We knew a healthcare crisis was looming. But this wasn’t the crisis we were expecting. 

Until COVID-19 began its inexorable global spread, the greatest threat to the world’s healthcare systems seemed to be the rise of noncommunicable diseases (NCDs) such as heart disease, cancer, diabetes and chronic respiratory disease, combined with an ageing population. We knew that these conditions were already responsible for 70% of global deaths and that the worst was yet to come – a report by the World Economic Forum and the Harvard School of Public Health predicted that NCDs would cost the global economy more than US$30 trillion between 2010 and 2030, a substantial burden evolving into a staggering one.

We knew too that the risk of epidemics and pandemics had increased with globalization, urbanization and climate change, and that growing antimicrobial resistance could plunge us back into a terrifying pre-antibiotic era.

COVID-19 must be the priority now, but none of these other challenges have gone away. The pandemic has lengthened waiting lists as it delayed testing and treatments – more than 28 million elective operations will be cancelled or postponed worldwide during 2020, according to a projection by the CovidSurg Collaborative, published in the British Journal of Surgery. What it has given us is a once-in-a-generation opportunity to rethink how services could be delivered and what it is possible to achieve. So what can we take from this crisis to help the world’s healthcare systems perform better over the decades to come?

In this series of articles, published over the coming weeks, WSP will explore the lessons we can take from the COVID experience, and the challenges and potential solutions it presents – from re-engineering hospital environments, to resilience planning, to reshaping cities to support healthier, happier populations. But perhaps the most fundamental question is how healthcare should be delivered: what is the most effective way to improve outcomes when there will be ever-diminishing resources to go round?

COVID has completely shaken up healthcare operations, emptying outpatient departments and doctors’ waiting rooms, and virtualizing many activities overnight. Providers needed to make space for an influx of COVID patients; patients were too scared to seek care in-person. Both were forced to overcome their reservations about telehealth. In a matter of weeks, it went from little-used novelty to the mainstream, with consultations via telephone or video replacing visits.

Anecdotal evidence suggests that many have been pleasantly surprised, and that both patients and doctors would choose to continue using telehealth at least some of the time. In the UK, for example, the Royal College of General Practitioners says that the proportion of in-person to remote consultations has reversed since lockdown, with 70% of appointments now taking place via video or telephone. Post-COVID, it envisages that this will settle into a 50:50 split. “From an absolute reluctance to use IT, there’s been a realization from clinicians that actually it is a reasonable method of communicating and engaging with patients,” says Simon Kydd, WSP’s head of healthcare in the UK. “I think the use of telemedicine will rocket in the next few years, and that will ultimately have an impact on hospital design as appointments reduce.”

Virtual appointments improve access to care for remote populations, but they are also much more convenient for urban dwellers and physicians themselves, says Dr Stephen Duckett, who has held senior leadership positions in both the Australian and Canadian health systems and is now health program director at the Grattan Institute think tank in Melbourne. So far, he says, failure to attend appointments appears to be lower when patients don’t have to actually go to a hospital. In some cases, follow-up appointments after surgery can be done just as well over telephone or video, while ongoing treatments such as chemotherapy or dialysis may take place in a “virtual ward” with clinical teams visiting. “For some people, being able to lie in their own bed with their family around them is better than having exactly the same treatment in a hospital,” says Duckett. “The research evidence is pretty clear – rehabilitation at home is just as good.” This is also safer for those whose immune systems are already weakened and vulnerable to hospital-acquired infections.

Duckett believes that telehealth should be expanded, but not in such a way that it undermines existing care. “If we think that good primary care for a person with chronic illness is continuity of care – which the evidence says that it is – then we have to make sure that telehealth fits into that system rather than cutting across it.” Grattan Institute has published a set of recommendations for the Australian government, which include structuring payments and incentives so that telehealth providers must also offer face-to-face services, to ensure patients see their usual practitioner rather than a web-only doctor they have never met before. The first appointment should always be a face-to-face one.

There is of course the risk that telemedicine simply replaces one set of access issues – location, convenience – with another, namely those of age, poverty and connectivity. “We can’t let the perfect be the enemy of the good,” says Duckett. “You shouldn’t stop improving access for the majority just because it doesn’t fix the problem for everybody. If we decide telehealth is good, we then need to find the strategies to make sure that people don’t fall behind.”

There is a perception that it’s older people who will be excluded from digital services, but plenty have become more familiar with technology during lockdown to stave off social isolation. The more intractable barrier is poverty. Low-income communities not only have the highest rates of chronic illness, they are also most likely to find themselves on the wrong side of the digital divide. This is a gap that the Howard University College of Medicine in Washington DC is trying to fill with an innovation project to develop telehealth solutions tailored to medically underserved populations. (Howard University associate dean Michael Crawford discussed this project in the most recent issue of WSP’s The Possible magazine.)

COVID has also seen the expansion of in-patient telehealth, where physicians observe and communicate with patients from outside their room, using cameras, microphones and screens. Banner Health, an Arizona-based non-profit health system with 28 hospitals across six US states, had already installed a handful of these “eICU” systems, to give the most critically ill patients access to a wider range of specialties. When the pandemic struck, it installed hundreds more across its hospitals within just a few weeks. “That was for clinician safety and to decrease our PPE utilization – even if the doctor was in the hallway only 50 feet away from an infected patient, they were in a safer setting,” says executive director of facilities services Steve Eiss. “Now we’re starting to see doctors get more comfortable with treating people in that way.” He thinks this will continue after COVID, but for reasons of efficiency and access. “We could have a cardiologist sitting in a centralized location seeing patients in three hospitals or 30 hospitals. They might spend three-quarters of their time seeing patients at the hospital they’re in, and the rest being a rotating specialist for other facilities, either to save travel time or for access at more rural facilities.”

A video consultation may feel like the future, but this is only the beginning of telemedicine’s evolution. Princess Margaret Cancer Centre in Toronto, one of the world’s best, has successfully virtualized around 75% of outpatient clinic visits since the start of the pandemic. Smart Cancer Care design director Mike Lovas says they are now exploring how to extend the approach. “Telemedicine has shown some of its potential, but it’s been used as a blunt instrument to date,” he says. “How can we offer continuous and real-time connection with the healthcare system? After all, patients don’t have concerns, symptoms, or deteriorate conveniently during pre-scheduled visits. Life happens between hospital visits, and outside of the hospital, and we need to embrace that.”

One example is a nurse-led monitoring clinic where patients can submit symptoms or concerns to their care team, who respond in real-time via phone or secure messaging. Lovas says that the data captured during these encounters will feed algorithms to auto-recommend additional self-care education or services, and presents an opportunity to provide more remote care and weave hospital and community programmes together through auto-referrals to services such as sexual health or palliative care. “The data collected supplements the provider’s memory of programmes that might serve the patient, and it will also help us create predictive analytics to refine the way we provide proactive care for similar patients in the future.”

By extending care into patients’ homes on a continuous basis, telemedicine also sets the stage for a more preventative approach and better management of chronic conditions. This will be essential if services are not to be overwhelmed as lifespans lengthen and the rate of noncommunicable diseases continues to rise. “Healthcare has typically been reactive and intermittent, but we are finally moving away from an ethos of illness to an ethos of wellness and continuous, proactive health,” says Suzanne MacCormick, global healthcare lead at WSP. “COVID has shone a light on the fact that healthcare permeates everything we do and transcends all sectors. It is not just about seeking help when we get sick, it’s about how we keep people well in healthy, safe environments designed to enhance our wellbeing and quality of life.” 

Keeping hospitals only for the sick

But why are there so many people with chronic conditions in hospital in the first place? Before COVID, many were already questioning the use of acute facilities for so many services, and the over-use of emergency departments for ailments that could be better dealt with in a primary-care setting. In response, there is a nascent shift of diagnostic or outpatient services to smaller, community hubs.

In the US, for example, providers are now incentivized to keep patients out of hospital where possible. Banner Health is building outpatient centres with a mix of services, from primary care to specialties such as cardiology and women’s health, to imaging suites, laboratories for analyzing blood and an on-site pharmacy. “So you can go and see a primary care physician, and they could say, ‘I noticed your heartbeat didn’t sound right’ and send you down the hall to the cardiologist, and they could send you for an MRI and to get some blood drawn so they can run some labs,” says Eiss at Banner. “That could all happen in the same building and then you pick up your prescription from the pharmacy on your way out.”

This type of facility is particularly applicable in remote communities, which cannot sustain a full-service hospital. “You would go there for things like dialysis, or nutrition information if you’re diabetic, or if you need help,” explains Kevin Cassidy, head of healthcare for Canada at WSP, which is involved with several projects like this in Nova Scotia. These facilities will be combined with long-term care homes and coffee shops and, in one case, a school. “So it’s more of a hub for wellness that’s embedded in the community, a destination for people to stop. It helps you stay healthy so you don’t need to drive to a distant major city so often. If we’re looking at how to reduce the cost to the system, you need to have a healthy lifestyle to begin with and that’s supported by these community health centres.”

The bigger picture is that we need to stop equating health with hospitals, believes Lord Nigel Crisp, a former chief executive of the UK’s NHS. “We get trapped into thinking in very traditional ways and we always start with the acute. This should be the opportunity for us to think the other way around, so you don’t start by saying ‘what do we need to do for cardiac patients or cancer patients’, it’s ‘what do the people in this community need’. Only when you can’t provide that in the community should you end up taking someone to a facility.”

Community services are less visible and therefore lower priority, he says – “it’s easier to cut two district nurses than it is to close a ward” – but they play a massive role in freeing up capacity in acute hospitals. In 2015, Crisp led a review of mental health admissions in NHS psychiatric wards. “We found that on average 40% of people probably shouldn’t have been there, and it was because there weren’t community facilities for them to go to.” 

He has just published a book, Health is made at home, hospitals are for repairs, which argues for a much wider conception of health and distinguishes between preventative healthcare and broader health-creating activities in society. (We’ll consider the social determinants of health and the role that cities play later in this series.)

In a future of more virtual, more community-based care, there will have to be changes in the healthcare workforce too. Today, only half of all countries have enough healthcare workers to deliver quality services, and no country is on track to meet the World Health Organization’s health-related Sustainable Development Goals by 2030. There is a demographic problem too: over the course of the next three decades, the number of people of working age for each person over 70 will plummet from 10.4 to 5.4.

Crisp is also co-chair of the global campaign Nursing Now, and he believes nurses will play a much greater role. “We will always want highly trained specialist staff, but most need for healthcare is now in long-term conditions and most of those can be better managed in the community, where you can anticipate acute episodes and head off people going into hospital. I suspect that we will start to see that nurses can do 80% of what doctors do in primary care, especially with virtual consultations and new technology.”

In Africa, where Crisp has been working for the last 15 years, nurses are already the lynchpin of clinics in both rural and urban areas. In rural Kenya, midwives scan pregnant women using portable ultrasound machines and the readings are sent to a regional centre in Nairobi. “They get an instant report back so that they are able to talk to the mother about how her baby is developing and whether or not she needs to come into the hospital. There’s no reason at all why this sort of model shouldn’t develop in places like the UK. There’s a lot we can learn from low-income countries because they’re making massive changes without resources, and necessity is the mother of invention.”

The bottom line is perhaps that healthcare systems around the world are stuck in a 20^th century industrial model while other sectors have transitioned. “We still have a production line sort of approach and language and methodology, whereas society generally has moved to a knowledge-based economy,” says Crisp. “A post-industrial model will be much more individual, with a holistic approach that is horizontal rather than linear.”

The expansion of virtual and community services as a result of COVID-19 is a positive thing – but we can’t let fear be the driver. Healthcare systems cannot be successful if people are too scared to seek the care they need. In the next part of the series, we’ll look at the lessons for infection control in healthcare environments: what we need to do differently to make them safe, both in reality and perception.