Covid-19 has been the biggest challenge the health and care system has faced in living memory. It is essential that lessons are learned from this experience – whether from the extraordinary contributions of millions of staff and volunteers, the rapid progress achieved in digitising and transforming service delivery, or from the shortcomings and inequalities brought sharply into focus.
There is now not only an imperative to restore service provision while remaining prepared for possible future waves of the virus, but to build on this learning to bring about positive change and renewal so that the health and care system can support the greatest possible improvements in health and wellbeing for everyone, well beyond this crisis.
With this in mind, this piece does not explore the public health response to the pandemic, which is sure to be the subject of continued analysis and commentary over the months and years to come. Instead, it sets out five priorities to help guide the approach to renewal across health and care:
putting the workforce centre stage
a step change on inequalities and population health
lasting reform for social care
embedding and accelerating digital change
reshaping the relationship between communities and public services.
These areas will need to be prioritised by the government if it wishes to provide high quality health and care services, improve population health and make good on its promises to ‘level up’ society. These priorities will also need to sit within a wider economic strategy that supports investment in the socio-economic determinants of health.
This long read was originally published on 16 July 2020. It was updated on 8 April 2021.
Where are we now?
The Covid-19 outbreak has shown many aspects of the health and care system at its best. Health and care workers have responded with outstanding dedication and skill; clinicians and managers have gone above and beyond to rapidly develop new ways of delivering services safely; hospitals have joined forces to offer each other mutual aid and ensure continued provision of essential services; and in some areas NHS, local government and other local services have worked together like never before to co-ordinate their responses and support communities. The crisis has also underlined public support for the NHS and for care staff.
But the events of the past year have also exposed glaring issues and in some cases exacerbated existing shortcomings.
People who have been worst affected by the virus are generally those who had worse health outcomes before the pandemic, including people from ethnic minority communities1 and those living in poorer areas. Following on from England’s poor record on life expectancy, Covid-19 has exposed the deep inequalities that exist between different population groups and areas of the country.
Covid-19 has laid bare the weaknesses in a social care system that has been underfunded and overlooked for too long. The sector was neglected by the government at the start of the pandemic, with tragic consequences for service users, families and staff, and unacceptable numbers of deaths. This provides more evidence (if more was needed) that social care is in desperate need of attention, investment and reform.
Years of poor workforce planning, weak policy and fragmented responsibilities have resulted in a workforce crisis across both health and social care. Already under enormous strain, staff have now had to work through the demands of the pandemic; the impact on their wellbeing should not be underestimated. Covid-19 has taken a disproportionate toll on staff from ethnic minority backgrounds, who already face higher levels of discrimination and poorer workplace experiences than their white counterparts.
Following the longest funding squeeze in its history, before the pandemic NHS services were already running hot all year round with little capacity to spare, and deep cuts in local authority budgets had left the social care system on its knees. This meant the system entered the crisis already stretched to the limits; to prevent hospitals being overwhelmed, lengthy suspensions/reductions in the provision of non-emergency care have been necessary, leaving many people without the level of care or support they could usually expect to receive.
Beyond the immediate impact of Covid-19 on health and care, the lockdowns have caused deep damage to public finances and the wider economy. The social and economic consequences of the crisis will undoubtedly have an impact on the population’s health and mental wellbeing, and risk deepening inequalities further.
The health and care system faces significant challenges to restoring services, not only in hospitals, but also in social care, primary care, mental health and community-based services.
First, depending on the take-up and success of vaccination, health and care services will need to be fully prepared at local, regional and national levels for any future waves of Covid-19 and for the potential need for further mass vaccination against new variants. This will require the system to quickly learn from what has and hasn’t worked so far to avoid a repeat of previous mistakes.
Second, there are major practical challenges to delivering routine care while Covid-19 remains a risk. Changes have already been made to reduce the spread of the virus (including ‘hot’ Covid and ‘cold’ Covid-free areas) and personal protective equipment (PPE) may continue to be required for the foreseeable future. These considerations apply to all health and care settings, not only hospitals. No matter how well they are designed, enhanced infection control measures are likely to slow the pace at which patients can be treated, having an impact on waiting times and people’s outcomes and experiences of care. The health and care system will also face the challenge of delivering routine care at the same time as continuing to deliver the massive ongoing vaccination campaign that will be required to ensure protection from Covid.
Third, a major sustained effort will be required to address the backlog of demand for care and bring down waiting times. Importantly, this will rest on having the staff available to deliver care; it is not realistic to expect exhausted staff to move straight from responding to the pressures of Covid to driving up routine activity without sufficient time to rest and recover.
Despite being less visible in national data and waiting lists, demand pressures will also extend to community services, primary care and mental health services. These services will need to deal with the ongoing health effects of Covid-19, including rehabilitation needs stemming from the virus and prolonged stays in intensive care units, and support those whose health has deteriorated as a result of delayed presentations or gaps in routine care. In particular, there is anticipated to be a significant increase in mental health needs over the coming years as a result of the pandemic, particularly due to the impact of social restrictions and lockdown measures, with one analysis finding that demand for adult mental health services and child and adolescent mental health services could rise by as much as 40 per cent and 60 per cent respectively. The King’s Fund’s recent research into the experience of recovery from other disasters found that support for mental health and wellbeing is essential to successful recovery, with particular attention being needed to children’s mental wellbeing.
This underlines the need for a whole-system response spanning acute hospitals, primary care, community, mental health and social care services. A whole-system focus also requires attention to the sustainability of the voluntary and community sector, which offers critical support for health and wellbeing both through direct provision of health care services and broader support to vulnerable individuals and communities. Charities have been hit particularly hard by the economic consequences of Covid-19, with many suffering significant reductions in income at the same time as experiencing substantial growth in demand for their support.
Where next? Five priorities for renewal
Looking beyond the immediate challenges of restoring services, the disruption caused by the pandemic and the learning coming out of this experience (both good and bad) offer a unique opportunity to renew the focus of the health and care system to create a better, fairer health system for the longer term. The challenge will be to grasp this opportunity at the same time as restoring services and managing the ongoing risk from Covid-19, to achieve both recovery and renewal.
The approach to renewal will need to be delivered through co-ordinated action across the whole health and care system. As part of this, efforts that were already under way to establish local place-based systems of care through integrated care systems (ICSs) and the partnerships within them should be redoubled, with local authorities playing a central role.
The emergency response was characterised by much greater central direction within health and care. However, the limitations of this approach have been apparent in some aspects of the response such as the development of the test-and-trace strategy, in contrast to the successful roll out of the vaccination programme which has drawn on the efforts of local clinical teams and managers. Going forward, there are important lessons here about the need to balance central control with resources, autonomy and support for local leaders.
Insights and understanding about the impact of the pandemic response will continue to grow over the coming months. The five priorities set out below provide a framework to help guide the approach to renewal across health and care. We draw on existing evidence and experience, as well as lessons from the pandemic to set out the actions that should now be taken.
1. Putting the workforce centre stage
Health and care staff at all levels have demonstrated remarkable resilience and dedication to deliver the best possible care for patients and service users. The impact of the pandemic on staff wellbeing both in the short and longer term should not be underestimated. There are strong indications that the pressures and experiences of the last year are leading to increased stress, exhaustion and burnout. Evidence from previous disasters shows that, in addition to the initial impact, people who work in health and care are at increased risk of developing longer term mental health problems, such as post-traumatic stress disorder (PTSD), depression, anxiety and compassion fatigue.
Tragically, across the UK more than 900 health and social care staff had lost their lives to Covid-19 by February 2021. Staff from ethnic minority groups have faced a disproportionate risk of serious illness and death. This follows longstanding disparities, with evidence that NHS staff from ethnic minority backgrounds consistently experience discrimination, higher levels of bullying, harassment and abuse, and fewer opportunities for career progression than their white colleagues.
The workforce crisis was the biggest issue facing the health and care system before the emergence of Covid-19. NHS hospitals, mental health services and community providers were operating with more than 100,000 full-time vacancies and staff were working under strain with high levels of sickness absence and work-related stress. Shortages were even greater in social care, with more than 120,000 vacancies across the sector.
Before the pandemic, the government had made a series of commitments to grow and support the NHS workforce, including headline pledges for 50,000 more nurses, 6,000 more GPs and large numbers of other primary care staff. Alongside this, NHS leaders were developing a national workforce strategy, the NHS People Plan, although this was limited by the absence of clear long-term funding commitments from the government. The full NHS People Plan, published in August 2020, contained some welcome measures to support the health and wellbeing of staff and tackle discrimination but failed to provide the comprehensive strategy that is needed. The impact of Covid-19 on the recruitment and retention of staff remains to be seen, but there is a risk that severe staff shortages will continue, particularly as it looks likely to be increasingly challenging to find the 5,000 additional internationally recruited nurses that our analysis shows will be necessary annually for the next few years.
Work to develop a credible workforce strategy and ensure greater leadership focus (building on the NHS People Plan) is now even more critical, and equal efforts will be needed to address shortages in social care. Beyond the formal health and care workforce, better use can be made of broader support available by embracing the contributions of voluntary and community sector organisations and volunteers.
What can be done?
Concrete steps to improve recruitment and retention are needed to address shortages in the short and longer term. This will require an attractive pay offer, opportunities for flexible working and clearer career pathways. Efforts to boost retention should be targeted on those at the beginning or end of their careers and shortage groups and specialties. It is also vital to seize the opportunity to support those who have returned to the service during Covid-19 to stay. No delivery commitments should be made without a clear workforce plan to support them.
Wider action on the workforce crisis must be underpinned by better support for staff wellbeing to support good patient care and improve staff retention. Staff need to be given the time, space and resources to recover, for example through offering time off following intense periods, access to psychological support and supportive working environments. This should not just be seen as a short-term response to the pressures of working through Covid-19, but a sustained commitment to meet the needs of staff, tackle long-term drivers of poor staff experience and address chronic excessive workloads.
Leaders at all levels in health and care must prioritise developing cultures of compassion, inclusion and collaboration to improve care for patients and create high-quality workplaces for staff. Actions to tackle the discrimination and racism faced by staff from ethnic minority backgrounds must be central to this.
2. A step change on inequalities and population health
Covid-19 has starkly exposed the deep health inequalities that exist across England. Before the pandemic, improvements in life expectancy had almost ground to a halt and already unacceptable health inequalities between the richest and poorest were widening. Men living in the least deprived areas could, at birth, expect to live 9.4 years longer than those in the most deprived areas, while for women, the difference was 7.4 years. Between 2012–14 and 2015–17, this gap increased by 0.3 years for men and 0.5 years for women.
The virus has taken a disproportionate toll on groups already facing the poorest health outcomes. In particular, it has underlined the structural disadvantage experienced by people from ethnic minority communities who have been at much greater risk of contracting and dying from Covid-19. The economic and social consequences of measures to contain the virus risk worsening these inequalities.
It is time for a reset in public policy to improve the population’s health and tackle deeply entrenched inequalities. This includes responding to the direct impact of Covid-19 and redoubling efforts to reduce health inequalities more broadly, including by addressing socio-economic drivers of health such as housing, education, employment and access to affordable healthy food. This will be a true test of how serious the government is around its ‘levelling up’ agenda.
Sustained and coherent action is needed on the prevention and management of inequalities in health at all levels, including through local place-based partnerships spanning the NHS, local government, voluntary sector organisations and communities themselves.
What can be done?
As a first step, the government should move quickly to develop a cross-government strategy on health inequalities. This should include binding, ambitious targets to improve the nation’s health and reduce inequalities accompanied by clear accountability for meeting these targets. The strategy should make faster progress across the full range of important social and economic determinants of health. The government should be bolder in using all available levers to improve the public’s health, including tax and regulation.
Inequalities reduction should be a central focus for all local health and care partnerships, and this should be reflected in how they are constituted, measured and held to account. ICSs, local place-based partnerships and primary care networks should be seen as key vehicles to drive local improvements in population health. As ICSs move onto a statutory footing, they will need ensure that they support partnerships spanning the NHS, local government and voluntary and community sector.
The NHS should be more ambitious in its approach to improving population health and reducing health inequalities, making good on the promises in the NHS Long Term Plan for action on inequalities to be central to everything the NHS does. That means investing more in prevention, reducing inequalities in access to care and leveraging its assets, spending power and role as a significant employer to improve the wellbeing of communities and support local economies.
3. Lasting reform for social care
The scale of deaths in care homes from Covid-19 is a national tragedy. Between mid-March and mid-June 2020, more than 19,000 care home residents died from the virus across England and Wales (40 per cent of the total Covid deaths registered during the period) and the number of excess deaths was even higher. A further 16,000 care home residents died from the virus between November 2020 and early February 2021 (26 per cent of the total Covid deaths registered during the period) however, in contrast to the first wave of the pandemic, care homes did not see a disproportionate toll of excess deaths during the second wave. There has also been a significant impact on recipients of home care, with the proportional increase in excess deaths for this group being even higher than for care home residents.
Despite the best efforts of staff, it has been difficult for care providers to keep staff and people relying on services safe, particularly in the early stages of the pandemic. A variety of factors contributed to this, including: challenges obtaining adequate PPE, testing and financial support; difficulties in co-ordinating the response across a fragmented sector; longer-term weaknesses resulting from years of under-investment and workforce shortages; and rapid discharges from hospitals to care homes at the start of the pandemic. Despite strong international evidence that social care settings were at high risk from serious infection, the sector was initially treated as an afterthought by government, with support measures coming too little and too late. However, support for the sector did improve as the pandemic progressed.
Even before Covid-19, it was clear that the social care system is not fit for purpose and is failing the people who rely on it, their families and carers. There are also longstanding issues in how social care staff are treated, including low pay and poor terms and conditions. But despite widespread agreement on the need for reform and numerous commissions and inquiries, successive governments have failed to bring forward solutions, opting instead for piecemeal measures and short-term cash injections. On taking office, the Prime Minister pledged to ‘fix’ social care ‘once and for all’, a commitment he has since repeated.
It is imperative that the experience of Covid-19 be a line in the sand, ending the neglect of social care and the individuals and families who rely on it. At the heart of these efforts should be a positive vision of social care, promoting independence and supporting people to live the lives they want and be actively involved in their communities.
What can be done?
As a first step, the government must urgently address short-term funding pressures, which have been exacerbated by the pandemic, to prevent further deterioration in access, experience and outcomes for people needing social care support. This needs to be accompanied by immediate steps to stabilise the fragile provider market, including supporting an increase in the amount local authorities can pay for care.
The government should bring forward proposals for longer-term investment and reform as an immediate priority to create a simpler, fairer system. The proposals should offer a roadmap for reform and commit to significant progress in implementation before the end of the parliament. Importantly, this must recognise that the problems in social care are not just about funding: wider reform is needed to support greater equity of access, improve quality by tackling unwarranted variation and address fragmentation across the NHS and social care.
Wider reform must be underpinned by better pay, conditions and training for the social care workforce, bringing these more into line with those seen in the NHS, or there simply won’t be enough staff to deliver care in the future. The diverse nature of the sector and significant independent sector provision means this is likely to require a combination of central funding, regulation and legislation.
4. Embedding and accelerating digital change in the wake of recent progress
Covid-19, and the need to provide care while physically distant, delivered an unprecedented shock to both demand for and supply of digital health services. The results have been substantial. Within weeks of the epidemic taking hold, more than three-quarters of GP surgeries were conducting some patient consultations via video, and nearly half of all consultations in May 2020 were conducted over the telephone. Supported by a national platform, remote hospital outpatient appointments surged too. In its recent history, the NHS has never seen such a rapid and widespread channel shift. Alongside this, some parts of England accelerated the roll-out of digital technologies, such as tablet devices, to enable users of social care services to access support and advice from a distance.
This scale of change was enabled by clinical and support staff rapidly changing how they work and sharing learning and good practice along the way; digital suppliers making it easier for care providers to access and afford their services and products; and guidance and funding from national bodies. The focus has been on technology as an enabler to delivering care, not as an end in itself.
The achievements of recent months stand in stark contrast to the relatively poor record the NHS has of adopting digital technologies at scale. Longstanding barriers in England’s digital health landscape – including over-centralised decision-making, insufficient investment and infrastructure, lack of staff development, restrictive information governance requirements and poor interoperability – have hampered progress for too long. Likewise, the extent to which social care has been able to capitalise on digital opportunities has been constrained in the past by a lack of dedicated funding, supporting national infrastructure and leadership.
Looking ahead, the task for national bodies and local leaders is to learn lessons from this experience to make lasting adjustments to policy and practice to create an environment that is more supportive of digital health innovations that improve patient care. As part of this, it will be important to explore how these rapid changes in ways of working and accessing care are having an impact on both patients and staff – including any potential adverse consequences – and to embed standards and interoperability at their core. Importantly, the digital legacy of Covid-19 needs to be durable: it must be built on public consent; work for the broadest possible spectrum of services users; support health and care staff in their roles; and include a proportionate framework of safeguards.
What can be done?
Rapid evaluation of approaches and measures taken during the pandemic is needed to inform future digital change. This includes understanding the impact of the more permissive environment for innovation – covering changes to funding, procurement, information governance, and staff and peer support – and the consequences of the resulting changes for patients and staff, particularly in general practice and outpatient care, which have seen the greatest shifts.
Digital infrastructure and tools need to be built with transparency and involvement from the public and health and care staff. Given past blows to confidence from high-profile lapses in this area and concerns about data-sharing with independent companies during the pandemic, a different approach is needed building on existing best practice, such as co-development and deliberative engagement processes.
It is essential to take steps to prevent digital technologies entrenching or widening health inequalities. This requires greater understanding of the extent and nature of digital exclusion at national, regional and local levels, and for this to be central to decisions about policy, design and implementation. As part of this, it will be important to learn from existing initiatives that seek to address inequalities in access to digital skills and infrastructure.
5. Reshaping the relationship between communities and public services
The Covid-19 emergency brought an upsurge in community solidarity and activism, including hundreds of thousands of people offering their time and support through local mutual aid groups and the NHS Volunteer Responders scheme. This has underlined the vital role of local communities in supporting health and wellbeing. In addition, there is strong evidence from disasters around the world that community resilience is key to the process of recovery and that meaningful community engagement is an essential part of successful recovery efforts.
Channelling community energy to foster a new relationship with public services has long been an aspiration in England. Yet while some places have made real strides, overall change has been limited. In the wake of Covid-19, there is an opportunity to truly reshape the relationship between public services and the communities they serve, fostering cultures where public services seek to build on the strengths and assets of communities to improve outcomes. Based on the experience of recovery from previous global disasters, ‘community recovery’ – or rather ‘community-led recovery’ – will be essential, requiring investment in building community resilience and support for community-led approaches.
Changing how health and care services work with people and communities will be one part of this process. It is a different way of working that recognises the role people can play in improving their own health and supporting them to do so. Discrete engagement and consultation exercises on proposed service changes will need to give way to a culture of working with people on an ongoing basis to understand their priorities and needs and work with their strengths. This should include the most marginalised communities and excluded people to guide action to tackle the worst health outcomes and address longstanding inequalities. Given the unequal impact of Covid-19, particular focus should be afforded to involving people from ethnic minority communities including through community participatory research, as recommended in Public Health England’s report.
What can be done?
Health and care services should understand and work with communities’ priorities, needs and strengths. This should be achieved through meaningful local involvement – with a particular focus on those who experience ill health, disability and inequalities – and supporting people to improve their own health. For local systems, embedding this way of working will require sustained cultural change; places that have made progress on this agenda, like Wigan, can point the way.
Local health and care systems should take steps to safeguard the role of voluntary and community organisations as long-term partners in promoting health and wellbeing. This will require public services to work with, and provide support to, local community leaders and organisations. Evidence indicates that voluntary and community organisations can play a critical role in supporting recovery efforts and building community resilience, but many have been hit financially by the pandemic.
National organisations cannot mandate these kinds of changes, but they can help remove the barriers that make it harder for them to take root. Government departments and NHS national bodies should seek to support a community-led approach to public services by involving local leaders and communities in policy design, supporting a greater role for local government in shaping local health and care services, and changing the current top-down approach to how health system performance is measured and addressed.
Pitfalls to avoid in the approach to recovery and renewal
As leaders locally, regionally and nationally turn their focus to recovery and renewal, the methods they choose will matter greatly. Past experience points to a number of approaches that would be best avoided, where the balance of costs and benefits is unfavourable.
Overly ambitious attempts at system-wide structural reform
Various structural and legislative changes have been proposed to improve services and rectify perceived weaknesses revealed by the pandemic. These include changes to the public health system and proposals to establish ICSs in law. The history of the NHS is littered with reform plans that overestimated benefits and underestimated disruption and the system can ill afford major upheaval given the pressures it is currently under. In implementing these proposals, it will be essential to avoid distracting health and care services from dealing with the crisis at hand; targeted changes to support the integration of services would be preferable to a wholesale upheaval of local structures.
Unhelpful emphasis on top-down performance management
The NHS operates within a framework of national operational performance standards (social care to a lesser degree). There may now be a temptation to tighten the performance management regime that accompanies these standards, particularly in the drive to bring down waiting times. But attempting top-down performance management of undeliverable targets risks alienation rather than responsiveness.
Focusing on hospitals at the expense of other parts of the system
The very visible impact of Covid-19 on acute bed capacity risks reinforcing the default of hospital-focused responses to system-wide issues. Quantifying pressures in other areas – such as general practice, community services, mental health and home care – is much harder, not least because there is little data available. But these wider services are just as critical to ensuring a functioning system able to restore provision, respond to future waves of the pandemic and deliver the priorities set out above.
Excessive reliance on national control and central levers
Mobilising a response to the pandemic led to some centralisation of decision-making power within the health and care system. But aspects of the response (such as the faltering start to the test-and-trace programme which failed to draw on resources and expertise that existed locally) have highlighted the drawbacks of an overly centralised approach. Looking ahead, there is a risk that national leaders err towards retaining power centrally, rather than providing resources, support and permission for local systems to bring about improvement and change by working with local communities.
Failing to seek and act on learning
There are growing calls for a public inquiry to scrutinise the pandemic response. This is essential but waiting years for this to run its course will not help the staff, patients and service users of today. It is vital to avoid a blame game, with fear and silence standing in the way of learning and improvement. Health and care leaders would do well to revisit the recommendations of the Berwick review into the failings at Mid Staffordshire, ‘embracing wholeheartedly an ethic of learning’ in the next phases of the response. This is not only about learning from successes and failures in relation to Covid-19, but from past experience of bringing about change in complex systems.
Just over two years ago, the NHS in England outlined its strategic ambitions for the coming decade. At that point, no one could have anticipated the seismic shock the health and care system would soon face. It is now time to renew priorities in light of this, embracing learning wherever it can be found and seizing opportunities to create positive change for the longer term.
The 2019 Conservative Party manifesto made the NHS a key priority, promised to solve the problems in social care to give every person the dignity and security that they deserve, and to ‘level up’ every part of the country. Making good on these commitments in the wake of the global Covid-19 pandemic will require change and renewal: creating public services that can work hand in hand with local communities; honouring the sacrifices made by health and care staff by putting the welfare of the workforce at the top of the agenda; and focusing relentlessly on inequalities to turn every dial in favour of better, fairer health. This will require action locally, regionally and nationally.
There are financial implications to some of the actions we have set out. Given the wider economic context, it would be naïve not to recognise the very difficult decisions and trade-offs in public spending that lie ahead. However, if the government wishes to live up to its promises on prioritising health and care, a post-Covid-19 funding settlement will be needed, bringing investment in the health and care workforce, and in social care and public health, where years of austerity have been exacerbated by the pandemic. The measures set out are necessary to make good on the promise to `level up’ society, but they will also need to sit within a wider economic strategy that supports investment in the socio-economic determinants of health. Making progress will also require political courage, not least to push forward potentially contentious long-term social care reform; given its significant majority, the government is well placed to do this and should not duck difficult policy decisions.