Our 5 key asks for restarting the NHS in Scotland

Over the last few months, all of our attentions have been turned to tackling Covid19. However, as we look cautiously to the future, it is vital that we start to get as much of our NHS back up and running as we can, as quickly and as safely as possible for people who depend on it – and need our care. We completely understand the desire to resume more normal NHS services as lock down begins to ease.

But this has to be carefully balanced with the huge scale and complexity of the challenge we face. We know that many doctors are concerned about how they will cope with surges in demand as the NHS begins to open up, and a second wave of Coronavirus remains a real possibility. We already know the NHS cannot cope with both a high level of Coronavirus as well as everything else.

There are a huge range of issues to consider – from social distancing in NHS settings, to the need to give doctors and staff a chance to recuperate from the rigours of dealing with the pandemic, when many have gone well above and beyond what has been asked of them. We also need guaranteed ongoing supplies of PPE and robust testing and isolation of patients before procedures such as operations.

This means we must move cautiously and carefully and balance the need to see patients with the need to minimise further Covid infection and pushing already tired and stretched staff and services beyond what they are capable of.

BMA Scotland have been consulted by the Government on how best to restore NHS services, and our 5 key asks complement the principles of Scottish Government’s own paper, but we want to emphasise the importance of the safety and welfare of healthcare staff, and the crucial time they will need to recover.

We also need politicians across the board to work in a constructive manner with each other and ensure there is consistent and realistic messaging to the public about what is possible in the short, medium and long term. The understandable desire to use the lessons learned from Covid-19 to evolve and redesign NHS services needs to be tempered with a realisation of what is going to be deliverable.

I want to thank you again for your incredible work during these last few months, and together we can continue to move forward to providing a full range of NHS services for patients in Scotland.

Our five key asks:

1: As services are restored, there needs to be a realistic and cautious approach to balancing Covid-19 and non-Covid-19 capacity and workforce deployment

  • In terms of Covid-19 related treatment both in primary and secondary care we will need to retain a baseline level of service configuration to deal with the diagnosis and treatment of the acute phase of Covid-19 infection, and also the ability to “ramp up” if there are spikes or further waves of infection.
  • There will need to be ongoing clear pathways for separation of Covid-19 and non-Covid-19 care and effective triage to those clinical pathways.
  • Referral, outpatient review, diagnostics, treatment and follow up pathways for cancer care and vascular diseases (cardiac, stroke and peripheral vascular disease) need to be restored as soon as is practical, whilst assuring the safety of patients and staff.
  • Mental health services should be a priority (including those delivered at point of access by primary care) given the cumulative effect of postponement of previous services, the effects across a population of the effects of Covid-19 and related issues (lockdown, rising unemployment or employment uncertainty, psychological consequences of Covid-19 infection).
  • Staffing levels and deployment decisions must be safe and done in consultation with employee representatives
  • To cautiously begin resuming any non-emergency work, it will be important to know how much of the service is still going to be set aside specifically for Covid-19
  • For both of the above two points, we welcome the call in the recent mobilisation letter for an accelerated rollout of Team Service Planning as a means to ensure better engagement with and contribution from clinical staff towards local health service planning and delivery

2: There must be ongoing adequate PPE for health and care workers, and measures in place to prevent the spread of the virus within the NHS

  • We cannot for now return to high occupancy waiting rooms, particularly given many attending the NHS are elderly and with existing comorbidities.
  • Thorough cleaning of rooms between consultations will be needed
  • Time for sufficient “air changes” between cases in theatre or diagnostic facilities will be needed for any aerosol generating procedures, that are most likely to spread the virus.
  • Robust testing and isolation of patients before procedures will be needed.
  • There are also potential implications for staffing of services should increasing numbers of doctors or healthcare teams have to self- isolate following introduction of the test and protect system.
  • It will also need to be acknowledged that as the service gets busier, the risks to staff will increase unless PPE supplies are ensured, and use enforced, in the longer term.
  • Space and time to both put PPE on and take it off will also be needed.
  • On this basis, and as set out in other parts of this paper it is absolutely clear that capacity for patients will inevitably be substantially reduced. There can be no doubt that the NHS will simply not be able to see people or operate at anywhere near the same capacity as pre COVID-19 for some considerable period of time.

3: Comprehensive measures must be taken to safeguard staff wellbeing

  • Those staff groups who have borne the brunt of Covid-19 related work over recent months, must be given time and space to recover physically and mentally, and not be expected to just pick things up where they left off before the pandemic.
  • There will need to be a recognition of all the deferred leave that is building up and this must be considered in the short and medium term plans for restarting of services.
  • During the response to Covid-19 many changes have been introduced to help support the wellbeing of the workforce from the new online wellbeing hub to local, physical hubs and simple changes such as free parking, hot food and rest areas. These simply must not be given up or forgotten about as we recover from Covid-19
  • There is a need for further layers to support wellbeing – an example of this is the development of a practitioner health service to support doctors with mental wellbeing and addiction issues.
  • There must also be specific and targeted support for those in the workforce who have suffered due to the work in the highly stressful Covid-19 environments. This must be long term, as the affects will be long lasting.
  • Over recent years, there has been an increasing understanding that there is a widespread fundamental problem in the culture across NHS Scotland – so the work to implement the recommendations of the Sturrock review remains crucial and must not be lost. However, there is now a real opportunity building further on that re-envisioned NHS Scotland to move to a culture we want to see. This includes adjusting the approach to using targets.

4: Clarity must be given to healthcare workers about their current and future roles, and plans to restore education, training and career progression

  • With many normal activities around training, appraisal and revalidation paused or reduced due to Covid-19 for most of the workforce, there is an opportunity to review and reset some of the activities which, for doctors, had become over-burdensome and lacking in evidence of producing quality improvement.
  • Some doctors may have moved to emergency or shift working patterns as a result of this pandemic. As part of planning for return of more routine services, these doctors will need clarity around whether there are plans for these new roles to be extended, and on what terms. Equally recognition of the contractual job planning process will be needed for all career grade medical staff, including both those continuing in COVID-19 rotas for the time being and those returning to more normal roles.
  • Plans should be agreed as soon as possible on the recommencement of non-COVID-19 junior doctor rotas and the reinstatement of monitoring processes for these.
  • Giving careful thought to restarting the education, training and career progression of junior doctors and medical undergraduates is a priority – and the BMA will set out its views on this in more detail.
  • Equally arrangements for NHS staff who need to continue in non-patient facing roles, as they will be in the shielding group, will need considered carefully.

5: There must be effective and transparent public communication so that patients understand what they can and cannot expect from the NHS at this time – and for the foreseeable future

  • While messaging around the NHS remaining open for emergency and urgent care remains important, very clear messaging and expectation management will be required with the public about what mobilisation, and then a journey towards a ‘new normal’ will mean.
  • All politicians will need to be realistic with the public about what may or, in particular may not now be possible in the NHS while we continue to deal with the impact of Covid-19 and remain prepared for possible subsequent waves of cases
  • Pre-Covid-19, NHS Scotland was under huge stress in both primary and secondary care, and we believe that this needs to be acknowledged before we can move forward in any meaningful way.
  • Public expectations of what the NHS will look like for the next 2-10 years needs to be addressed.
  • A key part of this would be resetting the service and how we measure it to focus on quality and clinical need, not arbitrary temporal targets or volume of service.
  • The BMA believe that now is a good time to have clarity around the suspension of  arbitrary waiting time targets for the foreseeable future. As time progresses, we will need to have an evidence-based reason to re-introduce them, alongside a very careful consideration of how they are used.

Dr Lewis Morrison is Chair of BMA Scotland

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