The NHS entered the COVID-19 pandemic with 100,000 vacancies, a growing waiting list for elective care (NHS England, 2020b), increasing demand for mental health, community and ambulance services, and a social care system in a fragile state. This makes the achievements trusts, and their local system partners, have delivered to transform care within the first weeks of the coronavirus outbreak all the more remarkable.
At the time of writing the number of global deaths attributed to COVID-19 has exceeded 1,000,000. In the UK deaths from the virus are now over 42,000 and once again on the rise. In response to the pandemic there were a number of changes to the national operation of the NHS. As a level four incident central direction increased, CQC suspended all routine inspections, and NHS England and NHS Improvement introduced a new financial regime. Large scale Nightingale hospitals were opened to deal with anticipated surge in demand. The spirit on the service frontline – from top to bottom - was to do what needed to be done to avoid the NHS being overwhelmed.
So now, in many ways the NHS with COVID-19 looks very different to the NHS before the virus first arrived on our shores in February. When the threat became apparent, trusts quickly had to make capacity available for COVID-19 patients while continuing other vital services, and maintain social distancing and effective infection control throughout. In a survey of trusts carried out in May, 99% said they had seen rapid innovation in response to COVID-19.
At a time when the NHS has had to refocus its efforts and resources in response to the pandemic, trusts have led the way in innovating so that they can continue to meet people's needs while meeting the demands placed on them by the virus, and do so safely and effectively. From using technology to roster staff and maintain critical services, to adopting new ways of working to ensure staff are supported and engaged during the pandemic, trusts are clear that to get through the first wave, they had to adapt. This series of case studies shows how they did so to meet the challenges of COVID-19.
Innovating under pressure
Trusts have seen the impact of COVID-19 in a number of ways, from increases in the numbers of COVID-19 patients, to the challenge of meeting the needs of others who may have needed care but not accessed it, often due to being concerned about the risks of visiting hospital during the pandemic.
It hasn't just been acute hospitals facing additional pressures. London Ambulance Service NHS Trust, for example, described how they saw demand for NHS 111 services grow to 300% of normal levels, with a peak of 11,500 999 calls at the end of March. In response, they worked quickly to secure additional vehicles and fit them out so they could match the increased demand for ambulances.
Mental health services have also seen the impact of COVID-19, and many have seen a rise in people reaching crisis point and needing to be admitted for inpatient treatment. Leicestershire Partnership NHS Trust identified a need at the beginning of the pandemic to provide a new type of support to mental health patients while A&E services were under pressure and outpatient services were interrupted. They created an urgent mental health hub that could support people in crisis.
Collaborating in systems
A common thread running through the stories is the importance of working together with local partners to achieve a common goal. Many trusts describe how any challenges related to system working have been put aside during the response to COVID-19, with system partners recognising the need to work together to meet the needs of people in the area and share resources effectively. Sustainability transformation partnerships and integrated care systems have helped coordinate action to facilitate faster discharge processes, and regulatory barriers to joint working were removed in the early stages of the pandemic to pave the way for a coordinated response to COVID-19.
The pandemic has created new and innovative partnerships; London Ambulance Service worked with the London Fire Brigade to train fire crews to work with paramedics on ambulances, and at Northumbria Healthcare NHS Foundation Trust, a shortage of personal protective equipment (PPE) led to a new partnership with the textiles industry to scale up PPE production, and provide mutual aid to other trusts in the region.
One trust that saw the benefits for patients of collaborative working is Royal Surrey NHS Foundation Trust, who shifted their end of life care provision to a local private hospital, where staff from both hospitals worked together to make sure people at the end of their lives received safe and personalised care, minimising disruption from the pandemic.
COVID-19 has seen the sector embark on a rapid acceleration of system working, and in many cases trust leaders have pointed out that developments they have struggled to finalise for many years prior to the pandemic have been achieved in a matter of months. Part of this has been down to the unique circumstances, with COVID-19 getting everyone pointing in the same direction and removing competing priorities, but trusts are clear that they want to continue with newly strengthened relationships to keep the momentum going.
NHS staff have borne the brunt of of COVID-19. There is a need to support staff more than ever before, and trust leaders emphasise the importance of putting staff at the forefront of the innovations they have been putting in place as part of the response to COVID-19. From ensuring staff received the support they need to adapt to changes in their trust, to providing the right training for staff working in new areas of clinical practice, trust leaders we spoke to were unanimous that success is contingent on bringing staff with you and making sure they have the support they need.
At Bradford District Care NHS Foundation Trust, their improvement methodology, the 'Care Trust Way', helped keep their staff engaged and motivated during the hardest periods of the outbreak by ensuring they were empowered to drive change and take ownership of improvement where they work, which was all the more important during an incident like COVID-19.
The need to redeploy staff to new areas led Countess of Chester NHS Foundation Trust to develop a new trust wide staff roster, to help create an overview of staffing across the trust and ensure resources were being used in the best way. Part of this was engaging with staff to ensure they were clear on the benefits for patient safety, and the opportunities for staff to learn new skills. It also meant the trust could protect time off for staff so they had time away from the frontline.
COVID-19 has led many trusts to use technology in new ways. The need for social distancing has accelerated a move to more care being delivered remotely, with video consultations and remote monitoring of patients, and trusts using technology to communicate with staff including 'virtual town halls' and video updates from leaders.
Trusts have also been using technology as part of their direct response to COVID-19. University Hospitals of North Midlands NHS Trust identified a need to reassure people that it was safe to come to hospital if they needed to, as people were avoiding coming in with potentially serious illnesses out of fear they may catch the virus in hospital. They installed thermal imaging cameras in high footfall areas to pick up anybody passing by who might have a temperature. After a learning period they could use the cameras to help manage the flow of people through the hospital and reduce the risk of spread of the virus.
Leeds Teaching Hospitals NHS Trust, a partnership between their medical physics team and Leeds University led to them adapting machines commonly used for sleep apnoea to be capable of ventilating coronavirus patients. For both these trusts, it has taken an iterative process and an open minded approach to learning, to make the initiatives work, and they are both clear that the more permissive national environment allowed them to move quickly and find innovative solutions.
Learning for the future
In many ways, despite the challenges, COVID-19 has provided an opportunity to engender a cultural shift in the NHS, with more support for staff, flexibility to innovate and work together with system partners, and make processes more efficient. Trusts are clear that there is no going back to the old ways of working.
The trusts leaders we spoke to emphasis the importance of letting the experts working in the trust to get on with what they do best, and empower people at the frontline to be part of the ingenuity in a crisis. For many trust leaders, it's about giving people permission to do something new and trusting their staff to deliver, and they are determined to take this cultural change into the future, through future waves of COVID-19 and beyond.