By Caroline Redhead.
The effects of the Covid-19 pandemic on the NHS have been profound. The cycle of starting, suspending and restarting routine services, which will be ongoing for some time and continue alongside normal winter pressures, is in itself a major incident for the NHS. As we moved from the acute and into the ‘reset’ phase of the pandemic at the end of April and non-Covid-19 services were re-started, fairness dictated that consideration be given to how services would be (re)organised and resources (re)allocated for Covid and non-Covid care to take place in tandem. New kinds of ethical issues and dilemmas arose as decision-makers considered how to balance individual access to healthcare services and the continued protection of local communities from Covid-19, considering both the communities of staff, patients and carers within hospitals and other healthcare delivery settings as well as those outside. To date, there has been little ethical scrutiny of such delivery decisions by NHS England or others; although legal actions relating to, for example, the provision of PPE and discharge of patients to care homes have commenced.
The key question facing healthcare providers was how to prioritise and restart (reset) services. It might be expected that direction would have been found in guidelines and policies, but while many of these existed for the Covid-related response, they were (and remain) more limited for non-Covid services, although they are equally essential in this context. Guidelines and policies directed to Covid-19 can (and have) draw(n) on the ‘Ethical Framework’ set out in the Government’s Guidance on Pandemic Flu, but there is no similar body of suggestions relating to the re-setting of non-Covid services. Consequently, the ethical framework underpinning, and values contained within, documents relating to decision-making in this context remain unclear. This is of concern because ‘professional ethical guidance and clinical judgement need to be secured within a transparent, coherent, authoritative system as a whole’.
Decision-making practices regarding reopening, reprioritising, and reorganising non-Covid services must be robust, ethically justified, transparent, accountable, and open to scrutiny. The resetting of NHS services also needs to take account of the Covid-19 ‘second wave’, as regions of the UK experience the imposition of the new tiers of restrictions which, arguably, in some cases exacerbate the health and social inequalities that underpin the unequal rates of infections the restrictions are intended to address. Decisions about how to reset services, and how patients can access them, must also recognise the possibility of stress and moral distress being suffered by healthcare professionals, many of whom are still exhausted from responding to the first wave of Covid infections. Non-Covid services must be reset in ways that balance the needs (physical, mental and social) of healthcare providers, patients, and wider communities, while ensuring adequate protection from the potential harms caused by Covid-19. To achieve this balance, a fair and transparent ethical framework must guide policymakers’ and NHS decision-making, ensuring that communities can understand and trust the healthcare decisions that affect them.
Our team, led by Lucy Frith with Heather Draper, Sara Fovargue, Anna Chiumento, Paul Baines and Caroline Redhead, has received funding from the UKRI AHRC to define and support ethical decision-making in this new era. Our project will explore the ethical challenges that living with Covid-19 poses for both clinical staff and trust managers (professionally and personally). It will concentrate on maternity and paediatrics. These two very family-focused services have been significantly affected by the response to the pandemic, as highlighted by professional and patient organisations. The impact of Covid-19 on these services, and the way they are reset, will extend beyond individual patients to their partners, children, siblings, and wider support networks. People need to feel visible to, and safe within, the reset maternity and paediatric healthcare environment.
We will conduct an ethical analysis of current policies and processes guiding the reorganisation of NHS services, and collect the experiences of healthcare providers reconfiguring and resetting services, those delivering care, and maternity/paediatrics patients and service users. Our findings will be used to develop and test approaches to ethics support tailored to the needs of professionals working in these settings. A fair and transparent ethical framework for the reset phase, based on interactions with relevant stakeholders, will then be produced to guide future decision-making by policymakers and NHS staff. This will be essential to ensure that NHS decision-makers, service users and their wider family and care networks are supported when critical, ethically difficult, decisions about the delivery of maternity and paediatric services are made.
Authors: Paul Baines, Heather Draper, Anna Chiumento, Sara Fovargue, Lucy Frith.
Baines/Draper: Division of Health Science, Warwick Medical School, University of Warwick, Coventry, UK
Chiumento: Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
Fovargue: Law School, Lancaster University, Lancaster, UK
Frith: Institute of Population Health, University of Liverpool, Liverpool, UK
Competing interests: None declared