Stewardship for universal healthcare in a post-covid-19 world

After covid-19, it is imperative that we act as stewards of finite healthcare resources to support the principles of universal healthcare, say Tim Wilson, Joe McManners, Gwyn Bevan, and Muir Gray

The covid-19 crisis has been the equivalent of a mass switch off. The public has stopped doing things at a scale never seen by this generation. Normal healthcare has paused so resources can be diverted elsewhere. In countries around the world that have finite numbers of clinicians, beds, personal protective equipment, ventilators, and more, those working in healthcare have acted as stewards of the resources available.

There are likely to be resource constraints for some time, at least until the majority of the population is immune. Countries will incur debts from a combination of support for the economy and reductions in revenue from taxation, so all public services will likely have to manage with new constraints. Even if countries give healthcare a more generous settlement than other sectors, there will still be limitations in staff numbers, space, diagnostic equipment, and other key assets. For instance, waiting rooms designed for 40 patients may now only safely accommodate 15.

The technical innovations that have come about through remote consulting have been welcome (astounding many with the speed at which they’ve been taken up) and offer the possibility of new models of care delivery. But a virtual consultation is not appropriate for all, should be no quicker than one conducted face to face, and may result in an increase in demand; indeed, virtual care is no panacea for resource shortage.

After covid-19, when healthcare does “switch back on,” it is imperative that we act as stewards of healthcare resources to support the principles of universal healthcare—not least of all principles like “available to all” and “on the basis of need.” We identify four areas in which stewardship can be applied in the after covid-19 period:

First, pent up demand through the lockdown may have worsened Julian Tudor Hart’s “inverse care law”: with a greater increase in unmet need in those living in the most deprived communities. Inequity of access to health services was widespread before lockdown, it must not be allowed to worsen. Better still, let’s take this opportunity to reduce it by routinely measuring equity of access and then focusing and tracking efforts to reduce inequity.

Second, services that can be rationed by volume, like elective surgery, should be defined in terms of their capacity to benefit based on the informed preferences of patients. After all, using decision aids improves outcomes, and reviews have demonstrated that their use means around 16% fewer people opt for surgery. Now is a moment to make sure that those patients put onto lengthening waiting lists definitely know they would prefer surgery to other effective treatments.

Third, there are interventions provided based on their cost effectiveness; should we pause the introduction of those that are lower value but which meet a QALY threshold? For instance, in England, is this the time to choose to implement the new NICE threshold for treating hypertension, when it means treating an additional 720 000 people and what we’d therefore calculate as an extra 5.4 million* general practice appointments? This is one among many lower value interventions across a range of conditions that needs to be reprioritised during a period when resources will be constrained.  

Fourth, there is a small, but significant, list of interventions that it is generally agreed do more harm than good but that are doggedly persistent. The time has come to simply stop doing them.

By acting as stewards of finite resources, clinicians can make access more equitable and better direct services to benefit the populations they’re serving. If we work towards this, covid-19 could be the disjuncture that allows the reaffirmation of core principles of universal healthcare. 

*This is calculated on the basis of a patient having around 3-4 appointments associated with hypertension and 3-4 appointments associated with the individual taking on a sick role.

Tim Wilson is the director of the Oxford Centre for Triple Value Healthcare.

Joe McManners is a GP in Oxford.

Gwyn Bevan is an emeritus professor of policy analysis at the Department of Management, London School of Economics & Political Science.

Muir Gray is a professor in the Nuffield Department of Surgery at the University of Oxford.

Competing interests: Dr Tim Wilson, Dr Joe McManners, and Prof Sir Muir Gray are directors of the Oxford Centre for Triple Value Healthcare, a social enterprise that receives fees for capacity and capability building in health systems who want to deliver value based population healthcare.