This pandemic brings an opportunity to reassess and plan for the future. Healthcare will be like pre-pandemic, only less money and greater Procurement pressures to improve productivity and cost-effectiveness. Healthcare delivery will be less efficient, there will be less administrative manpower and disrupted clinical teams.
Prepare now for a highly competitive, post-pandemic landscape where insistence on national training standards for commercial visitors to hospitals should become the new nationwide norm.
Indications are that for some considerable time in the future, even if an effective vaccine and/ or treatment for Covid-19 are on track for rapid development, return to ‘the way life was’ will require a strategy to cope with further resurgences of Covid-19. That’s because unless the coronavirus is eliminated world-wide, sectors of the population will for evermore remain vulnerable and many who are currently low-risk will become high risk with time. Vaccines work less well in older people (over 70 years of age); effective treatments are unlikely to be comprehensive ‘magic bullets’ for the vulnerable, and any immunity after infection or vaccination is likely to be short-lived. International travel by asymptomatic ‘super spreaders’ or those with mild symptoms may remain the cause of further outbreaks. So a ‘new normal’ will emerge.
Spanish flu (so-named because war-torn Britain and Germany and the USA, unlike Spain, censored Influenza A H1N1 deaths) caused a pandemic that lasted nearly three years world-wide (Jan 1918 – Dec 1920), this was associated with three high-peaked ‘infection waves’ in the UK during the 12 months from June 1918 to June 1919 (1), killing more people than the Great War (between 20 and 40 million worldwide vs nine million), which infected one in three and had an overall mortality of anywhere between 1 and 6% of the global population. Spread of infection was along trade routes and by travel, and the 20-40 age-group was most vulnerable (2) – the so-called ‘cytokine storm’ of younger people’s immune system, and secondary bacterial pneumonia causing most deaths. There were no tests, no vaccines, no treatments. Population nutrition was poor in Europe through war and poverty, and other infective illnesses were still a serious public health hazard since antibiotics had yet to be developed. Cities more severely affected saw a sharp and persistent decline in economic activity lasting many years, although where early and extensive social interventions occurred (shops and schools closed, people staying at home, masks being worn – sound familiar?), economic recovery occurred sooner (3, 4, 5).
Fast-forward to Covid-19 today. At the time of writing, it was six months ago when the first censored reports of illness and death from a novel coronavirus started to emerge from China. The first wave of deaths peaked in the UK five months later, plateaued, then gradually declined. Overall mortality rates are estimated at between 3 and 4%, mainly affecting the medically vulnerable, elderly, obese and those in high-density or impoverished living conditions. Because of post influenza pandemic medical advances, many people living with chronic disease had near-normal life expectancy in the run-up to Covid-19, but were highly vulnerable once the new pandemic hit. We have modern medicine during Covid-19, but no vaccine or effective treatment or antibody test for the virus. We have good nutrition and no war in Europe, but a significantly higher proportion of the population is medically vulnerable. Mortality is higher with Covid-19 than Influenza A H1N1 (6). So, at present, we are in a similar place to where we were a century ago: unarmed for a new infection, and with a significant proportion vulnerable in our population. No vaccine, no treatment other than supportive care (albeit more advanced than 100 years ago), and only basic strategies for managing the disease and its economic impact: a concerned, grieving public and a government balancing computer models, scientific advice and the demands of lobbyists.
Britain will be different by the time the infection peaks have passed, and we can be sure Covid-19 is behind us. The developed world will practise new norms and ways of working around the constraints of uncontrolled respiratory viruses: more and new virtual versions of everything. Advanced IT skills and simulations as good as reality will be the new business standard.
People will continue to develop all other medical conditions at similar rates as they were pre-Covid-19, and yet there will be limited elective investigations or clinic assessments for many months, perhaps even until the pandemic is over. NHS capacity for all services was already under significant pressure before Covid-19 emerged.
The public’s fear of becoming infected in a healthcare setting and uncertainty about available medical services has caused reluctance to seek medical attention for other serious symptoms during this pandemic, resulting in an additional healthcare backlog whenever the ‘new-normal’ service is established. Increasingly, people are beginning to question where the balance of competing healthcare pressures lies (Covid-19 vs ‘the rest’), so some services may return sooner rather than later. It is likely, though, that healthcare will become more costly and less efficient during the transition due to the continuing draw of Covid-19 on resources, R&D costs to change systems, continued need for social distancing and the ongoing disruption of clinical teams.
Computer modelling in 2008 in anticipation of a 12 month SARS pandemic suggested an 8% fall in UK GDP based on four weeks of school closure during pandemic conditions (7). To put that economic impact in perspective, the entire NHS budget for 2019/20 was 7% of UK GDP (£134Bn). So the economy is unlikely to support anything other than ‘must-haves’ in post-pandemic Britain, unless in the sphere of future pandemic management, for years to come. At the time of writing, school closures are into their fourth week and there is no projected date to reopen, suggesting an 8% drop in GDP at least, is likely due to the pandemic in the UK.
Some think the 1918 flu-pandemic caused serious economic depression in badly affected areas lasting five years and made them more vulnerable to future economic shocks (3, 4). The Great Depression which followed the 1929 Wall Street crash lasted until the outbreak of WW2, a decade later. So a decade of post-pandemic austerity is worth planning for. It’s also worth noting that the flu-born cohort achieved lower educational attainment by adulthood, experienced increased rates of physical disability, enjoyed lower lifetime income and a lower socioeconomic status than those born immediately before and after the flu pandemic (8, 9). So some sectors of society will need support for a lot longer than a decade.
Add to that our most recent experience of an economic downturn (financial crisis of 2007/8), which lasted 10 years, and a post-pandemic period of austerity of a decade looks like a reasonable assumption. Again. And there may be reduced levels of skilled staff in critical care and other specialities for the first half of that decade due to staff illness and burn-out, suggesting that training needs may be greater for some clinical teams.
Health service cuts under these circumstances often occur first and deepest among managerial staff which normally have local oversight of administrative processes. So what governance can easily be put in place centrally by the NHS now to ensure uniform standards in the Medical Device Industry and how can companies best position themselves to succeed in this new landscape?
Healthcare providers will be pushing money-saving procurement strategies and the process checks and balances to the limit to maximise productivity and cost-savings – even more so than after the 2008 economic crisis. Medical device companies that have invested in education and training for their customer-facing staff (the better to support clinical teams with effective and time-efficient training, both virtual and real) will have a head start on their competitors for contracts. The most effective and diligent support for clinical teams still reeling from the impact of Covid-19 will be needed more than ever, and medical device representatives with the best professional skill-sets will shine through. Effective training for end-users and stock management will remain the cornerstones of successful bids, but the need for medical device companies to prove their competence will be crucial. Delivery of cost-effectiveness and increased productivity will become ‘must-have’ core criteria, and medical device companies which have invested in their customer-facing employees during the pandemic will be front and central among preferred bidders.
Will all UK hospitals formalise a need for the appropriate National Occupational Standards (RQF Level 5 required for all critical care areas – theatres, anaesthetics, ITU, HDU, A&E, day surgery, interventional radiology; RQF Level 3 required for all other Hospital areas) for medical industry representatives to gain access to their premises and bidding processes? Well, that process was already well underway before Covid-19 arrived (10, 11, 12, 13).
At a time (post pandemic) when the NHS workforce may have many relatively new and inexperienced staff in unfamiliar roles, national standards are easy ways to boost public safety and value for money, so expect that Hospital Trusts will soon if they haven’t already started to insist on these national standards for all device representatives of medical industry companies entering/ selling to UK hospitals.
This will ensure that non-NHS personnel admitted into NHS clinical environments have at least the same base-line training as their own clinical staff, which is key to matching the expectations and assumptions of patients and hospital managers: only commercial visitors with a national occupation standard as a pre-requisite can deliver that level playing field. So how would this fit with pre-pandemic credentialing mechanisms for admitting Commercial Visitors to UK hospitals? Pressures were already building nationally for the medical industry, hospitals and credentialing organisations to conform to National Occupational Standards in the interests of patient safety (14). It is an anathema that medical industry representatives can be integral to patient care in an operating room, but be unaware of the protocols and appropriate behaviours required to limit infection control and prevention risk and other patient safety issues associated with significant medicolegal exposure for both hospital and medical industry company. With private hospitals contracting for NHS care, both UK sectors will surely align. Has the time come for hospitals or the credentialing companies they employ (which admit commercial visitors lacking nationally agreed training standards to clinical areas) to be held accountable when things go wrong for patients, staff or commercial visitor?
Because there’s much we don’t yet know about the coronavirus pandemic, it’s wrong to be overly prescriptive. However, when planning for an uncertain future from difficult or uncharted waters, it makes sense to use reasoned projections based on current knowledge as starting-points.
One thing is certain, oversight of medical devices by the medical industry and the support of clinical teams in the use of their products are legal and contractual obligations that will have to resume and return to pre-Covid-19 levels soon (either in person or virtually), and as hospital contracts come up for renewal, the competition will be fiercer than ever. While many routine healthcare administrative processes may have been deferred during the acute phase of the pandemic, the economic impact on the public purse will necessitate redoubled efforts to strengthen procurement processes once the pandemic is deemed over.
They should insist on the appropriate National Occupational Standard for training (in addition to DBS check, relevant inoculation status and professional indemnity) for every healthcare-related commercial visitor accessing hospital premises (or ensure that the credentialing companies they use/ recognise to do so) in the interests of patient safety and limitation of liability.
They should carefully review their customer-facing representative training policies as a matter of urgency, and make up any National Occupational Standard shortfalls to reduce the risk of vicarious liability and to prepare for ‘new-normal’ service-wide procurement Ts&Cs for the NHS and private sectors.
This article was compiled by HC Skills international and first appeared in the Operating Theatre Journal.