isolation time (particularly with delays in testing).
In the meantime, NHSE have challenged hospitals and systems have been challenged to rapidly and safely increase planned activity across, making full use of the capacity available in the ‘window of opportunity’ before winter, with a full restoration of cancer services, and activity hitting 100% of pre-COVID numbers by October 2020.
As referrals to secondary care still remain much lower than prior to the pandemic (still, in our experience, at around 50% in August, although cancer referrals are at about 80% of pre-COVID-19 levels), there is a theoretical opportunity to use that freed capacity to start to address some of the backlogs which have developed over the last few months. The practical difficulties in meeting these challenges will vary by specialty and area, and also by type of activity.
In outpatients, we have seen the overall number of patients on the waiting list reduce by almost a quarter (whilst time waiting has increased). There are a number of ways in which hospitals and systems are using the crisis as an opportunity to drive change:
Widespread use of telephone, virtual and video consultations
The average time taken for such consultations is usually much less than a face to face meeting, and, as long as targeted where the consultation can be clinically meaningful, is more satisfying for both patient and clinician. Once embedded and linked to other virtual consultation tools (such as ‘smartphone retinal imaging’) this has the potential to become at least as significant as face to face consultations with time freed up to see and treat other patients.
Changing the relationship with primary care
Hospital clinicians have often spent more time reviewing referrals (as there have been far fewer) and have had the opportunity to enter into a dialogue with the GP. Some clinicians have reflected to us that this experience has underlined the importance of clinical triage and changing the relationship with primary care. Referrals have been often seen from a transactional, process viewpoint; perhaps there is a longer-term benefit for referrals to be more of a conversation helping to inform the GPs decision.
Some clinicians have found themselves with time to use to look at cases where the patient has been booked for a future follow-up appointment or is on a waiting list to come back. We have seen examples where up to a third of these patients have been discharged or put on a “patient initiated” pathway. Lessons can be learnt from such reviews and if applied to future cases, significantly reduce the pressure on outpatient services, and, yes free up capacity to deal with backlogs.
In our experience, although the number of patients waiting for treatment has not significantly increased and may even have marginally reduced, the proportion of those waiting over 18 weeks has increased threefold. Getting theatres back to anywhere near pre COVID-19 capacity is tough, there are potential zoning issues, challenges to throughput presented by IPC requirement, patient reluctance to come to hospital for treatment, and staff shortages. Against this what we have seen is a determination from clinicians to get back to work and treat their patients, and innovative solutions to complex logistical issues. Theatres have long been regarded as the “engine room” of a hospital, with theatre capacity and staff a scarce resource. Never has it been more important to fully utilise both the physical and staff capacity. This means that tight clinical oversight of administrative and pre-operative processes is vital – creating pools of patients who are willing to come in at short notice, strong communication with patients to help and reassure them through the lead up to surgery and making sure that all lists are full! Staff will inevitably come under increased pressure as activity increases with demands for longer days and weekend working, and some will get frustrated when, for instance, their child is off school awaiting a COVID-19 test. Strong clinical leadership is even more vital in these circumstances to help engender a team commitment to tackle the mountain of work which lies ahead.
Kingsgate have worked with clients throughout the pandemic and supported them in finding and delivering practical locally designed solutions. Get in touch if you would like to know more.
Get in touch to find out more:
Andrew Murphy, Associate Turnaround & Transformation Director firstname.lastname@example.org