In this first in a series of short, rapid-fire health quality intelligence papers, the Health Quality & Safety Commission raises the question of our national response to the consequences of measures to contain and eliminate COVID-19 in Aotearoa New Zealand, in particular that of the gathering backlog of scheduled or elective work. We look briefly and generally at the responses of different parts of the system and address some theories of how to ‘return to normal’. We suggest that a return to the conditions of February 2020 is neither simple nor perhaps desirable, and that there is an opportunity to build a stronger, equitable health system, and to manage emerging issues more proactively and effectively. This paper expands on a recent piece in The Spinoff and aims to prompt discussion within the sector about positioning our health system to succeed in an uncertain future, taking into account both the complexity and constraints of the system and situation we work within.
Health care as a complex, adaptive system
In complex, adaptive systems there are actions that are deliberately planned and worked toward, but agents of the system interact and connect with each other in unpredictable and unplanned ways, including in response to knowledge of present and emergent system conditions. We see this in the current range of responses to, and preparations for, COVID-19. These interactions ‘begin to form emerging patterns, which in turn feed back into the system and further influence interactions of the agents’. Patients in the system are agents too, not just recipients of health care, and change in patient demand for services is an example of this complexity of response. For example, there will be complex and unpredictable responses from all agents to both current and emergent conditions and current constraints, and both knowable and unpredictable effects of those actions.
The Cynefin framework makes distinctions between simple, complicated, complex and chaotic situations, where responses and requirements of leadership differ. Under normal conditions health systems are complex and best practice is emergent – tested and observed and adjusted. In many countries the COVID-19 outbreak has created chaotic situations where crisis is the norm and practice is novel. In Aotearoa New Zealand, strong central measures appear to have prevented the system entering chaos mode and we have the chance to navigate a situation of increased complexity, where distributed leadership with maximum diversity of input in a collaborative fashion in an atmosphere of trust is critical. We see this happening in many spheres already. However, there are dangers in a simplistic response to a complex (rather than chaotic) situation. When we have complexity and fail to rise to complexity, who suffers? History suggests those who already suffer from barriers to and inequitable outcomes of health care may see them worsen.
Internationally, those working in health quality recognise that health systems are complex and adaptive. Health care occurs in a dynamic process that is not characterised by simple relationships of cause and effect – health systems are not linear production systems where ‘treatments’ are produced and applied to relatively predictable demand (see box).
The local response to the global COVID-19 pandemic has impacted on the entire Aotearoa New Zealand health system in a range of ways, with some immediate obvious effects, including positive ones such as advances in transforming models of care that might have seemed impossible two months ago. There will be a range of further effects that we can expect to emerge over time. How can we learn from what went well, and how ought we rise to the complexity of the future we face?
Supply of care
Addressing the backlog of normal work created by the response of agents in the health care system to the threat of COVID-19 and the effects of central measures to restrict transmission is crucial. Much elective and scheduled work has been cancelled or deferred. There have been credible suggestions that the National Hospital Response Framework is being inconsistently applied across the country, and services are rejecting primary care referrals, withdrawing or reducing services and cancelling or deferring elective and scheduled activity in ways that are not consistent nationally.
Demand for care
Coupled with complex actions and responses from the supply side are uneven and unpredictable effects on demand. Some people who need care have been so concerned about COVID-19 that they have avoided seeking medical help for health issues. Alongside emergency departments, general practice and hospitals have seen large reductions in demand. This has served us well in our efforts to combat COVID-19, but in spite of the Director-General of Health urging people to seek medical attention when needed, people have instead stayed away. Therefore, cancellation of elective work in favour of management, however temporary, in primary care is no fix-all. After two weeks of scrambling to assemble and coordinate a response, including an unprecedented wholesale transition to virtual consultations, demand for (and revenues of) primary care has plummeted (consultation numbers fell ‘by 50–80% within days’), exposing vulnerabilities of the business model and threatening practices with inability to meet payrolls, and with insolvency.
‘General practice as we traditionally know it ended on 25 March 2020.’
There are those who are seeing the positives outweigh the negatives in the transition to digital primary health care, and are working to maximise these in an emergent context of changing patient presentation and demand.
However, unmet need in the community, some of which is invisible to the system, is therefore likely rising and certainly evolving and will make itself known in unpredictable ways we need to understand better.
Particularly worrying is that this unmet need may increase inequity. In February 2020 there were marked and entrenched inequities for Māori and Pacific peoples in the determinants of health, access to health care, and quality and outcomes of that health care. These inequities were evident across the system, across the life course of people and across the country. In general, a system with inequity will, under pressure, default to more inequity. There is a palpable risk that the displaced demand caused by our responses to this crisis will immediately impact on the most vulnerable populations with the least power. Innovations in telehealth care may reach those hardest to reach, or exclude them more profoundly, further exacerbating inequities. Those facing barriers in February 2020 may end up watching those barriers rise or fall depending on our response, and in years to come the health outcomes of those previously marginalised will judge our thinking and actions now. Risks must be examined and understood quickly, and purposefully addressed with a sense of a very real window for positive change.
Addressing the practice of backlog theory
‘Bouncing back’ will likely be more complex than clearing the backlog created by the pandemic, and by our own and the public’s response to evolving conditions. It may be naïve to hope that the numbers of ‘missed cases’ during the response period can be worked off through a temporary addition of excess capacity with a foreseeable return to normal. The limitations of this kind of response to management of health care demand were first noted in 1963 by the UK Ministry of Health, which found that,
‘It is disappointing to have to report that in spite of a gratifying increase in the numbers treated, the total waiting list figures for England and Wales increased by 5%. It should be noted, however, that the largest increases in waiting lists are mostly in respect of those departments which have shown significant increases in the numbers of patients treated either as outpatients or inpatients or both. It would seem, therefore, that the demand for certain types of treatment has increased at a rate greater than the increase in the use of resources to meet the demand.’
‘Backlog theory’ fails because it conceptualises a health system as a linear production system where ‘treatments’ are produced and applied to relatively predictable demand. Once one views health care as a complex, adaptive system with actors making decisions based on their knowledge of evolving system conditions (hence recursive loops in the system) the deficiencies of this view become obvious. The specific design, operation, or non-operation of the system itself changes the demand and the conditions of both the response and those responding.
Complexity effects to consider
Furthermore, there are complexity effects on demand that will be unpredictable or difficult to predict. Some of these effects include the following:
- In terms of physical space limitations and workforce capacity, the system was operating at full capacity prior to COVID-19. There is no current capacity for the system to operate at more than what it was, in order to remediate a backlog.
- Physical distancing requirements (and other infection prevention and control measures) will mean delays and bottlenecks around delivery of backlog as well as usual care.
- Changes in need may differ by ethnicity, domicile and socioeconomic status, risking worsening inequities over time for those already most vulnerable and under-served.
- Those facing barriers to care may find those barriers to be growing either in fact or in perception.
- Delayed activity will not be the same activity due to the effect of time – cancer and coronary disease are obvious examples with serious consequences following a delay in diagnosis or treatment. A patient cohort not seen becomes a different patient cohort in time.
- Latency of return into the system will not be consistent – missing patients will emerge and/or re-enter the system in different places at different times, and health risk will become visible to the system in emergent and unpredictable ways.
- As a corollary to this, some patients will experience conditions resolving or stabilising without treatments they might otherwise undergo in the system functioning ‘normally’. Clearly discerning those most likely to benefit from follow-up care from those for whom ‘watchful waiting’ may be most appropriate is an issue already on many radars in terms of health care resource allocation. In an even more strained environment the wise use of resources is even more important, yet maintaining consistency and timeliness of high-quality care is equally crucial.
- COVID-19 preparedness has meant diversion of capacity to where it may be needed to address COVID-19 – ie, there is lost capacity due to preparedness without COVID-19 cases presenting.
- Stressed and exhausted staff need to recover from the efforts of preparing for and managing COVID-19. Many are speaking of anxiety, ‘survivor guilt’, ‘stress without the stressor’ and even ‘pre-traumatic stress disorder’. One intensive care doctor likened it to the preparation for battle: ‘It is strange standing in the trenches preparing hard for battle with no sign of the fight and uncertain whether it will ever arrive.’
- The system also needs to retain capacity for possible future COVID-19 outbreaks. Staff capacity and physical space are required for this readiness. How will we allocate separate space and staff for treating people with COVID-19? How much capacity will be required? How can we upscale fast, if the need arises?
- Staff also need to be supported to manage the inequitable outcomes that are anticipated as a result of COVID-19. Cultural safety and health equity practice will be essential capability for everyone in the health system. How do we maintain quality services and fully capable staff, if we are expanding at speed?
If we look to increase supply, there are several questions to consider:
- How do we manage our limited physical and staff capacity? Do we look to expand these?
- What role will the private sector have and what can we expect of them? In some specialties actors in private are the same as those in public – there is at present no underutilised private capacity to ‘soak up’ public work.
- What additional workforce opportunities are there? Can we draw upon innovative thinking or international examples?
- How does quality remain appropriate, also quality of clinical governance? What risks need to be managed? Under the ‘law of stretched systems’, increased demand pushes normal performance ‘operating points’ or spaces of action towards ‘accident boundaries’ – ie, unsafe care.
- How do we fund it?
- How long will increasing capacity really take?
- Has thinking around LEAN systems and waste reduction – both in secondary and tertiary care but also in our public health units and overall public health system – introduced a lack of redundancy that has made the system overly vulnerable to unpredictable events like pandemics?
- Can some highly specialist services be consolidated into fewer areas to maintain or improve supply without reducing access to those groups who face barriers already? Can staff scope of practice evolve – do we need more ‘versatilists’ to be able to cover more aspects of demand with fewer staff?
- Can quality improvement strategies like collaboratives and compact, delimited improvement projects with focused measurement and reporting regimes help us with emergent problems?
This is the first in a series of rapid-fire health quality intelligence articles on focused aspects of the impact of the COVID-19 crisis on our health care system, and the way forward. Knowledge will grow and evolve as the data and the evidence grow – this piece is neither exhaustive nor final. We want to start a conversation with the sector about the challenges ahead and the opportunities we have to improve and change for the better. A return to February 2020, if even possible, would be long, costly and difficult, and for many in fact undesirable. We want to find ways forward that will help us to position our health system to succeed for all. We want to manage emerging issues proactively and effectively in strong partnerships, characterised by the trust and collaboration that has been so strongly evident in the sector’s response to this crisis so far. If you are interested in taking part in a discussion/Zoom hui about taking our system forward rather than backward get in touch via firstname.lastname@example.org.
- Van Aerde J, Gautam M. Leadership agility in chaotic systems. Canadian Society of Physician Leaders COVID-19 Crisis Bulletin #2. URL: https://m365-emarketing-uploads.s3.amazonaws.com/images/cspl/COVID-19article2.pdf.
- The Health Foundation. 2010. Evidence scan: Complex adaptive systems. London: The Health Foundation. URL: www.health.org.uk/sites/default/files/ComplexAdaptiveSystems.pdf.
- Baddock K. 2020. COVID-19—the frontline (a GP perspective). NZ Med J 133(1513): 8‒10. URL: www.nzma.org.nz/journal-articles/covid-19-the-frontline-a-gp-perspective.
- Health Quality & Safety Commission. 2019. A window on the quality of Aotearoa New Zealand's health care 2019 – a view on Māori health equity. Wellington: Health Quality & Safety Commission. URL: www.hqsc.govt.nz/our-programmes/health-quality-evaluation/publications-and-resources/publication/3721.
- Ministry of Health. 1963. National Health Service reduction of waiting lists, surgical and general. HM (63)22. London: Ministry of Health.
- Choosing Wisely Aotearoa New Zealand. https://choosingwisely.org.nz.
- ICU intensivist. Twitter. 23 April 2020. https://twitter.com/cjpoynter/status/1253183586833846273.
- Woods DD, Hollnagel E. 2006. Joint cognitive systems: Patterns in cognitive systems engineering. Boca Raton, FL: CRC Press/Taylor & Francis.