Faced with the monumental challenge of COVID-19, health and social care staff moved into crisis mode, reorganising, recalibrating, and realigning to meet the demands of a pandemic-struck nation. But what impact did this have on the shape of patient pathways, and what can we learn from the tragedy of the last 18 months?
Top 5 takeaways
1 Perfect storm of pressures disrupted pathways across the whole spectrum of care.
2 Patient pathways, from diagnostics to treatment, monitoring to follow-up, have been transformed.
3 Technology and data sharing has increased collaboration between primary and secondary care.
4 Cross-speciality working has enabled teams to build new pathways that straddle traditional silos.
5 Triage is the name of the game.
More joined-up working, fewer outpatient appointments, and right first-time diagnostics and care have been among the NHS’ ambitions for some time. Yet despite multiple national policy documents and countless local initiatives, progress has been slow – until now. United behind a common purpose and an urgent need, professionals from across the health and social care ecosystem have worked together to streamline pathways. But what next?
At the start of the pandemic, a combination of infection control measures and the need to divert resources – including staff – to the front line rendered business as usual untenable. It called for drastic change.
Dr Nav Chana, medical director of the National Association of Primary Care and south London GP, said: “For some people with long-term conditions, monitoring in secondary care stopped.
“These people were unable to access investigations or scheduled specialist care. This created not only physical, but also mental health and social challenges.”
It also laid bare the NHS’ pre-existing staffing issues, said independent healthcare consultant, Sue Thomas.
“Specialist staff being deployed to the frontline has had a significant impact on patients,” she said. “Many clinicians have been working single-handedly to keep their services afloat.”
All this was compounded by a drop in presentations and emergency admissions, driven as much by people not wanting to bother their healthcare teams as it was by fear of SARS-CoV-2.
This perfect storm of pressures disrupted pathways across the whole spectrum of care, with serious consequences for outcomes.
“Although the impact of heart attacks and strokes is significant, a lot of people with neurological problems, for example, experience frequent urinary tract infections. What has been happening to them if they have not been seeking help?” asked Sue.
“Glaucoma is another area of concern. An eye problem might sound a low-key issue compared to cancer, but if people are not diagnosed and receive the required eye drops, they can lose their sight.”
The path to solutions
To meet the challenges of COVID-era healthcare, patient pathways – from diagnostics to treatment, monitoring to follow-up – have been transformed.
A large part of this has been attributed to the use of technology to conduct remote consultations, facilitate multi-disciplinary meetings, and enable the sharing of data.
“We must never gloss over the great hardship and loss many people have experienced during the pandemic, but there have been some positives. For some people, remote access has been a positive thing,” said Dr Chana, whose general practice went from assessing 20% of people remotely to 80% in the space of just three days.
Thomas agreed, saying that some people appreciated the convenience of virtual appointments, but adding that technology was only part of the answer.
“The point is that it has enabled an increase in collaboration between primary and secondary care. It seems to have improved team working, and enabled people to contact each other more easily,” she said.
This increased clinical integration has been a force for good in terms of ensuring patients are referred in a timely and appropriate manner, said Dr Chana.
“There has been this general feeling that we are all in this together, whichever silo or sector you are in. It brushed some of the bureaucracy that sometimes gets in the way of providing quality care, especially for those really complex cases,” he said.
“I was able to directly reach out to consulting colleagues, and we could talk about particular investigations, rather than sending letters to each other. We have not worked like this for decades.”
Cross-speciality working has enabled teams to build new pathways that straddle traditional silos, with the patient at the centre. The result is fewer outpatient appointments, more multidisciplinary team (MDT) working, and a greater focus on population level health, agreed Thomas and Dr Chana.
“I was able to directly reach out to consulting colleagues, and we could talk about particular investigations, rather than sending letters to each other.
We have not worked like this for decades”
Streamlined pathways reduce demand
Attention is now turning to what happens next, as the NHS moves to deal with the next wave of infections while also tackling burgeoning waiting lists.
Dr Claire Colebourn, consultant medical intensivist at Oxford University Hospitals and president of the British Society of Echocardiography (BSE), said thousands of people were currently waiting for an echocardiogram – a problem that is repeated across the diagnostic landscape.
“Backlogs are measuring at 12–15 weeks against the standard of six weeks for an outpatient echo referral in some areas. Work rates have been elongated by necessary PPE and room cleaning, staff who had to isolate or have had COVID, and also staff have been shielding. Many patients also did not attend their appointment because of fears of going to a clinical area,” she told Pf Magazine.
“On top of that, there are many more people who need scans because they have had COVID and now have chronic shortness of breath.”
Echocardiography, she explained, has a workforce shortage of around 20%, meaning demand was, as in many specialities, outstripping supply long before the pandemic.
BSE’s solution, in keeping with the collaborative ethos of the last 18 months, involves working with primary and secondary care colleagues to ensure referrals are appropriate.
“Triage is the absolute name of the game,” said Dr Colebourn.
“To streamline requests, we are asking people to triage using our new national guidance and, where necessary, recontact the referrer to make sure that person really needs an echo.
“If we can identify people who do not need an echo, we can relieve weight from the system. It’s also about reprioritising to maintain patient safety for those who really do need this test urgently.”
Along with the triage guidelines, the BSE has also sent primary care providers posters explaining the clinical where echo is not required. This provides clinicians with the backing they need to prevent over-requesting.
The BSE has also published a position statement, which sets out a range of time – and resource-saving initiatives designed to streamline services, on its website.
Collaborate to create new, outcome boosting pathways
Collaborative networks have extended further than primary and secondary care, said Dr Chana, pointing to a project designed to tackle the glaring health inequalities brought into sharp focus by COVID-19.
“In one area of London, we are seeing a great collaboration between secondary care, the voluntary sector, social care, and primary care, who have got a leadership group together,” he said.
“The aim is to use data sources to identify vulnerable communities with unmet need, and build targeted schemes that would improve their health and wellbeing, while also reducing demand on a variety of services.”
The bigger picture
Overall, the pandemic has focused people’s attention on the importance of comprehensive pathways – and how they can help the NHS achieve its overall aims.
“Many services have been delivering care for a long time without having or realising the implications of a defined pathway. My hope is that all of the changes we have seen will make people realise that there are better ways to deliver care, and produce better outcomes as a result,” said Thomas.
In MS, for example, new therapies are coming online all the time, but many require cross-specialty involvement.
“You might need an ophthalmology assessment after three months of being on a new treatment, for example. But if the service does not have access to ophthalmology because of waiting lists, it can’t implement the pathway,” she said.
“Teams need to understand all the steps of the pathway and build their services around them collaboratively.”
Grasp the nettle of momentum
Necessity, as Dr Colebourn said, was the mother of invention during the pandemic, and the last year or so has borne witness to something of a transformation in the way care is organised and delivered.
Maintaining that momentum will not only push down waiting lists, it will also help the NHS achieve its long-stated goal of doing more with less.
Said Dr Colebourn: “We need to look at any way of working more efficiently that protects patient safety. I want the person in front of me to need to be there and for their service to be as streamlined as possible.
“It is vital that people are in the right part of any pathway at the right time.”