Published: 17 April 2020
Author: Professor Sir Chris Ham
Adaptability and agility will be key leadership attributes in the recovery phase
The old adage that ‘necessity is the mother of invention’ is playing out in real-time as the NHS responds to the Covid-19 crisis.
General practice was first out of the blocks with practices working together to create hot hubs for patients suspected of having contracted the virus and cold hubs for patients with other urgent needs. Equally important has been the use of telephone and online triage and remote consultations by telephone and video. NHS 111 has served a vital role in support of primary care and practices have stopped doing some routine work to release time for other priorities.
Acute hospitals have radically reshaped their work by discharging medically optimised patients and releasing around 30,000 beds. Cancellation of most planned surgery and outpatient clinics has enabled hospital staff to focus on the growing number of patients admitted with Covid-19 and other patients with urgent needs. There has been a substantial increase in intensive care capacity to accommodate patients with the most serious illnesses as additional facilities have come on stream at the new Nightingale hospitals.
None of this would have been possible without the support of community health services and social care. These services are caring for discharged patients who have spent less time in hospital and have more acute needs than that would have been the case for many patients discharged before Covid-19. Community nurses are drawing on support from other colleagues to ensure care is provided safely.
Many of these changes have been possible because staff are working differently. Doctors and nurses have thrown their weight behind intensive care teams who have been at the forefront of work to respond to the needs of critically ill patients. Rapid training has enabled staff from other specialities to contribute to this care as the expected surge in demand has materialised.
NHS and social care staff are supported by voluntary and community sector organisations including hospices whose expertise at the end of life are needed now more than ever. Care in people’s homes also depends on the contribution of families, friends and neighbours and the 750,000 volunteers who responded to the call to offer their services at this time. By drawing on all the assets in our communities, policy rhetoric about care closer to home has come closer to becoming the reality for many people.
The contribution of people and communities is evident in the way each of us has helped slow the spread of the virus by acting on the advice on handwashing and social distancing. People with long term conditions, acting as expert patients, have taken on more of the routine care they need with access to advice and support by phone and video. Carers have become even more important as care providers in the community when NHS staff have been forced to self-isolate.
New partnerships between the NHS, universities and businesses have been one of the unexpected benefits of Covid-19. These partnerships include the design and manufacture of ventilators and equipment like visors; the use of laboratories to analyse test results; and studies to investigate the use of existing drugs in the treatment of Covid-19 and the search for a vaccine. A partnership between the NHS and the armed forces has also contributed to the distribution of PPE and other supplies and the construction of the Nightingale hospitals.
The NHS has always embraced innovations in care but the changes that are underway are occurring at unprecedented speed and cover most areas of care. There will undoubtedly be adverse effects for some patients, for example where delays in accessing care result in poorer outcomes. Some areas are seeking to mitigate these effects by using private hospitals for urgent cancer treatments and by reorganising NHS facilities to protect services for patients with other urgent needs.
The existence of sustainability and transformation partnerships and integrated care systems has facilitated partnership working within the NHS and between the NHS, local government and other public services. In the NHS this has been particularly important in planning and delivering increases in intensive care capacity, putting in place arrangements for mutual aid between hospitals, and enabling patients to be discharged from hospitals to free up beds for Covid-19 patients.
NHS leaders are now beginning to turn their attention to recovery from the current crisis. Priorities include holding onto the gains of new ways of working and meeting the needs of patients whose care has been put on hold. The latter includes extending the use of telephone and video consultations that have been used in many hospitals in place of face to face communication. Supporting health and social care staff whose own physical and mental health and wellbeing has been put on the line is one of the highest priorities.
The challenge for leaders will be to plan for the future in the face of many uncertainties. At the time of writing, research into vaccines and repurposing existing drugs to support the treatment of Covid-19 patients is continuing, and debate on how and when the current lockdown might end is underway. The probability of a second wave of infections after the lockdown is lifted must also be taken into account.
Experience during the crisis is a reminder that ‘no battle plan survives first contact with the enemy’. All the more important therefore that leaders are agile and adaptable in response to the challenges that arise and the solutions that are needed. General Stanley McChrystal’s book, Team of Teams, describes how agility and adaptability were developed in the US Army in the fight against al-Qaeda, and his insights are directly relevant to the NHS and its partners as we move into the next phase.
These insights include understanding the limitations of command and control structures, shortening lines of communication between those at the front line and leaders at the centre, and devolving responsibility for decision making. McChrystal also emphasises the dangers of silo-working and the critical role played by a team of teams in overcoming this. Emerging integrated care systems are learning a similar lesson and the partnerships and shared leadership they have formed have played a key role during the crisis.
There can be no going back to old ways of working after Covid-19 has passed. The sense that ‘we are all in this together’ has helped mobilise people and resources and this will be even more important during the recovery phase. Leadership must be collective as well as shared, encompassing people and communities and all parts of the public sector. Only in this way will we secure our common future.
Professor Sir Chris Ham is an expert adviser to CF. He chairs the Coventry and Warwickshire Health and Care Partnership, co-chairs the NHS Assembly, and is a non-executive director of the Royal Free London Hospitals Foundation Trust.