I cannot count the number of times I have heard a newsreader use the word unprecedented and the use of this word is accurate, we have not been in times like these before. There are daily comparisons to war times and blitz mentality in the media but I would like to make the suggestion that health systems around the world do deal with large scale crises on a fairly regular basis.
In 2014 I worked in Surrey Memorial Hospital near Vancouver BC. The hospital had just opened a brand new Inpatient Tower with 7 floors of the best infrastructure, technology and architecture for acute patient needs. Staff were called into an urgent meeting in “The Tower” and told that our hospital had been designated the Ebola centre. We quickly got used to seeing people wearing beekeeper style hats in corridors as they were Fit Tested and we carried our perfect fit 3M mask with us at all times.
I reflect on this just to share that we have been through similar experiences in the past and we came through. Perhaps not me or you personally, perhaps not your NHS Trust or our country but systems and healthcare organisations have successfully dealt with crises before and there are things we can learn from these experiences.
At the start of this year I embarked on my Churchill Fellowship researching international Advanced Practice in Physiotherapy. My investigations took me to Christchurch, New Zealand and I would like to share the experiences and reflections of clinicians and leaders who lived and worked through the most traumatic years of Christchurch’s recent past. The city of Christchurch has had its fair share of crises in the last decade, namely the Christchurch earthquakes in 2011 and the Christchurch terrorist attack in 2018. I hope my interviewees stories can open a discussion about what we can learn from others experiences of how health systems cope with disaster.
Similarities with Covid-19
On a superficial level I can understand the opinion that a natural disaster is not the same crisis as a pandemic. However, the similarities in the cultures and systems of commonwealth countries allow a certain degree of comparison between different crises. A comparison made between countries previously impacted by epidemics, such as SARs or MERS, and the UK may not be as insightful due to potential differences in culture and systems.
- Surge capacity (huge casualty numbers)
- Fatality management
- Transfer of non-disaster related patients
- Health and safety of staff
- Maintaining other services
- Long term impact
- Long lasting health implications
Long term Impacts: mental health and rehabilitation needs
The high number of casualties, known as surge capacity, is similar in all forms of natural disaster and pandemic. The benchmark for surge capacity in a disaster is 300% of average patient load. During the Christchurch earthquake, which struck at 12:51pm on a weekday on February 22nd 2011, 182 people died and 6659 were injured in the first 24 hours, 185 people died in total. Repercussions of this disaster were still being felt 4 years later when the local health system recognised a 67% increase in new child and young mental health assessments.
As I am writing this over 27,500 people have lost their lives in the UK due to the Covid-19 pandemic. If a death toll of 185 can have a mental health sequelae over 4 years for young people we should expect the impacts of this pandemic on our health system, health staff, patients, citizens and society to be long and deep. We need to prepare for the long haul.
Emergency plans tends to lack foresight of long term impacts, especially psychological impacts (Al-Shaqsi et al. 2013). In Christchurch they were dealing with the psychological and emotional effects for years post-earthquake including grief, loss, fear, low confidence and lack of self-determination.
Professor Brian Dolan and Ken Stewart introduced me to the Design Lab in Christchurch which is a large warehouse with movable parts. Clinicians and leaders come together in the Design Lab to workshop ideas to clinical problems and design services. There I met Maya, Christchurch’s hypothetical pre-teen around whom the young persons’ mental health initiative, Mana Ake (meaning Stronger Together) was designed in response to the long term mental health impact of the earthquake disaster. The flexible and responsive approach of Christchurch’s health system using methods such as the Design Lab has allowed them to address the needs of its citizens post-crisis.
The needs of post-ICU patients are well documented. Data emerging from Italy suggests 16% of all patients admitted with Covid will require ICU admission (Grasselli, Pesenti and Cecconi, 2020). Anxiety, depression and PTSD post-ICU can be as high as 33% or 1/3 patients. It is suggested up to 67% of these patients will suffer ARDS, be left with lung scarring, breathlessness, high levels of fatigue, significant muscle deconditioning and loss of strength (Yang et al. 2020).
Due to these long term effects we will be managing the fall out of this pandemic within society for many years to come.
I would like to take this opportunity to share some of the systems and approaches which Christchurch leaders and clinicians identified as being key to helping their city heal from the trauma of disaster.
Integration and Collaboration
Every leader you meet will impress upon you the Trust values and workstreams or networks which demonstrate the organisations dedication to integrated care and collaboration. This is well intended but too often these efforts lead to more meetings than actions. In Christchurch the Canterbury Clinical Network and Alliances approach was repeatedly highlighted to me as a working example of these principles and their tangible outcomes.
An Alliance of principles and vision
The Canterbury Initiative was birthed around 2007 when it was estimated that by 2020 Canterbury would need twice the number of acute care beds, 20% more GPs and 40% more residential care beds. This is a narrative familiar to those working strategically in our health system. Workshops were happening and plans were being made for changes within Canterbury before the earthquake occurred but after the quake interviewees told me how the Chief Exec of Canterbury District Health Board, David Meates, recognised the new urgency of these changes and moved the timelines from Vision 2020 to Vision 2012 with the goal to deliver the changes 8 years earlier than planned.
One of these developments included the proliferation of the Canterbury Clinical Network (CCN) and their Alliances. Kim Sinclair-Morris, Executive Director of CCN describes the Network as “A shared vision, one around a connected system that’s focused fundamentally on people.” The CCN identifies the need for Alliances based on the population needs. The CCN will then invite partners relevant to that population need to form an Alliance.
Kim describes an Alliance as “a very simple concept about agreeing to work collectively on common goals for mutual benefit. A really important part of the Alliance Approach (is) around bringing everything back to integrating and connecting us.”
Alliances are not new concepts to our health system. The Chartered Society of Physiotherapy, prior to Covid-19, had already established a Rehabilitation Alliance with 25 partners from across the rehab spectrum. Alliances such as this will be crucial in tackling the system wide approach needed to healing our society in the years to come. I hope to see the influence of the CSPs Rehab Alliance grow and their members continue to advocate for patients impacted by Covid-19 whether through experiencing the virus or missing out on rehab because of it. I hope the CSPs Rehab Alliance can have a more local flavour and that Trusts across the country adopt this way of working for the future.
Here are some the of key principles which leaders continually highlighted as successful elements of the CCN and Alliance approach in my interviews which I hope we can integrate into our conversations and organisations:
- Collective responsibility: we all win or we all lose. Kim describes a few methods which help to keep the conversations on track and away from organisation specific or funding specific focuses. These include having an independent chair or clinician chair on each Alliance group and citizens involvement. The funder attends all Alliances to ensure there are no surprises and no inappropriate resource expectations
- Citizen focused: one or more citizens, Agnes or Maya (hypothetical patients) help to form a common view and avoid tribalism
- Citizen outcomes: they use citizens time as a key metric, the aim is to not waste their time which helps the system view time efficiency from the citizens perspective.
- Data informed: they use data to drive and monitor change.
My immediate question is whether we can adopted some of the concepts which leaders and clinicians who have lived and worked through disasters identify as key to the successes of bouncing back after crisis.
Can we all be more citizen focused?
A colleague recently shared her experience of being on the receiving end of a health system reaching out its citizens. She describes receiving 6 phone calls in one week from different health professionals checking in because her child ordinarily attends a SENCO school. This level of “checking in” was not required or requested and may actually add to the burden rather than relieve it. This leaves me wondering if we are asking our citizens what we can do to help rather than paternalistically providing what we think they need.
There has been a proliferation of shared work spaces and groups developed to respond to this crisis. Should we be asking for citizen representation in these arenas? Around 10-70% of all responders in a disaster are volunteers and we have seen the incredible offer our citizens have extended to the NHS in the huge numbers of volunteers signing up in the last few weeks. Could some of these volunteers be used more strategically to represent the voice of wider society as has so aptly been demonstrated by the CCN and their Alliances.
Can we be more data savvy?
I was recently advised that the Electronic Staff Record system only identified 2 physiotherapists in the UK as respiratory physiotherapists. This is a shocking example of we undervalue the need for accurate data and information in our healthcare system. Accurately recording someone’s job role seems like such an insignificant data piece but it is also very simple and its inaccurate input has made the job of predicting the need of the workforce much more difficult than it needed to be.
In Christchurch I saw multiple examples of how data input and analysis was respected and allowed predictive modelling and planning to evolve with the new pace of change required:
- Live data updates: screens of live admissions and discharges were visible across the organisation allowing managers to see where the blocks were occurring and where the slower areas were. This allows real-time decisions to be made about workforce redeloyment and any changes can be evaluated easier. It also allows managers to predict potential blockages developing in the pathway.
- Mapping complexity: the Integrated Community Older Persons Team sued nationally collected frailty indexes to assess patient complexity and overlaid this data on a map of worse effected areas. This allowed them to prioritise visits and interventions. Could we use frailty indexes matched to covid diagnoses to direct rehab support to those most in need?
- Analytics in the moment: the Transformation Team collaborates data analysts with clinicians to address current clinical problems on the ground. This collaborative approach allows clinicians, leaders and analysts to co-discover solutions together making the change process more efficient and effective. This is critical because emergency planners report that the disinterest of clinical staff in emergence planning can be a huge barrier (Al-Shaqasi, 2013).
What could we be doing now to collect the information which could shape our predicted models for rehabilitation and funding in the future?
Can we adopt an attitude of collective responsibility?
Another important aspect of the CCN is that it spans organisational boundaries. It is not answerable to a single master. It was created through a shared vision between the public and private health organisations servicing the Canterbury community. Pegasus Health’s CEO, Vince Barry, expresses that “Pegasus’ greatest achievement of recent times has been its relationship with CCN”.
An announcement this week confirmed that Cancer Hubs will be set up around the country to allow patients to continue their cancer treatment in lower risk environments. This demonstrates the collaboration between the private and public health sector. These measures are crucial to maintaining vital services during the pandemic but I wonder if we could expand this ethos of collective responsibility to maintain rehab for post-op patients or those with long term conditions who have been discharged or put on hold from their NHS physiotherapy. Perhaps this could also support private physiotherapy businesses. Thinking as a collective health system could also allow us to develop relationships we can continue to nurture after the peak of the epidemic has past.
Despite the difference between a pandemic and a natural disaster our health systems may respond in much the same way due to similar pressures. We would benefit from learning from the example of Christchurch as well as planning for the Alliances of the future.
Yang et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centred, retrospective, observational student. The Lancet, 2020
Grasselli, Pesenti and Cecconi. Critical Care Utilization for Covid-19 Outbreak in Lombadry Italy. Jama Network. 2020
Al-Shaqsi et al. Challenges of New Zealand healthcare disaster preparedness prior to Canterbury earthquakes: a qualitative analysis. The New Zealand Medical Journal. 2013