John Oldham: No turning back from service redesigns in light of covid-19

Last year over 70% of consultations in general practice were face to face, despite the technological availability of remote consultations. In April 2020, in light of the covid-19 pandemic and nationwide lockdown, 70% of GP consultations were remote. [1] Similar service redesigns have been delivered throughout the UK health and care system during the pandemic. The literature on change developed over the last 20 years has established some clear principles. [2,3] What have been the principles behind implementing in weeks, changes that would normally have taken months, if not years? I undertook structured interviews with a range of people who had delivered service transformation during the pandemic. [4-9]

In Wolverhampton NHS Trust, video outpatient consultation had been resisted beforehand, but as in general practice, has in recent months become the norm. The Wolverhampton population are now able to use online self diagnosis, remote interaction with clinicians, and direction to physical facilities when needed, a service change also previously resisted. These examples illustrate a key dynamic in change. The anxiety about status quo has to exceed the anxiety about the change. [10] In normal times this can be achieved by demonstrating the change alongside robust data on outcomes to allay fears about the change. Covid raised anxiety about maintaining the status quo, and seeing patients face to face due to fear of passing on infection. 

Tracking the impact of change with data is a vital principle of implementation for governance and safety shown by all. For example, in West Hertfordshire Hospitals NHS Trust, virtual wards were set up. Patients were followed at home with an app and advisory phone calls from healthcare professionals made rather than admitting patients to wards. This was set up in weeks. [8, 11] Quality Improvement methods were used to create rapid iterative learning driven by data to reassure healthcare providers that patients were being managed safely. A previous project to improve medical admissions had taken six months to implement. In Reading, a virtual ward is demonstrating similar results. [8] Here, additionally, hand held chest ultrasonography at covid hubs was set up rapidly, with remote interpretation, to help triage admission. 

The disincentive of “payment by results” (PBR) for hospitals to work differently has been well documented. [12] Removing this requirement at the start of the pandemic facilitated the delivery of the changes in hospital trusts as shown in Wolverhampton, West Hertfordshire and Reading. Similarly, removal of restrictive governance facilitated a community service provider in Yorkshire to train patients for self care of wounds. Healing rates were better than normal. The pandemic was a catalyst for the removal of barriers to innovation.

The majority of innovations seen during the pandemic have been within not across organisations. [13] Those service changes have been worthwhile, but we should recognise that most people using services have multiple issues crossing organizational boundaries. Social care is too often an afterthought to NHS changes. However, in North West London the removal of the PBR disincentive maximized engagement between hospitals, community and care services that benefited the response to the pandemic. [9]

It has also led to a plan which takes the opportunity to speed up integrating and transforming services during recovery. Before covid integration and collaboration was seen as an extra to the day job and progress was slow. Now it is perceived as essential to do the day job. 

Collaboration is also at the heart of a virtual support group for care homes which has been set up by the Regis primary care network. [4] A WhatsApp group was created in mid March (“too urgent to wait for guidelines”) to provide support for care homes. This group led by a GP, involved a geriatrician, mental health services, the local authority, community nursing and others. This rapidly expanded to 40 care homes and established a weekly team meeting, which was used to organize personal protective equipment (PPE), minimize admissions, and improve end of life care. 

Despite the disruption caused by the pandemic, organisations across the country have delivered change at scale and pace. All demonstrated known principles for change. Crucially they were driven by iterative improvement science rather than traditional research techniques. The accelerants were; having existing relationships to build upon, changing the level and speed of decision making, and a willingness to remove barriers. The removal of the disincentive of PBR was pivotal to Trusts working differently. There is every reason and imperative for this learning to be taken forward into future transformation. The future for these examples is clear. Each used a similar phrase – no turning back. 

John Oldham, Adjunct Professor Global Health Innovation Imperial College London.

Competing interests: None declared.


  1. Royal College of General Practioners Research  Surveillance Centre 30th April 2020
  2. Kotter John P:  The Heart of Change ; 2002 ;Harvard Business School Press 
  3. Feser Claudio : Serial innovators : 2012; John Wiley & Sons
  4. Interview with Dr Louise Beaverstock Regis Healthcare Primary Care Network  Multidisciplinary WhatsApp group supporting  60 care homes
  5. Interview with Carol Waudby and the senior management team City Healthcare Partnership Hull  Virtual Community nursing
  6. Interview with Prof Sultan Mahmood Director of Innovation, Integration and Research , Royal Wolverhampton Trust. Virtual out patients and whole population Covid19 app.
  7. Interview with Drs Matthew Knight and Andrew Barlow; Consultants,  West Hertforshire Hospitals NHS Trust  Virtual Wards
  8. Interview with Dr Andrew Walden, Consultant Royal Berkshire Foundation Trust  Virtual admission triage
  9. Interview with Simon Morioka Advisor, and Dr G Small, Chair Harrow CCG North West London Health and Care Partnership
  10. Oldham J The small book about large system change : 2004; Kingsham Press
  11. Thornton J; The virtual wards offering home care ; BMJ2020;369:m2119
  12. One Person One Team One System; Report of the Independent Commission on Whole Person Care; 2015; PWC