Author: Edward S.
Fourth Year Medical Student
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
A good starting point would be to reflect on how previous pandemics have changed healthcare – I.e. the 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. But 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 the 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/)
Before the 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. But the Spanish influenza affected all classes but not to the same extent. But 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 a shift towards centralisation of healthcare. These anecdotes highlight how the Spanish influenza revolutionised healthcare. Now, as we fast forward to 2020, 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 in healthcare
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/)
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 were 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 start to arise about how best to maintain patient confidentiality and about 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/)
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.
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 will be 2,200 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. 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 changes as last week 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.
If we consider life post-covid 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.
The Infodemic outbreak: Public Health vs social media
Public health was improved from the last pandemic, as public awareness changed for the better. However, the covid-19 pandemic has brought with it a plague of misinformation that damages public health, that has gone viral. Social media, to an extent, has enabled this spread of hysteria and conspiracy theories. These have ranged in the amount of harm caused but have led to the damage of 5g towers in the UK, alcohol poisoning in Iran, and xenophobic theories concerning Chinese takeaways. WHO have labelled this as “the Infodemic”.( https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19–8-april-2020) Sources of misinformation can spread rapidly, not fact-checked and can be damaging to patient’s health–belief and result in non-adherence and confusion with public health policies. However, health officials often take time to prepare statements which creates a space that these rumours quickly fill. As people become misinformed, the workload of public health officials increases, as they must inform the public as well as debunk the myths and conspiracy theories. The public using social media as a health resource is not a new phenomenon. Patients often seek advice on online support groups such as Nancy’s Nook for endometriosis and support groups for parents on vaccinations for child. Patients can share experiences and information on how to manage the condition, which can have beneficial effects on their health. However, the most recent pandemic is a lesson that public health must work with social media to encourage the public to use reliable websites, as information on these support groups is not always evidenced based, especially concerning vaccinations. However, during the Infodemic visits on the NHS website have increased from February to March and peaked at 3.4 million on the 17th March 2020. (https://digital.nhs.uk/coronavirus/nhs-digital-tech-analytics)
Conspiracy theories are nothing new to pandemics. When cholera struck the US in the early 1830s, citizens blamed the Irish immigrants; and there was anti-Semitism associated with bubonic plague in 1349 in Europe. However, social media allows a faster spread of these rumours. Social media can have a positive impact on the distribution of information. For example, people in China were able to utilise social media to raise awareness of the doctor Li Wenliang, a whistleblower of the covid-19 in Wuhan. (https://www.bbc.co.uk/news/world-asia-china-51403795) It also has been able to keep people well informed and raise awareness with the coronavirus tracker on Facebook. Therefore, Public health needs to continue to work with social media in order to keep people best informed. It highlights the potential promise of social media in managing patients’ ideas about their health and expectations of their healthcare.
Furthermore, to both limit the spread of misinformation but optimise the dissemination of public health information public health should work with social media. Social media will continue to shape our patient’s ideas, concerns and expectations in the post-covid era, and clinicians are naïve to think otherwise. The Infodemic is a lesson that we need to work closely with and not against social media. Hopefully, through a cohesive relationship between public health and social media, we will be able to recommend and direct patients to reliable sources of information.
Limited Resources: results in a change of the discourse of DNARs
Cautionary tales from affected countries have warned that limited resources can result in ethical dilemmas. For example, a limited number of ventilators result in decisions on their allocation. As a result, clinicians have changed their approach do not resuscitate forms (DNARs). (https://www.resus.org.uk/faqs/faqs-dnacpr/) These forms are a medical decision and are made by qualified clinicians who take on board the patient’s wishes. Clinicians recommend DNARs for patients who would not receive a survival benefit from CPR, which can be a traumatic experience. Covid-19 has resulted in increases in DNARs as doctors are increasing the frequency of the conversation of end of life wishes with patients. Also, healthcare professionals are asking patients about their wishes regarding treatment and resuscitation in A&E. These conversations are precautionary and allow patients and staff to be best prepared and enable transparent care. However, the conversation can induce anxiety and therefore, healthcare professional should discuss DNARs with an appropriate tone.
However, reports from AgeUK highlight that a lot of elderly patients are feeling pressured to agree to DNARs. (https://www.ageuk.org.uk/latest-press/articles/2020/04/age-uk-response-to-dnr-forms/) The charity has branded the practice as verging on unethical. It is vital that clinicians consider the patient’s wishes, and that no patient feels pressured to have a form. However, there is often poor education on resuscitation and the DNAR forms, as even the name aides to misconception. The reports from AgeUK also highlights that clinicians should take time to discuss DNARs, to improve patients and families understanding. As well, patients expectations need to be managed on a national scale to expect a discussion about their wishes on resuscitation in any medical consultation. It will help to alleviate the fear surrounding the conversation and improve our approach to it. Unfortunately, patients are receiving DNARs now, even though they have always been needed. It begs the question why weren’t these forms in place before the covid-19 outbreak? It highlights that perhaps we have shied away from consultations about end of life care which has resulted in a lack of preparedness. A lack of readiness can often lead to traumatic experiences with CPR, which is effective, around ~20-30% of the time.(https://mycares.net/sitepages/reports2019.jsp ) Clinicians need to improve their practice, by having transparent conversations about end of life care. It is a lesson for the post-Covid era that better patient education on DNARs is required, and increased encouragement about an open discussion about end of life care.
The Forgotten Frontline: Transformation change of social care
Covid-19 has struck the UK’s social care, where silent outbreaks have spread throughout care homes. The BBC was told by a care company that covid-19 had affected patients in two-thirds of the group’s 329 homes. (https://www.bbc.co.uk/news/uk-52275823) As of last week, the covid-19 cases in care homes had quadrupled to 1043 cases. There are currently over 11,300 care homes in the UK, of which there are approximately 400,000 residents, and small businesses own the majority. There is a separation between social care and the NHS, which puts care home staff and patients at risk. For example, they receive less protection than staff in hospitals; some nursing homes have received only 300 masks. (https://www.telegraph.co.uk/news/2020/03/29/care-homes-have-received-300masks-protect-staff-residents-against/) Also, Nursing homes receive fewer tests resulting in limited ability to investigate patients with suspected covid-19. The lack of testing poses another issue, as often patients who have passed away do not have a confirmed covid-19 case, and as a result, the current UK statistics do not include them. It results in UK statistics that belie the true extent of covid-19 on our healthcare and masks the spread of disease in our population.
Furthermore, staffing shortages have been problematic due to anti-immigration policies and staffing illnesses in care homes. This means there is also a reduced capacity of staff who are often overworked and underpaid, with 50% receiving less than the minimum wage. (https://www.theguardian.com/society/2020/apr/19/half-of-frontline-care-workers-paid-less-than-living-wage) The staff assist patients with activities of daily living, which means established relationships are built over a long period. As the attention of staff focuses on supporting patients who are infected with covid-19, the basic care needs of unaffected individuals are potentially compromised. Also, it is difficult to imagine the emotional strain on the staff, residents and families as the pandemic silently sweeps through these care homes.
The lack of support for staff, patients and families is a moral failure which reflects a backwards approach to social care in the UK. The UK’s adult social care budget has decreased by 9.9% between 2009/10 and 2016/2017.( https://www.ifs.org.uk/uploads/publications/comms/R143_Chapter1.pdf) Furthermore, the UK has an ageing population and therefore increasing demand for social care. All of these issues coupled with the effect of covid-19 point towards a crisis in social care. But perhaps the needs and requirements of nursing homes could have been anticipated, and avoided? Covid-19 has highlighted that our old care model, which focuses on responding to need, needs to change to amodel that anticipates need. The King’s fund outlines our old model and argues that a drastic transformation change in our healthcare model is necessary. For example, we need to reduce secrecy and care based on visits and develop a transparent healthcare system that tracks changes in the individual’s health. (https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/transforming-the-delivery-of-health-and-social-care-the-kings-fund-sep-2012.pdf ) More evidence suggests that there is long term recovery of patients with covid-19 with effects on the neurological, renal and gastrointestinal systems; the demand for care will only be exacerbated by the current pandemic. (https://www.today.com/health/coronavirus-long-term-health-covid-19-impact-lungs-heart-kidneys-t178770) There needs to be a transformative change in social care. Our healthcare system is in its 70s, and there have been little reforms along the way. Social care is underfunded, and there needs to be better integration between care homes and the NHS, more respect for the care staff, and better care for our patients.
The article discussed a select few points about how covid-19 could change healthcare on a national scale. However, it did not consider the global implications of the pandemic. There is uncertainty over the future that the post-Covid19 era will bring. But what is certain is that this pandemic is testing the resilience of our healthcare, especially the staff, and we need to protect and support them through it.