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The future of the NHS
A&E doctor Stephen Fabes imagines a brighter tomorrow for our NHS
So what will the NHS look like once the coronavirus crisis has eased? Dr Stephen Fabes, a 39-year-old A&E doctor and writer working at Guys and St Thomas’ NHS Trust in London, who has been working on the front line for the past two months, gives his predictions
On 8 January this year, a Wednesday, my A&E department in central London was its typical, swirling self. The waiting room brimming, the paramedics backed up. On a quieter day, I might have noticed an article in the British Medical Journal about a cluster of patients with a new pneumonia in Wuhan. Ten weeks later, when the Army unloaded a consignment of surgical masks to the forecourt of our hospital, even A&E doctors like me, for whom workaday life is used to calamity, felt blindsided by the nature of things.
A year before that BMJ piece, almost to the day, Theresa May and NHS CEO Simon Stevens announced the details of the NHS 10-year plan at Alder Hey Children’s Hospital in Liverpool. Military support wasn’t included.
In this great upset, 10-year plans will naturally be realigned, but already I have seen gargantuan efforts within the NHS to adapt. Something entirely awesome – there is no other word – has happened to my workplace. The hospital restructured, reinvented itself. A&E segregated. Intensive care capacity expanded threefold and wards were given over to the breathless. Staff were redeployed to areas of greatest need, and our working lives were reconfigured – speciality training scratched, rotas upturned. We embraced the earthquake, mostly with pride and a sense of duty. This was what we’d been trained for.
A few months later, there is no more talk of war medicine and an ethereal calm has descended on my department. At last, there is a moment to reflect and to prepare. There are lessons hidden within the numbers if we have the courage to seek them out, questions about the preparedness, capacity and logic of our systems. And (without back patting) that we weren’t, on the whole, overwhelmed, speaks perhaps to the agility of the NHS.
There will be astonishing change to come, some opportunistic, some mandated by the menace of this disease. History invites optimism: crises inspire us to step up, to forge ahead with new tech and new capabilities. The wake of the Second World War saw expanded use of antibiotics and blood transfusion, advances in trauma and plastic surgery. Bugs, too, have been helpful, inspiring improvements to sanitation or, in the case of polio, helping create intensive care itself.
Amid the various exponential curves, finally, one we will welcome: that of knowledge – of the coronavirus and individualised response. With knowledge comes power: vital if we face a further peak. The mainstay of treatment so far is ‘supportive’: oxygen, paracetamol for fevers, monitoring. And while I’ve witnessed this brutally upended on occasion by critical-care teams brandishing tubes and lines, even then, you couldn’t fault the strategy for being over-complicated. ‘Forget all the medicine you’ve ever learnt,’ one ICU consultant told me. ‘There is one plan now… tube now, tube later, never tube.’
This will change as complexity takes off. Every patient is data, but if that sounds heartless, it should be reassuring. From the outset, new protocols appeared in the time it took for a toilet break. Emails with clinical advice began disconcertingly: ‘Please understand that this information is experience, not evidence…’ Twitter was scoured by intensivists hungry for guidance. Now we have the Recovery Trial, which will look at whether currently available drugs are effective in the treatment of Covid-19. It has recruited patients faster than any trial in the history of our health service – 5,000 in 165 hospitals. Meanwhile, studies are replicating fast, putting anti-virals and human plasma to the test. Expect advances in forecasting who will suffer severe disease ( genetics may be key) and novel treatments, infusing hope into all our veins. Junk science will be crowded out by a more resilient strain of data.
After weeks of restricted healthcare, there will be a backlog, and surgeons in particular will be desperately playing catch up. We hope patients recovering from operations do not contract Covid-19 in hospital. Some will. The faster tests of the future will help segregate patients at the front door, but until they are available, hospital-spread will be a risk to endure.
But we can. I imagine a future without corridor medicine and packed waiting rooms – in one fell swoop, some scrap of protein, on the edge of life, has solved a dilemma that politicians and NHS managers have struggled with for years. There will be more side rooms, perhaps even pods or infection-control tents. The whole ‘front door’ of the NHS – presently A&E – could be unhinged and patients guided first through a ‘digital front door’. This will reduce demands on A&E, a necessary step, aided by self-managing health through education, delivered digitally too. None of this will come without trade-offs. Fewer patients in, more pathology missed, a tragedy redoubled if hospitals are seen as intimidating edifices, too thick with infection to risk. Recent analysis estimates cancer mortality increasing by 20 per cent over the next year because of treatment delays and reduced screening.
Surviving intensive care does not mean an easy leap back into jobs and family life. For most, it is a brutal experience that takes months or years to truly heal from. Initially, patients lose between two and three per cent of their muscle mass per day in ICU: we will need physios. Eighty per cent suffer psychological trauma, and PTSD is commonplace: we
We will feel valued long after the clapping fades and the free pizza runs out
will need psychologists too. How lungs will be damaged in the long term remains to be seen, but rehab for fibrosis of the lungs may be required. Twenty to 40 per cent of patients in ICU with Covid-19 require renal replacement therapy to treat damaged kidneys, on which many will be dependent after they leave. It is not the ventilators we will be short of, but the complex, costly dialysis machines.
Technophobes working in the NHS, I am sorry to tell you this, but you will be hit hard by the virus; many patients, though, could prosper. Health apps are proliferating, telephone and video triage ramping up, online prescriptions have not yet peaked. I only hope the hyperbole of the venture capitalists touting artificial intelligence doesn’t divert attention from getting the basics right. Adoption of what’s already out there will allow us the most salutary break from the past – we may choose to resolve sketchy digital datasharing and patchy coordination of care.
The impact on Britain’s mental health, and on services for those afflicted, is perhaps the most immune to speculation. Our suffering, while far from evenly spread, is communal to a degree, causing some to divine no special crash in our well-being. Equally, an uptick in anxiety and depression is easy to imagine amid the pain of lost jobs, estranged friends and bereavement. Physical illness too commonly accompanies mental problems, and such patients are vulnerable to both the virus and unmet social-care needs. Whether mental-health services, historically the unloved Cinderella of NHS funding, will be resourced to cope remains uncertain.
Now forgive me if I indulge some wilder hopes. NHS workers, riding a wave of public appreciation, will continue to feel valued long after the clapping fades and the free pizza runs out. With political pressure to hike up our salaries after years of real-terms cuts, vacancies might fall. In most hospitals, ‘staff well-being’ is limited to a debrief after an unusually traumatic event, but in the pressure cooker of Covid19, it is already front and centre. Wellbeing spaces have popped up, massage chairs, counsellors on call and posters to promote self-care. I hope such measures will endure, and so should you: loved doctors and nurses are better ones.
Debate will rage over whether centralised or localised services best serve our new interests. Consolidation of some services, such as trauma and stroke, have been effective, and we have moved away from the model of ‘everyone doing everything’. This blueprint, though, has drawbacks, from sourcing staff to the closing of treasured local services, and it may not be well-suited to managing a communicable disease. Good public health surveillance requires local teams and local control over services. For track and trace, we’ll need consistency, not a patchwork of providers. But as GDP dwindles, the proportion we spend on health will climb, and the once worrisome ratio of ICU beds to population will be relegated to history. Staffing them will be a priority and a challenge – funding initiatives for trainee nurses will help, but the grim backdrop to Covid-19 is a shortfall in trained staff. There will be no quick fix.
As statistics mount up, an opportunity to tackle the social underpinnings of disease in Britain will be there for the taking. Cramped living conditions and insecure work can help propagate infection. Public health might be weaponised to reduce the demand on A&E: already, there are pushes to get tougher on speeding and smoking. With obesity and diabetes risk factors for severe infection, expect Public Health England to double down on junk food.
But if there are spot fires of Covid-19 for years, or if a vaccine is not the elixir we hope for, then the peak we are descending today may be the first in a rambling mountain range. How the NHS responds will be predicated on political will, which may itself depend on how the virus tests us next. A catch-22, perhaps: the most exciting innovations might require us to battle further peaks. The faster we recover, the less we’ll be inspired to adapt.
Myownhopeisthatwewillbeableto admit what’s rotten in the NHS. Then the story will be one of medium-term strains and longer-term gains. Some advancements should have happened before, others will be radically progressive, making the ‘ambitious’ initiatives in the 10-year plan look rather lame. We will be divided over some. But while we do not know how the story will unfold, we have a chance to better the ending, to emerge phoenix-like from the ashes, with a confident, battle-hardened NHS, updated, re-staffed, future-proofed, with a loving public behind it. If that sounds quixotic, well, I would have thought so once too, but the upheavals I’ve seen so far have taught me one thing: it’s OK to believe. Dr Fabes’ first book, Signs of Life: To the Ends of the Earth With a Doctor, about his journey by bicycle across six continents, using human stories to explore health and disease, will be published by Profile in August; visit stephenfabes.com