Lead: Prof Dan Lasserson (Acute Care Interfaces), Prof Russell Mannion (Meths), Prof Simon Conroy (ARC EM)

Dates: October 2019 - October 2021 (originally funded by NIHR Policy Research Programme for winter pressures, DHSC as the policy client, changed the focus to COVID-19 system resilience in April 2020).

Background:

COVID-19 has had a profound impact on the organisation and delivery of acute healthcare. Prior to the rapid increase in COVID-19 admissions, acute trusts and acute community providers had opportunities to re-engineer acute care through new care platforms (e.g. changes in processes of care, re-deployment of staff and rota changes, new pathways of care). These changes are designed to provide a rapid increase in capacity across a system of care, not just for intensive care and ventilators, but also for general care of patients with COVID-19 who have become too unwell to stay in their usual place of residence. We are seeking to understand the impact of these changes and to learn which approaches are more likely to be associated with ‘COVID-19 Resilience’ – the ability to meet the healthcare needs of the population during COVID-19. The challenge for health and social care is not only to support patients with COVID-19 (including timely access to care for all patients, monitoring, oxygen if needed, or more advanced respiratory support, access to symptomatic treatment at the end of life) but also to ensure that patients with acute illness not due to COVID-19 can also get access to timely treatment, alongside detecting and treating important conditions such as cancer. The learning from the variation in rapid re-design of acute care (and any attempts to maintain non-COVID-19 pathways) is essential in preparedness for further peaks of COVID-19 and how we can plan the rapid and sustainable recovery of non-COVID-19 pathways. Importantly, we should identify positive changes (such as reduced crowding in emergency departments) and seek to understand how to maintain such improvements in system function.

Policy and Practice Partners:

Department of Health and Social Care.

Co-Funding Partners:

N/A.

Aims and Objectives:

Overall research question: Which care delivery models are most resilient to the impact of COVID-19, to meet the needs of patients with COVID-19 as well as non-COVID-19 illness in the NHS?

Aims:

1. To determine the variation in approaches to COVID-19 preparedness among NHS acute care systems (acute hospitals, acute community providers, primary care).
2. To identify which approaches are associated with improved organisational outcomes (maintaining patient flow during peak COVID-19 presentations), clinical outcomes in COVID-19 and non-COVID-19 diseases (length of stay in acute hospitals and mortality, severity of heart disease and cancer at diagnosis during/after COVID-19), adjusted for confounders (e.g. deprivation, co-morbidities).
3. To develop methods of identifying how acute care systems can develop COVID-19 resilience through rapid in-depth case studies at exemplar sites with high resilience, contrasting with studies of sites with sustained challenge (adjusted for confounders).

Methods:

1. National survey of acute medicine units and their local ‘acute care systems’ in community settings, using a co-developed questionnaire with acute care stakeholders. We will use the existing Society for Acute Medicine audit network (currently includes at least 130 acute hospitals (network lead, Lasserson) to identify variations in care approach and in particular to look for novel care pathways/structures.
2. National dataset analysis (HES – attendance and in-patient, NHS Digital for workforce, CQC) to map patient flow and clinical outcomes for COVID-19 and non-COVID-19 acute diseases at hospital level, cross-linked to Society for Acute Medicine hospital data. This will identify high performing hospitals during COVID-19 (adjusted for demographic/co-morbidity data) as well as examine outcomes in settings with novel care pathways.
3. Qualitative studies (conducted remotely, using translators where needed) to understand healthcare seeking behaviour for patients from BAME populations (to explore if delays contribute to poor outcomes) and in patients with non-COVID severe disease (e.g. late presenting heart attacks).
4. Site visits for COVID-19 and non-COVID-19 high performing systems/novel care pathway units to determine organisational context and culture, how any novel structures were implemented and embedded.

Main Results:

Awaited.

Conclusions:

These will be relevant for policy-makers and clinicians working in the acute care pathway.

Implications for Implementation:

To inform organisation of acute services in hospitals; precisely how this is done will turn on the findings.