The first question to be asked is what is the system trying to be resilient for? If there is not enough thought about this, there is a risk we create a system that has near perfect resilience for this recent crisis, but does not have the flexibility to cope with future challenges. Having a health and care system that is able to learn from historical and international experience, and rapidly translate that learning into what it means practically for future resilience in England is key.
There will be a lot of focus on the national action taken to prepare for the current pandemic, and how this feeds into the approach to readiness for future shocks. This will include legitimate questions about stockpiles of personal protective equipment (PPE) and the security of domestic distribution in competitive global supply chains. But while a national angle is important, building effective system resilience will need more than that. Local planning is also vital.
So, how can local health and care services adapt to be more resilient to a wide range of future shocks and risks? Capacity is likely to be first on the list in any debate about local resilience. Early in the pandemic, discussions in the NHS were dominated by bed numbers and occupancy rates. The UK has a low number of hospital beds compared with other countries and the high and rising bed occupancy rate was an easily visible sign of a system under pressure. There was a clear recognition of the need to get bed numbers up and occupancy levels down.
There is a clear risk that approaching resilience by focusing primarily on acute hospital beds or occupancy rates reinforces the default of hospital-focused responses to system-wide issues. However, understanding unmet need and hot spots in community health, community mental health, home care is much harder because there is little data collected for other key health and care services that is the equivalent to bed occupancy or waiting lists. But this shouldn’t mean avoiding discussions about capacity in these services that are a core part of a resilient health and care system. In addition, bed numbers mean little without staff to look after the patients in those beds. Having enough staff is a key part of capacity – the pressure that vacancies put on existing staff in normal times is bad enough, but in a crisis it’s exacerbated. There need to be concerted efforts around recruitment and retention to shift the current vacancy and turnover rates in health and care.
Second, flexibility needs to be at the heart of resilience, so the health and care system can respond effectively to unforeseen events. During the current crisis, staff have re-skilled at breakneck pace to ensure sufficient critical care staffing levels. This was impressive to see and relied on the contributions of many people locally and nationally. But flexibility in the workforce means more than ensuring rapid flexibility of the right clinical and professional expertise, it’s also about a wider set of skills including how are people supported to be able to build new relationships and form effective new teams quickly under pressure. Investment in developing broader skills and behaviours across the workforce will be important for resilience.
Third, organisations need to think about the impact on the whole system before they act as individual organisations – what is the consequence of taking that action on others, and are the consequences better or worse than the problem being addressed? This requires at least two things. There must be action to close the data gap so there is much better information across health and social care services on needs, activities and outcomes. This would give a much better sense of the different pressure points across health and care locally. But it’s not all about the data. Putting systems, rather than organisations, first when thinking and acting under pressure relies on the good, trusting relationships developed in the more normal times. Over the next few years this means really focusing on developing the right behaviours and relationships both in integrated care systems and at place level so those relationships can stand the test of time and help shift the default response to system-based solutions.
Finally, community capacity is a core part of resilient communities and a resilient health and care system. No public service should think it can be perfectly resilient by itself – there is an eco-system that extends well beyond the statutory sector. A resilient health and care system needs resilient community networks and support, facilitated by a strong voluntary and community sector. This has been crystal clear in the Covid-19 pandemic. The public sector needs to think about both how it financially supports this sector, and also how public sector systems and processes can help or hinder the viability and effectiveness of this sector.
It’s right that resilience should be part of the debate about the shape of the future health and care system. For me, the concept of what makes the health and care system resilient needs to be about much more than stockpiles, supply chains and hospital beds. My starting point for local resilience is about capacity across the system, flexibility in the workforce, system-based action (backed by data and behaviours) and community capacity. What would resilience in a local health and care system mean for you?