COVID-19 in the UK NHS: why hospital management matters

Beyond the Crisis: Spotlight on the UK Economy

Sir Andrew, a former deputy chair of an NHS governing body, opens the conversation with his thoughts on judgement in a healthcare context and explains why he hopes the NHS will take the opportunity for organisational change created by the pandemic. Professor Sadun explores the challenge posed by the recent surge in demand and touches on the unexpected positives presented by the crisis, including some of the ‘amazing’ organisational capabilities she has witnessed. Professor Savva then explains how objective, scalable, data-driven decisions can optimise performance and mitigate disruption.

Key Takeaways:

• The government is not going to have an ‘open tap’ indefinitely; hospitals need to understand the resources they have available to them, whether it be looking at the spare beds available for any new wave, the capacity of staff for such a new wave, how to protect the staff, and how that coincides with winter flu in the Northern Hemisphere;
• There is a lot of heterogeneity in the adoption of basic management practices across hospitals, this matters for clinical quality; there needs to be greater collaboration between different bodies to address this, not just in terms of equipment but also people and expertise;
• It’s not enough to change the top of the organization to achieve sustainable change in our complex setting, it is important to focus on those middle layers of the organization; there needs to be a much more intensive effort to foster management practices in middle layers, especially HR management; in an ideal world we would teach doctors how to be good team members and through that, make them become good managers.
• There needs to be a greater understanding of the impact COVID-19 has had and the backlog it has created, to formulate a plan that allocates resources so that hospitals can catch up with shortfalls in both screening and operations as quickly as possible; the will require optimising pathways through more effective use of technology, and barriers to adopting new technology will be reduced because of a lack of an alternative;
• Policy and public dialogue have been based around epidemiological models, but these are the tip of the iceberg. Many of the issues we are now facing, for example about deploying resources to deal with a second wave, will be better informed by models, which should be easier to do in future.

Core Messages:

• The NHS needs to look at frameworks based on existing knowledge and experience to date, through the national level and devolved levels to identify areas where there is more to learn;
• The dangerous way of thinking is once we have gone through the crisis, now the system can just go back to doing everything exactly as we did before. The NHS has not had a great history on embracing change, it has been quite resistant to change and can be quite bureaucratic;
• At the national level, there has been a degree of collaboration between different bodies that normally operate independently. Many thought would be difficult and this is an opportunity to reinforce the links that have been made and make sure they are kept after COVID-19 is gone;
• Collaboration was demonstrated through the accelerated building of the Nightingale hospital in London, which brought together many different bodies which would have ordinarily found this process difficult, especially at such speed, but there will also be links in areas such as local government and local authorities and the care home sector where links that have been forged through the pandemic that should be retained;
• There are opportunities through the application of artificial intelligence and remote working. This can save time as well as enhance the sophistication of the NHS’ offer. There has been an acceleration of the use of technology, such as GPs deploying video consultations, which was an initiative that struggled with implementation for years before the crisis but is now here to stay;
• The system is also going to be better prepared for a second wave because of recent experience dealing with equipment such as PPE, ventilators and emergency beds;
• There are lessons to be learnt regarding working conditions; they need to understand how to keep people in work during a crisis and the conditions in which they can operate. However, there is not a systematic way that lessons can be shared across the system; there might be good practices in individual hospitals but there does not seem to be a way to communicate into the overall system;
• There was no local precedent as to how to deal with a pandemic before the crisis, but also there is a danger in thinking that we can tackle a ‘second wave’ in the same way we approached the first, which won’t be the right direction to take;
• Hospitals also need to understand how they are going to reintegrate non-COVID patients back into the system, as well as better understand performance measures – when measures should be used and what they mean;
• The pandemic created an enormous challenge; a demand shock and supply shortage. Clinical and nursing staff have demonstrated unexpected and amazing organisational and managerial capabilities; we’ve seen a series of managerial levers that have been hard to change for a long time being effectively adapted during the crisis;
• This goes to show that something can happen to improve management in hospitals when it is needed and when staff believe that it is important, but there is heterogeneity across hospitals; there needs to be a more standardised and coordinated way to transmit knowledge across systems so that it can be disseminated quickly;
• Accordingly, we need to think more carefully about the actions and the decisions that need to stay at the central level; this makes sense where there are strong economies of scale, such as procurement and IT spending – these need to be assigned at the centre to be more responsive;
• The pooling of resources across organisations and within hospitals is important and the barriers that often make pooling resources difficult have gone away during the crisis, not just in regards to equipment but also at a staff level; the patient needs have taken primacy rather than the sense of hierarchy and silos between speciality areas that can exist in a hospital;
• Hospitals need to go through an organisational change to take full advantage of technology opportunities, so there needs to be a greater investment in management, how we identify manager and how they get trained to combine their technical and clinical expertise with administrative expertise;
• There needs to be a more general approach to management, rather than focussing on the training of CEOs, hoping that one person can change everything. Alignment among people at the top as well as the middle layers about how to make decisions based on data and breaking down hierarchal barriers and knowing how to implement cycles of improvement throughout the system;
• Many learning opportunities can come from industry into healthcare; a hospital in the US called Virginia Mason is a leader in lean adoption, something they learnt from visiting Toyota plants and the realisation that certain processes that coordinate experts and making sure that knowledge that exists in different parts of an organisation can come together; therefore if someone has experience making engineers and marketers work together, or can develop and implement technology, these innovations are portable into the healthcare sector.
• There is currently a poor understanding of how to measure ‘intangible capital’ within a hospital; there needs to be an assessment of the processes that help staff do their job, and disseminate continuous improvement;
• Some processes were paused during the pandemic, such as cancer care, to free-up resources to deal with patients with COVID-19, as well as to protect vulnerable cancer patients. There will be difficulties dealing with this backlog because the system was working at near capacity before the crisis. There needs to be an assessment of the implications for patient outcomes, and an attempt to estimate the additional resources needed to deal with this backlog;
• Technology will be a route to overcoming issues such as the backlog of treatment post-COVID, and there will be fewer barriers to the deployment of technology because of a lack of alternatives; however, technology needs to be introduced in a way that compliments doctors, rather than adding tasks and increasing their burden;
• Application of technology will not lead to doctors being out of work, but that they can spend more time with their patients. Similarly, the use of video conferencing can also how of how technology can improve information sharing; instead of travelling to conferences and meetings they can set up a conversation instantly, meaning they have access to the most up to date information, quicker;
• Countries that have responded well to the crisis, have cooperation between the public and private sectors, as they are better at managing demand surges are leveraging capacity; strategies to improve the governance of these relationships are needed, rather than seeing the private sector as a competitor for human capital.
• The value of AI in the short term is in complimenting and scaling up what people do and leaving more time to do more value-adding activities, instead of menial activities that can be automated. The era where we will have autonomous systems undertaking diagnosis and replacing human decision-makers is not around the corner. In the next decade, we will be at a stage where information systems can deploy an element of artificial intelligence to assist physicians, such as with note-keeping, perhaps in making recommendations and checking that no obvious mistakes have been made and in aspects such as medication, dosage and so forth.

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Please visit the Wheeler Institute COVID-19 series, if you’re interested in reading more articles on this topic.