Nuffield Trust - Overlooked, but not overcome: smaller hospitals and the staff response to the Covid-19 pandemic (9 December 2022)

Summary

This research by the Nuffield Trust looked at how smaller hospitals have fared over the pandemic. Smaller hospitals are sometimes overlooked when system planning gets done, so this report focuses on the operational responses and management approaches taken by staff from 10 smaller hospitals over the course of the first and second waves of the pandemic.

It aims to tell the stories of those working in small hospitals in order to understand what happened to acute and emergency care in these institutions during the pandemic. The authors interviewed staff in smaller hospitals around the country during 2021 to understand their key concerns. The report makes a set of recommendations for future crisis planning and response.

Content

Recommendations

1. Disaster planning – No hospital had disaster plans for a prolonged, noninfluenza pandemic and all failed to imagine and plan for a second wave that might be worse than the first. The development of templates for local responses to major disasters, developed by experts, would relieve smaller organisations of tasks for which they do not have the appropriate staff, skills or experience.
2. Estates – The problem of ageing and often inadequate infrastructure was a dominant theme. Problems with estates actually drove, and constrained, the pandemic response. A national stocktake of the shortcomings of hospital estates needs to be urgently undertaken, in preparation for any future pandemics. The Health Infrastructure Plan needs to be reviewed in light of the pandemic, with a view to ensuring robust supplies of oxygen and adequate ventilation and appropriate infection control measures in all hospitals, rather just in the planned new builds.
3. Capacity – Concerns over capacity are tightly linked to the above issues with estates and buildings. Most organisations struggled with bed capacity in all clinical areas (ED, ICU and the downstream wards) even prior to the pandemic. Those that were able to readily expand capacity were those that, by chance, had unused spaces that could be rapidly repurposed. This points to the urgent need for the capacity of smaller hospitals to meet their current need, particularly with regard to intensive care provision, as well as giving consideration to how surge capacity can be embedded within organisations. 
4. Management – No organisation felt that all aspects of their management and communications were entirely right, and the interviews highlighted a number of problems with approaches taken by different organisations. The most pervasive issue was a failure to recognise that different stages of the pandemic would require different approaches. The transition out of the ‘emergency’ phase of the pandemic proved to be particularly problematic almost regardless of the approach taken. The other major issue was the extent to which organisations were able to put in place managerial structures which were robust and responsive, capable of both making short-term/tactical and long-term/strategic decisions. Few organisations actively built ‘learning loops’ into their pandemic response. These findings suggest that improving the ‘situational awareness’ of executive teams about what types of management ought to be used when, and how to switch modes, would be highly beneficial. The appreciation of streamlined processes and speedier decision-making suggests that thought ought to be given to how aspects of this can be retained, while still ensuring quality controls and good governance.
5. Dealing with difficult behaviour – Even in organisations where operational issues could be considered to have been well managed, perverse behaviours were able to disrupt aspects of the pandemic response. Questions over who is responsible for the management of staff and to what extent staff can be compelled need to be explored at national
   and local levels, and the question of what the appropriate response is to such difficult behaviour needs to be answered.
6. Mental health and wellbeing – All organisations took mental health and wellbeing seriously, putting in place programmes of support for staff. We had not expected the levels of distress that were shown from our cohort of interviewees, which strongly suggests the resources in place to support the emotional health and mental wellbeing of senior managers is s inadequate and this needs to be addressed urgently at local and national level.