Author: Edward

4th Year Medical Student

Why Reflection Is Important For Your Medical Journey

How COVID-19 forced change on the NHS

COVID-19 has had drastic effects on the economy, healthcare, and education. It is a surreal yet defining moment in human history and will result in tragedy on a global scale. Our healthcare will need time to recover, and as it does, it will provide a chance to reflect on the response to the pandemic.

Pandemics can result in the innovation of modern practices, as it forces individuals and governing bodies to embrace change out of necessity. The purpose of this article is to discuss how COVID-19 will revolutionise healthcare and focus on the long-term effects of the virus on the NHS.

Lessons from history

Spanish influenza

A good starting point would be to reflect on how previous pandemics have changed healthcare – I.e. Spanish influenza. In the 1920s, our understanding of viruses and their rate of spread was lacking. Public health authorities did put in place public health measures such as quarantine and the closing of public meeting places to control the spread of the virus. 

These were introduced too late and therefore undermined the effectiveness of the crowd control. A contributing factor to this was that influenza was not a reportable disease, i.e. doctors weren’t obliged to report cases to public health. Therefore, public health officials failed to see the extent of the pandemic in the general population. (https://history.blog.gov.uk/2018/09/13/the-flu-that-wasnt-spanish/)

Furthermore, doctors in industrial countries often worked alone in practices meaning that communication between healthcare officials was minimal. As a result, countries were unable to take the rapid, widespread action to lessen the burden on their healthcare, and ultimately save lives. This highlighted that communication between health officials needed to be organised and optimised. Countries also recognised the need to organise public health at an international level, as the virus passed over borders with ease. In 1919 world leaders established an international bureau for fighting epidemics a precursor to the World Health Organization (WHO). (https://time.com/5797629/health-1918-flu-epidemic/)

Pandemics and class inequalities

Before Spanish influenza, it was public opinion that disparities in health between the social elite and the working class were due to a predisposition of the working class and poor hygiene of the individual. Therefore, the public chastised an individual for why they were ill, a practice which was shrouded in eugenics. (https://www.bbc.com/future/article/20181016-the-flu-that-transformed-the-20th-century)

Pandemics often expose class inequalities as comorbidities lead to unfavourable outcomes; as well as the spread being worse in confined spaces and postcode lotteries can result in deprived areas having worse resources resulting in a deteriorating prognosis. Spanish influenza affected all classes but not to the same extent. This led to a change in the theory behind the contraction of a disease.

Governments established healthcare for everyone for free, i.e. socialised medicine, and there was a shift towards centralisation of healthcare. These anecdotes highlight how Spanish influenza revolutionised healthcare. Now, as we fast forward to 2021, the focus of this essay shifts to how our current healthcare will change as we cope with a pandemic in the digital era.

Tech companies and healthcare

The speed of the response to a pandemic

A lesson learnt from the Spanish influenza was to improve communication strategies to strengthen the timing of the response to a pandemic. However, 66% of poll takers thought that government response was too slow for COVID-19.( https://www.ipsos.com/sites/default/files/2020-04/coronavirus-covid-19-infographic-ipsos-mori.pdf)

The slow response indicates a problem: once we have collected the data on public health, we are unsure how best to respond to it. The NHS has recruited tech companies such as Google. The companies enable the NHS to collect real-time information on hospital responses to COVID-19 and construct an evidence-based intervention.

Although a lot of bodies in the NHS already collect this information, tech companies aide these bodies to streamline the information to enhance the response. Examples of how tech companies are assisting the NHS are on; how the virus is spreading at a local level and identifying risks to particularly vulnerable populations, the allocation of testing, provision of protective equipment, and the delivery of ventilators to hotspots. (https://healthtech.blog.gov.uk/2020/03/28/the-power-of-data-in-a-pandemic/)

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How to use the data?

Example countries where data has been used are South Korea and Germany. (https://theconversation.com/how-south-korea-flattened-the-coronavirus-curve-with-technology-136202) These countries exemplify how data usage, paired with ubiquitous amounts of testing, can help to slow the rate of infection and flatten the curve. South Korea had already learnt its lessons after the MERS outbreak and was swift to introduce contact tracing for the COVID-19 outbreak.

Contact tracing is where affected individuals with COVID-19 have their movements tracked. Then they perform testing on others to track the spread of the disease. The legal basis for collecting personal data was in the wake of the 2015 MERS outbreak. The government learnt that tracing the movement of infected individuals was crucial.

However, when using health data, questions arise about how best to maintain patient confidentiality and privacy. Concerns about privacy were the subject of a recent Guardian article by Paul Lewis. (https://www.theguardian.com/world/2020/apr/12/uk-government-using-confidential-patient-data-in-coronavirus-response) The article criticised the approach taken by the NHS. However, the report does not necessarily tell the same narrative as the NHS and statements from the tech companies. The data are taken from existing NHS stores and follow GDPR rules and data governance rules, which protects against patient confidentiality.

The NHS also stated that the data in the store would remain under NHS England and NHS Improvement’s control. Then after the pandemic, data will either be destroyed or returned in line with the law. (https://healthtech.blog.gov.uk/2020/03/28/the-power-of-data-in-a-pandemic/)

Data collection and cost-effectiveness

It is difficult to believe that the NHS will use this approach only once. Data collection and analysis techniques that tech companies use will only increase the efficiency of the NHS, and therefore increase the cost-effectiveness of the NHS. It would result in the ability of better tracking of standards of care and better anticipation of problems before they become crises. It will help to merge information between trusts improving communication between hospitals and GPs. The technological approach to healthcare is here to stay, despite what the NHS has said.

Telemedicine Takeover

Important part of the response to a pandemic

Clinicians have postulated that Telemedicine is the consultation of the future for about a decade. Since the COVID-19 pandemic telemedicine is a sole reliant in the US system, and GPs have started to embrace it as a primary use of operating in the UK. (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30818-7/fulltext)

Previously, the momentum behind the telemedicine movement had not been lacking, but the NHS has been slow to integrate it. However, Trisha Greenlaigh noted that “The risk-benefit ratio for virtual health care has massively shifted, and all the red tape has suddenly been cut.” Telemedicine might prove to be invaluable after recent evidence suggested that there have been around 2,000 undetected cancer cases each week during the COVID-19 period. (https://www.shropshirestar.com/news/uk-news/2020/04/22/charity-warns-2200-cancer-cases-going-undetected-each-week-due-to-covid-19/)

The increase is due to a myriad of reasons. But primarily patients are anxious and putting off booking an appointment with their GPs and increasing reluctance of GPs to refer patients to secondary care. Although the use is essential, it is difficult to see if Telemedicine will ever be preferential over traditional face-to-face appointments.

Barriers of Telemedicine

Telemedicine poses blatant barriers such as the inability to carry out a physical assessment except for inspection, and the screens can hinder rapport. But the biggest problem is the lack of guidelines for clinicians on how to conduct the consultation. However, this has changed since a Swedish telehealth company LIVI released guidance for clinicians on how to manage patient symptoms over Telemedicine, especially COVID-19. (https://www.mobihealthnews.com/news/europe/swedish-telehealth-provider-livi-launches-first-national-covid-19-medical-guidelines)

Another barrier to Telemedicine is that it can be inaccessible to specific cohorts of the population, who are less technologically savvy. Often considered to fit this category are the elderly, who are a vulnerable part of the community, especially during the current COVID-19 outbreak. There needs to be raised awareness of Telemedicine as an option, paired with education on how to use the apps to maximise access to GPs, especially during this time.

Telemedicine in the post-COVID-19 life

If we consider life post-COVID-19, will GPs and patient continue to use Telemedicine out of preference? Or was the use out of necessity? Patients do not attend or miss 15.4 million general practice appointments each year, costing the health service an estimated £216m annually. (https://www.england.nhs.uk/2019/01/missed-gp-appointments-costing-nhs-millions/)

Furthermore, Telemedicine is likely to have a beneficial impact on the availability of GP appointments. Whether Telemedicine will result in better attendance at clinical appointments and provide access to patients who struggle to travel to GP surgeries remains to be seen. Another potential benefit of Telemedicine is in the early discharge of patients from hospital. A recent study by Ponte et al. found that Telemedicine meant that patients were 63% more likely to spend fewer days in the hospital. (https://www.ncbi.nlm.nih.gov/pubmed/26065105) Telemedicine might not be a replacement, but it is a respected alternative available, and it is likely to play a role in the post-COVID consultation.   

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