In alert level two, a slew of hospital and GP services become available again. That presents a challenge to get back to normal, and ‘normal’ should not be what we are seeking in any case, write Richard Hamblin and Carl Shuker of the Health Quality & Safety Commission.
Surgeries have been halted. Hip and knee replacements have stopped. Procedures for glaucoma – stopped. Cancer surgery – stopped. Not only that, we aren’t being screened for cancer. We aren’t getting endoscopies, colonoscopies, cervical or breast screening – all on hold. And by “on hold”, what we really mean is added to an already long list that is growing in ways we don’t fully understand.
We don’t fully understand it because (a) the problems that are happening quietly out there in our homes under lockdown haven’t “touched” the system yet. We can predict some of them based on previous trends, but we simply don’t know about them. And (b) conditions and disease don’t wait, obey rules, play fair. The “normal” health risk the system was perfectly designed to address in the way it was doing in February 2020 (inequitably, unevenly, imperfectly) is evolving and growing and mutating. Everything we were already dealing with in February 2020 is now on steroids – we have something way more complex than a backlog.
So how do we return to February 2020? How do we use the government’s freshly announced injection of funds to the DHBs to deal with this mutated backlog of health need? And is the health system of February 2020, with its profound failings for Māori, something we ought to strive for? A huge part of the conversation we need to be having around the recovery is not how do we get back, but how do we move to a better health system than the one we had in February 2020?
Health has supply and demand, and both of these are complex
Thinkers and wonks in health policy now usually refer to health systems as “complex, adaptive systems”. One particularly dark and witty ICU nurse calls them “complex maladaptive systems”. The point is our system is not a linear production line where treatments are applied to relatively predictable demand. No one pre-Covid was standing in an orderly queue for their stitches, their hip replacement, their insulin. Some people were constantly pushed back in the queue. People were caught between queues needing multiple things. Some found their treatment in the queue was intolerable. Some weren’t queuing at all, lost, resigned, resisted, or baffled by the complexity of the thing.
When Covid happened, not only those treating the queues but the queues themselves disappeared. Despite the director general of health urging people to seek medical attention when they needed it, people stayed away from GPs and emergency departments. How much of this was done out of fidelity to level four lockdown rules, fear of what’s called “nosocomial” infection (infection in a healthcare setting), or simply a very egalitarian and admirable New Zealand concern about burdening a system in a time of emergency will be picked apart by researchers for years ahead.
What we know is that GPs and many specialists conducted an unprecedented wholesale transition to virtual and telehealth in a matter of days – a revolution in the delivery of primary care people would have said was impossible three months ago. Despite this revolution and all the benefits (and risks) it brought with it, demand for (and revenues of) primary care has plummeted (consultation numbers fell “by 50-80% within days” ) exposing the tremendous vulnerabilities of the business model of primary care itself, and threatening general practices (which we must remember are small businesses) with inability to meet payrolls, and with insolvency.
‘General practice as we traditionally know it ended on March 25’
What is further alarming about this massive drop in demand is that what’s called secondary care (surgeries and other medical treatment in hospital) was cancelling and deferring all the work referred to them by those GPs – and sending those people back to their GPs for “management” until they had prepared for and dealt with the massive emergent shock of Covid-19 on the wards we were all waiting for. Hospital carpenters have built new wings (with airlocks) to our ICUs in weekends. Whole hospital buildings previously dedicated to elective surgery have been repurposed to deal with infectious Covid patients. And, because lockdown worked, those patients haven’t appeared. And neither, yet, have the elective surgery patients whose operations have been postponed.
Something called the National Hospital Response Framework was drawn up, a sort of hospital version of our four levels of alert. But high-level concerns have been expressed that different DHBs have applied this differently, and at different times. Elective or scheduled “work”, as it is referred to in the language of health policy and management, has been put off, cancelled or reduced in different ways for patients in different parts of New Zealand.
And meanwhile, their health need grows, changes, evolves.
Addressing the practice of backlog theory
“Bouncing back” will likely be far more complex than simply clearing the backlog created by the pandemic. More money such as has just been announced is essential and of course very welcome. But it is probably naive to hope that the numbers of “missed cases” during the Covid response can be simply “worked off”. In 1963m the UK Ministry of Health tried to treat its massive backlog with this approach – by throwing money and resources at it. In its subsequent report, the ministry noted, “It is disappointing to have to report that in spite of a gratifying increase in the numbers treated, the total waiting list figures for England and Wales increased by 5%.”
“Backlog theory” fails because it conceptualises a health system as a linear production system where “treatments” are produced and applied to relatively predictable demand.
The demand is no longer predictable. The actions of those demanding healthcare have changed and the actions of the suppliers of healthcare have changed, both massively, and both unpredictably. And they are still changing.
The system was working at capacity in February 2020. Doctors and nurses were stretched and exhausted. They will be more so post-lockdown. ICU doctors and nurses, watching Italy and Spain and the US and the UK, have been mentally and physically preparing themselves not only to be intubating patients in corridors but to make the impossible decisions about rationing of care (who gets a ventilator if you don’t have enough?) for weeks on end. They are talking about anxiety, guilt over having that anxiety, “survivor guilt”, “stress without the stressor”, and even “pre-traumatic stress disorder”. One ICU doctor likens it to the preparation for battle: “It is strange standing in the trenches preparing hard for battle with no sign of the fight and uncertain whether it will ever arrive.” The stress has fallen unevenly. Aged residential care staff are dealing with a completely different and far more concrete version of the battle to ICU staff.
Covid will return and return as, after the hammer of lockdown has fallen, we enter the dance of dealing with sporadic outbreaks over the coming months or even years. Our healthcare workers are going to have to deal with constant stress, maintain constant vigilance against another outbreak, deal with fearful and suspicious patients, and all this in the context of a system already stretched to capacity in February 2020.
A new future
There’s a thing called the Cynefin (a Welsh word, pronounced ku-nev-in) framework, invented by a Welsh polymath and complexity genius named Dave Snowden. It talks about the different responses people need to apply when a complex system moves from a state of complexity into a state of chaos. Under normal conditions, health systems are already complex and the best way to lead and deal with issues is called “emergent” – we test stuff and observe the results and adjust accordingly. In Spain, in Italy, in the UK and US, the Covid-19 pandemic has created chaotic situations where crisis is the norm and practice is “novel” – people are trying new things in new ways as best as they can.
In New Zealand, lockdown has prevented the system entering chaos mode. So we have the chance to navigate a situation of increased complexity. Cynefin says that, under complexity, distributed leadership, maximum diversity of input, and a collaborative approach in an atmosphere of trust is critical. Some not working in health may be surprised to hear that wasn’t the case pre-Covid. In many parts of health – in particular the Māori response – it is the case post-Covid, and we need to build on this.
There are dangers in a simplistic response to a complex (rather than chaotic) situation. When we have complexity and fail to rise to complexity, who suffers? History suggests those who already suffer from barriers to and inequitable outcomes of healthcare will see them worsen.
In February 2020, inequities for Māori and Pacific people in the conditions and opportunities that give rise to good health were marked and entrenched. However, decades of data also show that once you’re sick, inequities in access to healthcare, and in the quality and outcomes of that healthcare, are also distributed according to the colour of your skin. Across the system, across the life course of people, and across the country.
In general, a system with inequity will default to more inequity under pressure. There is a palpable risk that the displaced demand caused by our responses to this crisis will immediately impact on the populations already made most vulnerable, and most disempowered. “Prioritisation” of Māori and Pacific by including ethnicity in elective prioritisation scores has been broached and, like all such measures, may be controversial.
Innovations in telehealthcare may reach those hardest to reach, or exclude them more profoundly, particularly the elderly, making a bad situation worse. Those with barriers in February 2020 will end up watching those barriers rise or fall depending on our response, and in years to come the health outcomes of those previously marginalised will judge our thinking and our actions now.
Richard Hamblin is director of health quality intelligence and Carl Shuker is principal adviser, publications, at the Health Quality & Safety Commission