Recovery, Renewal, Resilience

TMB Issue 36 mentioned the need to identify and address the impacts of ‘Long COVID’ on people who receive and provide care and support in local communities (e.g. social care services/unpaid carers). The most recent Office for National Statistics (ONS) figures (July 2021) report that just under one million people in the UK have self-reported symptoms of Long COVID. The symptoms associated with ‘Long COVID’ (e.g. fatigue, shortness of breath, joint pain, cognitive dysfunction) have the potential to impact people’s ability to work, and their physical and mental health. The impacts of Long COVID have the potential to increase long-term demand on local health and social care services. Consider:

• How a rise in demand will impact current capacities and resources in local health and social care services
• Where re-deployment (e.g. of volunteers) may be possible to alleviate pressure on health and social care workers and meet the needs of people who might require continuous support e.g. with transport/shopping
• What training and safeguards would need to be put in place to ensure any additional support provided by volunteers is done safely
• The impacts of Long COVID on other services such as housing, transport, welfare and employment
• Conduct a review to:
  • assess current resources and surge capacities
  • understand who in the community does and might need additional support and estimate the length of time this might be for (using information such as people who have underlying health conditions)
  • estimate what funding might be required to meet a rise in demand and how this potential rise can be forecasted, budgeted, and planned for

Throughout the pandemic, many health systems across the world have come within days of being overwhelmed with COVID-19 patients, and others have been unable to prevent their systems from being overwhelmed. Pakistan have adopted “health stewardship” as an approach to ensure public health is a “joint function of national and provincial governments, where service delivery relies on mixed health systems”. The response in Singh district, which has the highest rate of COVID-19 cases in Pakistan, was underpinned by public-private partnerships with local government. This provides insights into how public-private engagement can be accelerated during the crisis and how “existing policy windows can be used for longer-term planning for pandemics and Universal Health Coverage”. Consider that:

• Stewarding partnerships enabled rapid acceleration of testing through private laboratories, supported surge capacity to be met in local private hospitals and increased “critical care training of public sector hospitals” through partnerships with private hospitals
• “Health stewardship” can enable advisory relationships with the private sector to create a joint operational response and strategic communications during crisis
• Procurement (e.g. of PPE) and supply chain management can be enhanced through “digitalised data-sharing of cases and hospital capacity across private and public providers”
• Stewardship relationships may be transactional (e.g. limited to purchasing arrangements) but can also include “wide-ranging formal agreements for co-production”, providing an opportunity to reform public and private health partnerships
• Devolved operations have proven to offer a flexible and effective response where there is rapid “data sharing for national-provincial coordination, and well-informed local governments who can mobilize inclusive and co-produced responses”

Social innovations in health and care are “inclusive solutions that meet the needs of end users through a multi-stakeholder, community-engaged process to address the healthcare delivery gap”. They concentrate on local community needs and priorities, strive to establish “low-cost solutions” and build upon the pre-existing strengths in a community. This paper produced by the LSHTM demonstrates how social innovation during COVID-19 has mobilised local communities, adapted existing health services at rapid pace and developed partnerships between local government and civil society. Consider the following international examples of social innovations in health during the pandemic:

• Peru mobilised communities by adapting their ‘Mamás Del Río’ programme which “selects and trains local people as community health workers”. This project adapted during COVID to both ensure the “continuity of maternal and neonatal health services” while also educating and training local people on COVID-19 prevention
• Malawi’s existing free hotline created by local people to provide health advice was scaled up nationally during the pandemic. The government then capitalised on the capabilities of this local service to “triage people with COVID-19 symptoms, identify and refer people at risk of domestic violence, provide health information to the public and gain a greater understanding of local needs”
• The Philippine’s multi-sectoral partnership brings together the “strengths and resources from the private sector, academia, local government and communities”. COVID-19 response was strengthened by these partnerships which enabled rapid deployment of a “hunger management campaign, the establishment of a call centre to manage returning resident’s and a role out of local testing teams”

Social innovation initiatives have proven a “powerful means of mobilising communities to respond to emergencies that can complement and extend government and private sector responses, and in turn build more resilient communities”.

London School of Hygiene and Tropical Medicine (LSHTM)

Public health has taken centre stage throughout the pandemic. Pre-existing fragilities have been exposed, but opportunities for reform and renewal have also presented. The White Paper ‘Integration and innovation: working together to improve health and social care for all’, recently presented legislative proposals for a health and care Bill in the UK. A recent briefing by the NHS recognises an opportunity for change, which lies in reform of “how population health is prioritised and resourced in the future”, to not only recover from the pandemic, but to renew systems so that they prepare for (and protect against) future public health risks by building resilience.

The White Paper is a complex and intricate document which is hard to summarise. Discussions of it with a health professional may help to illuminate its main implications for civil resilience. We identify a few lessons from it, but there are others that you may find. We focus on the challenges that lie ahead as part of a restructure of public health functions. Some challenges include:

• How to retain existing expertise:
  • Taking into consideration that responsibilities will change hands, such as those for health improvement functions, those which Public Health England are currently responsible
  • Continuing to fulfil local and national leadership responsibilities
  • Investment to “make up significant shortfalls over recent years”
  • Ensure effectiveness in health improvement functions moving forward
• The sustainability of public health services given budgetary pressures:
  • “Robust and long-term investments in public health services”
  • Acknowledging the critical role they play in building resilience to crises is crucial
• The potentially reduced agency and disempowerment of local government and local partners:
  • By considering that they are positioned most effectively to tailor services and communications to the needs and priorities of the communities they serve
  • Strategic partnership working between NHS organisations, local government and the voluntary sector is essential to promote empowered and flexible working at the local level
• Ensuring that local authorities are involved in resource discussions to locally distribute health improvement responsibilities
• Improving the commissioning arrangements for public health services to address the vulnerabilities exposed by funding cuts and resource shortages

The health and social care system is complex, spanning a broad range of services delivered by both statutory and third sector organisations. COVID-19 has had a significant impact on society and on health and social care services. A recent impact assessment ‘Health and Social Care in Wales COVID-19: Looking Froward’ presents “high level expectations” for NHS and social care recovery. It also identifies the challenges and constraints ahead, and priorities for each part of the system. Social care services are one of the key priorities, recognising the critical role that social care workers (including unpaid carers) have played in frontline responses to COVID. Consider:

• Learn lessons from the pandemic. Assess and identify the “hidden harms” caused by COVID-19 and implement services that can mitigate the longer term impacts of COVID on communities and individuals
• Facilitate opportunities for families to “identify and own solutions to challenges brought about or exacerbated by COVID”, to support families to remain together
• Identify and address the impacts of ‘Long COVID’, work to understand the effect of this on people who receive care and support, including unpaid carers and the social care workforce
• Introduce strategies that tackle the disproportionate impacts of COVID-19 on unpaid carers, focusing particularly on challenges related to “respite and support for carers”
• Recognise that the Local Authority Hardship Fund has been central to the continuity of many critical social care organisations during the pandemic. “Ensure that commissioners of care and support services, in local authorities and health boards, use this financial support in ways that enable them to match the provision of services to changing population need” as the full impacts of the pandemic play out
• Introduce the ‘Real Living Wage’ across the social care sector, to support wellbeing and mental health
• “Build on and improve the collaborative working that has been evident across the health and social care sector throughout the pandemic”

A recent UN policy brief identified the significant gap in health coverage as a core reason for COVID-19 having such devastating impacts on people's lives. Universal health coverages means that all people and communities can access the health services that they need, with three key priorities; "equity in access, sufficient quality and no undue financial risk". Consider:

• Establish universal provision for "COVID-19 testing, isolating, contact tracing" and treatment
• Ensure protection of essential health services during the critical phases of the pandemic (e.g. services for sexual and reproductive health)
• Through international partnerships, ensure future COVID-19 vaccines are a "global public good with equitable access for everyone, everywhere"
• Protect and invest in core health systems functions that are critical to protecting and promoting health and well-being, known as "Common goods for health"
• Suspend user fees for COVID-19 and other essential health care; reduce financial barriers to service use
• Strengthen local, national and global pandemic preparedness and aim for healthy societies for the future through a whole-of-society approach

In health systems across the world, screening programmes and non-emergency surgical operations have been postponed and cancelled to reduce transmission and free up capacity to treat Covid-19 patients. The USA, UK and Canada have been working to re-start non-COVID related healthcare since the first wave of COVID-19, with subsequent COVID-19 surges creating further challenges, particularly for those countries who are yet to tackle healthcare waiting lists. Those working to reduce the backlog report that some patients continue to defer seeking care so not to increase pressure on services, or because they fear catching the virus. Continued delays will decrease quality of life, increase treatment costs, and worsen outcomes, as the conditions individuals are suffering from deteriorate. There may also be knock-on effects on social care. Consider the measures explored by the UK, USA and Canada:

• Proactively engage the public (e.g. through local communications) to instill confidence in the safety and continued functioning of healthcare systems and encourage them to seek care if they need it
• Ensure ample PPE is available to prevent unnecessary challenges in the delivery of health and social care
• Inform plans by developing rigorous forecasts of future patient demand and service pressures
• Enhance national and local partnerships developed during the pandemic to address the backlog of people needing care. For example:
  • Begin to increase resource capacity through recruitment now to ensure sufficient capacity is available in the future
  • Extend surgical operating hours, including at weekends
  • Draw on volunteers to support vaccination programmes to enable trained healthcare staff to focus on elective care
  • Pool resources between local hospitals and centralize waiting lists so that patients can be treated wherever there is capacity
  • Make greater use of virtual care to increase outpatient access
  • Pilot alternative health care testing programmes (e.g.home testing kits for HPV)

Primary health care workers providing care in remote areas have faced challenges during COVID-19 including inaccessibility to locales, poor hospital infrastructure and facilities, and meeting the needs of vulnerable communities. In Australia, remote health services also face challenges in maintaining adequate appointment and retention of healthcare workers. Consider how to protect remote healthcare staff and remote communities, for example:

• Be mindful of competition between remote and metropolitan areas for staff and resources during COVID-19
• Consider the reliance of remote health services' on short-term or fly-in, fly-out/drive-in, drive-out staff, and the increased risk of transmission into remote areas
• Ensure there are adequate point-of-care COVID-19 testing sites in remote communities to avoid unnecessary travel to centralised locations and to reduce delays in test results
• Consider distribution and storage challenges in maintaining adequate stocks of PPE. Remote health service may also benefit from stocks of hygiene products to distribute to community households through remote health services
• Ensure remote health services are meeting regularly with other essential services e.g. police, schools, and hospitals locally and regionally, to develop local plans for concurrent emergencies in isolated areas
• Ensure the availability of an adequate, appropriately trained local workforce, especially for outbreaks in healthcare buildings
• Consider heightened costs for accommodation for remote healthcare workers due to staffing constraints or COVID-related isolation
• Consider staff burnout due to impact of insufficient staff, frequent orientation of new staff, concerns about the clinical and cultural competency of incoming short-term staff and continuity of care

Consider:

• That systems are not always focused on all the needs of people but rather on specific health conditions. Support for people and their overall health is vital rather than the restoration of specific services.
• That there will be challenges about aligning all the different health and care activities that are required in each place. Central government organisation may mean a lack of alignment at a place level depending on the department. For example, health systems, local resilience forums and environmental infrastructure are all different in England. We have learned that effective partnerships need to be developed 'bottom up' at place level, and many of these have worked well during COVID-19 response.
• Partnerships between organisations and between and in communities have worked well because of relaxation of information governance, financial constraints, central guidance and regulation. Careful consideration must be given to the extent to which these are reinstated and the timing of this.
• New processes that have been established during response, and the extent to which they can and should be continued. IN particular, remote consultations between health care providers, both in hospital and primary care, currently comprise the vast majority of interaction. Reverting to the pre-COVID method of primarily face to face will have both positive and negative consequences, which will differ across society. Careful thought needs to be given to the equality impact of retaining these changes.
• The power of each part of the health system - including that of the large health service providers (hospitals) but also the power of the people who live in each place. The longer-term consequences of e.g. establishing COVID-free (cold) hospital sties must be considered from a population perspective.

TMB Issue 10 brings together the reflections of our learning from the first 10 weeks of gathering lessons on recovery and renewal from COVID-19. Follow the source link below to read all of the reflections from our team (p.9-15).

In Korea, the COVID-19 Data Platform is:

Designed to:

• Support epidemiological analysts to quickly identify the transmission routes and places that an infected person has visited
• Use real-time analysis of data through location tracking, card transactions, and CCTV recordings for accurate tracing of routes and places

The process of using the app is:

• Citizens voluntarily record their whereabouts on their smartphones using Google Timeline
• The 'My Timeline' function on the Google Maps automatically records the users location and routes
• Data on Google Timeline can be captured as screenshots and shared with epidemiological investigators, who will use the data to trace contacts

The platform supports health officials to:

• Confirm the interview results of patient transmission routes with data on the system
• Allow big data analysis from real-time data feeds on COVID-19 patients, including their whereabouts and the time spent on each location
• Use these multiple data points to detect incidents of cluster infection and transmission sources for prompt

This response can include having the flexibility to create new capacity in the health system perhaps by creating new 'field' hospitals or by creating more space in existing hospitals.

For example, in the UK, capacity in the health system is being created by moving patients that are not at risk into hotels and similar facilities to free up health services for at-risk patients. Hotels in Dorset UK, with support from the local council, have offered rooms to "free up urgent bed space in the NHS by taking low risk patients and carers and being part of the solution... 230 hotels prepared to reopen their door". Developing a roster of hotels and similar spaces that can be used in case of resurgence would support emergency planning.