Where do we see the future? What will it be like? A futuristic, slightly shinier version of now or truly different? If nothing else 2020 has shown us that nothing is definite. There are no comfortable certainties of where we are heading, no indestructible shibboleths and nothing that cannot fail or fall. Before COVID-19 (yes there was once a time when it did not exist and we can maybe someday meet and reminisce about this) there was an NHS. It was an NHS which was struggling and failing to meet targets, with lack of capacity and a need to change pathways to catch up with medical advances. COVID-19 has shone a light on many things, but much of what is has illuminated is lack, shortfall, need.
For our specialties the evidence of lack was already there. In clinical radiology, COVID-19 has highlighted as nothing else previously did, the pivotal place of imaging in the management of the vast majority of hospital in-patients as well as a high proportion of community presentations. By all measures we do not support imaging services as other similar OECD countries do. Workforce, kit and therefore images taken – all less than the public needs from a modern health service. Interventional radiology (IR) also lacks. Very few other specialties can support patient outcomes with reduced time in hospital (and consequent reduction in burden on the health service) and offer the opportunity to effect the pathway changes needed as much as IR. The breadth of need for interventional techniques has long outstripped the ability to supply them to the detriment of patient care in the UK. Lack is also visible in clinical oncology services. Demographics drive spiralling demand at the same time as technology explodes and new therapeutic interventions improve survival, in turn leading to more demand.
On this background of relentlessly increasing demand, COVID-19 has illuminated the increasing gap between where we are and where want to be. It has also provided a hammer blow to the desire to cross this gap quickly. We have (as one eminent figure was heard to say) ‘trashed the economy’ and spent all the money the magic money tree could produce on the COVID response, not the future of the NHS.
The RCR campaigned strongly for the proper funded expansion of our specialties to ensure that patients can benefit from medical advances as they should. A one-year funding settlement rather than a fully comprehensive spending review (CSR) means expanded medical training places cannot be supported at the levels required. Health Education England (and other funding bodies in the devolved nations) cannot have the confidence to help shape future workforce as they want and see the need for. We might see some support for areas where timeframes are one year – boosting interventional radiology and nuclear medicine capacity being obvious potential wins. There is the tantalising prospect of a multi-year CSR settlement later this year. The RCR is already working towards stronger marshalling of the hard evidence to support our arguments for expansion across our specialties. However this begs the question what best to do in the meantime? How do we help ourselves and bridge the gap between what we can deliver in the current shape of services and what the service truly needs? The work doesn’t go away and as always, in my experience at least, there is more than enough to keep us occupied.
How do we make best use of the staff available? Working patterns which are more flexible would be a start. Home-working (especially reporting) or perhaps a focus on training seen as an acceptable part of job plans, especially for those towards the end of their careers, would encourage those who wish to contribute to do so. A uniform implementation of rules around ‘retire and resume’ would also improve the perception of fairness which is a potent psychological aid to engagement. Improving working conditions with simple measures to make staff feel valued would, I am sure, reap valuable rewards.
Improved networking offers an interesting challenge to those of us brought up to think about ‘my department’ and ‘my hospital’, indefinably supported by the adversarial nature of the internal market. It cannot give us a capacity that does not exist, but it could deliver a more resilient service for rarer areas of practice. More importantly it could effect a huge shift in focus. What is best for the patients we serve? Or the population healthcare need? Obvious barriers to contracts being held across competing organisations, including indemnity, need attention but cannot be insurmountable.
Last but not least, do we need to think how we organise ourselves and our services? How we use everyone in the team to best advantage? Can we redistribute the tasks needed to ensure high-quality, safe patient care to others? Can we, as team leaders, oversee a different, wider team all working toward the best patient outcomes? In many places this happens already, but it is piecemeal. Almost like only children, we hold onto ‘our’ changes, not always exploring those others have successfully used. We need to identify best practice and share it, but also adopt the best practice of others as we expect others to adopt ours. By helping ourselves to the innovation of others we will truly help the patients we serve.
Dr Jeanette Dickson