The NHS rose to the challenge of Covid, but its next test may be even harder | Bruce Keogh

Over the past year, our NHS has risen to the challenges of the pandemic. But it’s been a very close-run thing. There have been well-publicised difficulties such as the shortage of ventilators, ICU beds and PPE, and the physical and staffing capacity of the health service has been strained to breaking point. GPs have managed the risks to patients who have been unable to receive specialist care. We now face a growing backlog of postponed treatments and emerging mental health issues. So if we were to imagine a post-Covid NHS, toughened by the challenges of the pandemic but better prepared for the future, what would it look like?

The NHS was created during a completely different time, so it’s no surprise that some aspects now need modernising and reforming. Life expectancy has increased by an average of 13 years since the health service was founded in 1948 and it faces many new challenges, including providing care for older, increasingly frail people with multiple chronic conditions.

For too long, our elderly population has suffered the consequences of a health and social care system that is disjointed and bureaucratic. By 2050, there will be an estimated 19 million people aged over 65 in the UK. This will put a huge strain on both the NHS and on families to provide care. In short, we urgently need better ways of caring for the older people in our society.

Elderly patients with chronic conditions such as arthritis, diabetes and heart disease already account for the greatest proportion of the NHS budget. Before Covid-19, at least a third of patients in our acute hospitals didn’t need to be there. Many had ended up in hospital for conditions that could be better managed in care homes or at home with the right support. As our health and social care system is forced to adapt to Britain’s changing demography, it will have to find new ways of keeping elderly citizens out of expensive hospital beds. This is a win for everyone: it prevents costs from skyrocketing, keeps beds free for those who need them most and hugely enhances the quality of life of older people.

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Covid-19 has exposed the need to address NHS capacity and resilience. In normal times, flu puts huge pressure on the health service during winter months. Routine care suffers, operations are cancelled and NHS staff struggle with the backlog over the summer. This backlog will be far worse after Covid. Any doubt that we need more capacity in the NHS and social care has evaporated. The question is what kind of capacity, and where?

Increasing capacity is not just about providing more beds. It requires organising ourselves better to meet the changing needs of patients by distributing workforces more effectively, repurposing unused buildings and relying more on out-of-hospital services such as pharmacies to deliver a wider range of services. Not everything needs to cost money. For example, before the pandemic there were senseless hurdles to sharing staff between hospitals. Now, this practice is commonplace.

We already run our financial and social lives online, but the NHS has lagged behind in this field. The pandemic has shown us what’s possible. Within a fortnight of the first lockdown, more than 50% of all GP consultations were being conducted virtually, and hospital consultations soon followed. Tools that allow people to remotely monitor their symptoms have been shown to reduce the need for unnecessary hospital visits and admissions. After Covid, we are likely to see the continuation of digital consultations – though of course not everything should be conducted online, and many people will still want the personal touch of face-to-face appointments.

Where technology really will excel is when it frees up clinicians to deliver specialist care. In the near future, you might be able to take a picture of a skin lesion and an AI app will have the diagnostic capability to advise you on how to treat it and whether to seek medical help. In hospitals, AI could help with faster and more accurate diagnoses of some scans and biopsies, giving doctors more time to deliver specialist treatments.

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But such tools will require careful regulation. Digital information doesn’t respect the regional boundaries of the NHS. If somebody in Sheffield uploads a picture of a rash to an app where they receive advice from a doctor in Belgium, for example, who is then held responsible if the advice proves wrong?

New technologies will also help the NHS provide care outside hospitals. We’ve seen an explosion of digital therapies that alleviate anxiety, depression and insomnia. Some are excellent. Most aren’t. But with proper scientific regulation such tools could be enormously beneficial, particularly for those who may be struggling with isolation and loneliness.

AI isn’t the only field that is changing what the NHS will be able to do. Over the past century, vaccinations, antibiotics and monoclonal antibodies have transformed the way we prevent and treat diseases. We are now on the cusp of another major medical advance. British scientists are at the forefront of understanding how the human genome and cells work. This area of research could produce cures for previously incurable conditions such as haemophilia and some forms of leukaemia. The challenge with such treatments is that they will be very expensive, raising difficult questions about how to divide a finite budget: should we chose to spend resources on smaller, inexpensive health improvements for lots of people, or expensive, life-changing health improvements for a few?

Covid-19 has demonstrated how the NHS could be a world-class research laboratory. The UK is home to some of the world’s top universities, and we punch well above our weight in medical research. During the pandemic, NHS hospitals took part in rapid, large clinical trials that led to improvements in treatments such as dexamethasone. The relationship between academic research and the NHS has already proven its worth, and it needs to be embedded in the future of the health service.

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To ensure the health service is capable of meeting the challenges it will face in the next decade and beyond, it will require both structural and local reforms. The word “reform” triggers unease among many NHS professionals, who have been subject to numerous reorganisations over the years and have witnessed efforts being diverted into reforms at the expense of improving patient care. While some of the changes in the recent NHS white paper seem sensible, their effectiveness will depend on the final detail.

To ensure the focus remains on patients, all policy reforms and local changes should convincingly pass at least one of these six tests: will they reduce demand on the NHS by preventing disease or improving wellbeing? Will they speed up the time between a patient seeking help and receiving treatment? Will they enhance patient safety before, during or after treatment? Will they enable better clinical outcomes? Will they provide better taxpayer value? And will they reduce the inequality of access that has resulted in some groups receiving less care than others?

The pandemic has shown us all how much we depend upon the NHS. In this dark year, it’s worth remembering that the health service was founded during a similarly intense period of hardship following the second world war. It was the most ambitious social insurance project in history and became an icon of Britain’s social conscience. Our task now is to ensure its resilience for the future.


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