Biomedical science, and with it the discovery of the causes of diseases, was changed with Antoine van Leeuwenhoek’s microscope 300 year ago – where he viewed microbes in droplets of water and the red corpuscles in human blood.
This became the raw data – the equivalent today is the ability for researchers to examine data and information flows – which began the process of understanding the aetiology of disease and led to the discoveries in pharmaceutical and surgical interventions which have led to a profound and lasting transformation of society: in effect, the health and the wealth of the world today.
Across successive centuries emerging health systems adapted in response to new diseases, innovations, social expectations, and developments in biomedical interventions. Though only so far: the surgical pioneer and one time Surgeon Extraordinaire to Queen Victoria, Sir John Eric Erichsen, commented in 1873 that, “There cannot always be fresh fields for conquest by the knife. There must be portions of the human frame that will ever remain sacred from its intrusion – at least, in the surgeon’s hand. That we have nearly, if not quite, reached these final limits there can be little question…. [however]… from the base of the brain to the lowest organ in the pelvic cavity [are] triumphs of the surgeon’s art”.
Twentieth century developments
One of the defining features of twentieth century medicine was the reduction in premature death due to infection, as a result of the introduction of pharmaceutical medications in the form of antibiotic therapies in the 1940s. However, as one risk reduced, others emerged: health services across the globe have worked to transform their systems to respond to the epidemiological shift from infection to non-communicable disease (NCD) as the main cause of premature death or disability; with low and middle income countries, how they can learn from advanced health systems in their journey towards universal health care; and, how high income countries can learn from the cost-effective solutions created in many poorer countries.
According to the University of Washington’s Institute for Health Metrics and Evaluation (IHME), two of the top three causes of disability and premature death globally in 2017 can be attributed to NCD: ischaemic heart disease, lower respiratory infections, and chronic obstructive pulmonary disease.
What may be thought of as the impossible in healthcare frequently becomes the possible: take infant mortality. In 1971, 16.5 million children died before the age of five years. By 2017 this had fallen to 5.4 million. Achieved, according to the IHME’s Simon Hay in ‘Maintaining progress for the most beautiful chart in the world’ (International Health, January 2019), through a combination of safer drinking water and sanitation, insecticide-treated nets, vaccination, oral rehydration therapy, and antibiotics, which the US Centers for Disease Control and Prevention calls, “the greatest story in global public health”. A unique set of interventions and determination has brought about this remarkable achievement. The same commitment is now required to strengthens health systems to ensure that children not only live healthily to five years old, but also into adulthood and beyond.
However, trajectories changed dramatically in early 2020 when the World Health Organization (WHO) put countries on alert to the threat to humans from the coronavirus disease COVID-19, and its’ causal virus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Health systems rapidly pivoted to managing patients with COVID-19 symptoms through information and the reorganisation of services to treat patients suffering with the effects of the virus, whilst Governments issued urgent public health messaging to assist with containing the disease. For many countries, this is manifested in lockdowns, restricting the movement of populations. The public were variously told to stay at home and leave only for essential travel, such as for shopping or to seek urgent treatment. A consequence being the disruption to regular health treatment, which has impacted, in particular, the diagnosis, treatment, and management of NCD.
On 1 June, 2020, WHO issued the results of a survey which showed that the prevention and treatment services for NCDs had been severely disrupted since the COVID-19 pandemic began. The survey, completed by 155 countries during a three week period in May 2020, confirmed that the impact is global, but that low-income countries are most affected. WHO said that this situation is of significant concern because people living with NCDs are at higher risk of severe COVID-19-related illness and death. The main finding is that health services have been partially or completely disrupted in many countries.
Significantly, the survey reported that:
- 53% of the countries surveyed have partially or completely disrupted services for hypertension treatment
- 49% for treatment for diabetes and diabetes-related complications
- 42% for cancer treatment
- 31% for cardiovascular emergencies
- The postponement of public screening programmes, for example, for breast and cervical cancer, was also widespread, reported by more than 50% of countries
The most common reasons for discontinuing or reducing services were due to cancellations of planned treatments, a decrease in public transport and thereby restricting the ability of patients to travel to health centres, as well as a lack of staff because health workers had been reassigned to support COVID-19 services.
Finally, WHO has demanded a call to action and for health systems to “build back better”. The two early outcomes from C19 has been that:
- COVID-19 has flushed through weakness in health systems – especially those in middle income countries progressing towards the UN’s 2030 goal of UHC
- In established health systems, alternative approaches have had to be found to deliver patient services beyond COVID-19.
In summary, all health systems – whether established or developing – need to strengthen health services so that they are better equipped to prevent, diagnose, and provide care for patients with NCDs both in the wake of COVID-19 and in the future.
Case: Management of hypertension in the UK
WHO’s call for health systems to “build back better” offers an interesting approach to address the diagnosis and management of hypertension, which, as WHO’s survey showed 53% of countries partially or completely altered their hypertension services. In the UK, prior to COVID-19, hypertension was managed by predominantly nurses and pharmacists in primary care, with patients going into practice for diagnosis, management, and follow up; all performed in clinic. However, since COVID-19 this has stopped guidance issued by the Royal College of General Practitioners [10 April, 2020] said that chronic care was in the medium priority and that remote review was recommended. COVID-19 has meant that face-to-face care with blood pressure measurements taken in clinic now abnegated to people’s homes – meaning that for patients at all stages – those not aware and needing routine testing under the National Institute of Health and Care Excellence’s guidelines, those waiting to be diagnosed and stopped midway in the pathway, and those diagnosed and under clinical management, meaning that:
- There will have been missed opportunity to measure blood pressure accurately
- The potential for recording mistakes will have been made – even with modern and relatively easy-to-use home blood pressure monitors – and will patients understand when a potential problem is arising
- There will be concerns over the accuracy and reliability of the machines.
- The lack of integration of data – into medical records and for population health management
- There will be delays in diagnosis with many patients remaining on a waiting list for ambulatory blood pressure monitoring/seven-day home monitoring under the guidance of primary care
- There will be delays in requests for further tests, including ECGs and providing patients with lifestyle management advice to either prevent the need for medication or to ensure the patient is given advice to ensure stabilisation
The UK’s National Health Service (NHS) has already introduced at pace a series of new models of delivering outpatient consultations in both primary and secondary care, using telephone, apps, and other internet-based video services. This is likely to continue, however, the profound impact that COVID-19 has had on society has yet to be fully realised: isolation, loneliness, the failure to detect other diseases, and mental health, mean that moving towards purely digital services will not be a sustainable solution, but will need to complement the provision of patient management.
There may be a settlement to different models of care – all complementary to help support those at different parts of the patient pathway – as a consequence of COVID-19:
|Point in the Pathway||Potential models of care|
|Reaching the undiagnosed||– Faith groups
– Community groups
– Awareness messaging from industry and NGOs
|Diagnose those on the pathway||– Primary care – GP/Nurse and/or pharmacists
– Secondary care if required
|Management of diagnosed patients||– Primary care if necessary
– Non-clinical settings
New skills will be required for both the digital and non-clinical settings. Whilst COVID-19 has resulted in the rapid uptake of technology in healthcare, research by Brynjolfsson and Saunders shows that whilst IT can increase productivity – so may help with displacement due to COVID-19 and to speed up diagnosis post-pandemic. However, this has to be complemented with other interventions such as organisational restructuring and process changes – so the new models of care as outlined in the table (Table 1) – and crucially training. All of which, along with the implementation of technology, health systems including the NHS have traditionally struggled. This can be done; Japan is an example where a focus on health literacy and community-based interventions whether in the home or community settings has improved levels of self-care.
New models of care combined with new skills for nurses and pharmacists will improve patient outcomes: the important element is to ensure patient engagement and health literacy is seen as equally important.
Brynjolfsson, E & Saunders, A, Wired for Innovation. MIT press. Cambridge, MA 2009
NHS England, NHS England Long Term Plan. 2019
Oliver, A, Behavioural Public Policy. CUP. Cambridge 2014
RCGP Guidance on workload prioritisation during COVID-19 10 April 2020
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Michaela Nuttall, Associate in Nursing, C3 Collaborating for Health, London UK
Christine Hancock, Founder and Director, C3 Collaborating for Health, London UK
Shaantanu Donde, Pfizer Upjohn, Surrey UK