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There is a lot to be uncertain about these days: school, work, health, family. However, in July one thing was certain: the streaming release of “Hamilton” in the US was going to be epic. The acclaimed musical production tells the story of a U.S. founding father Alexander Hamilton, intensely American, exploring themes of love, anger, arrogance, heroism, betrayal, mistakes, politics, policy, devotion, family, sacrifice and death. In some ways, it sounds like healthcare in the era of COVID-19. While months of the coronavirus pandemic are behind us, the uncertainties caused by the pace of change and the expected surge of further infection spread bring continued stress, fear and frustration. Disruptions to services, processes and relationships are rampant. They demand continued experimentation across healthcare to address concerns to keep patients, communities and healthcare workers safe. And the lack of a coordinated collective policy response to the crisis only perpetuates discomfort about the unreliability of actions to improve safety and the substantial costs the future holds in store. Ambiguities and dread due to the pandemic are problematic and will be for some time. Continued patient avoidance of care is evident and could be contributing to lack of timely care and diagnosis. An ImproveDx article summarises how fear is keeping patients from getting the care they need, and highlights the importance of recognising that rebuilding trust will take time. To anchor this effort, leaders must view risk as individuals see it rather than just an academic exercise to inform reentry strategies in the months to come. The unsettled nature of care and access to loved ones during COVID can make end-of-life planning particularly fraught with uncertainty. Stanford University School of Medicine has developed the GOOD framework for clarifying steps forward when working with patients and families facing palliative care decisions during the pandemic. Its four elements – Goals, Options, Opinions and Documentation – provide an effective structure for clinicians to have conversations with patients and families to address care management when the path forward is unclear. Prolonged uncertainty can degrade healthcare staff mental and physical health. In Hawaii, one health system sought to make antibody testing available to staff as a strategy to decrease anxiety and improve sensemaking around the crisis. Hawai`i Pacific Health in NEJM Catalyst explores the reasons why those who were tested opted into the programme. The authors found “curiosity” to be a primary motivator. Knowing something – whether positive or not – can reduce one aspect of uncertainty, which the article posits will help clinicians and their community think beyond the doubt to achieve a modicum of control. This single piece of stability will enable a willingness to gather information, to plan and to act. Despite the challenge uncertainty brings, there are individuals who consistently believe the future holds promise. People who are able to act and make a difference despite uncertainty. Much has been said about those in the midst of the COVID-19 crisis, but others continue to address persistent uncertainties and unreliableness of care – beyond the pressures of the pandemic. There are many whose tenacity shores up the foundations of the healthcare system to improve its safety. One such leader from the US, John Eisenberg MD, is celebrated every year through an award programme in his name. John was a founding father of patient safety in the US. Through his leadership, national research and improvement programmes were developed and funded to lead government efforts to improve quality and safety. In July for the first time, the John Eisenberg Patient Safety and Quality Awards were bestowed virtually. These awards recognise individuals, local efforts and national programmes whose work provides evidence of the value and commitment to engage in work to improve safety. This year’s recipients demonstrated values core to improvement and perseverance in their work toward achieving healthcare that is safe. The awardees have accomplishments that focused on diagnostic error and sepsis reduction. Each of these stories started in tests and trials motivated by commitment to getting healthcare to a better place. For example, Tennessee-headquartered HCA Healthcare was recognised for its SPOT (Sepsis Prediction and Optimization of Therapy) algorithm as a mechanism to identify sepsis quickly to enhance quality and patient safety. Through this enhanced use of technology, SPOT uses basic laboratory and clinical data in real time to provide teams with the information they needed to reduce sepsis mortality across their 173-hospital system. Data triggered alerts that initiated actions to decrease response times by approximately 6 hours rather than relying on shift change as the information sharing mechanism. The SPOT algorithm enhancement to the electronic medical record partnered well with existing sepsis management processes to arrive at improvements. In the climax of Hamilton’s first act, the battle of Yorktown culminates in a chorus of “the world turned upside down”, with the hope that the cacophony will ultimately result in a new country with new freedoms only imagined prior to crisis. It is certain that COVID disruptions will continue to test us all worldwide. Can we challenge ourselves, our peers and our leaders to experiment as necessary to confront COVID-19 while guaranteeing that what was learned will be used to create something better?

Following discussion with patients’ groups, national clinical and stakeholder organisations, and feedback from seven regional ‘virtual’ frontline leadership meetings, NHS England and Improvement have set out NHS priorities for this third phase. Their shared focus is on: Accelerating the return to near-normal levels of non-Covid health services, making full use of the capacity available in the ‘window of opportunity’ between now and winter. Preparation for winter demand pressures, alongside continuing vigilance in the light of further probable Covid spikes locally and possibly nationally. Doing the above in a way that takes account of lessons learned during the first Covid peak; locks in beneficial changes; and explicitly tackles fundamental challenges including: support for our staff, and action on inequalities and prevention. As part of this Phase Three work, and following engagement and discussion, NHS Engagement and Improvement have published a more detailed 2020/21 People Plan,

HSJ revealed this month that the ’call before you walk’ model is being trialed in London, Portsmouth and Cornwall, with system leaders keen for a wider roll-out ahead of winter. In these trials, which have received the backing of the Royal College of Emergency Medicine, NHS 111 is being used as a “triage point” enabling patients needing urgent treatment, but not facing medical emergencies, to book access to primary care, urgent treatment centres or same-day emergency “hot clinics” staffed by specialists. Emergency patients just walking in, or those arriving via ambulance, will be treated, in theory, as per the current system. Similar models are used in Denmark, Norway and the Netherlands where they have high approval ratings. But these are vastly different healthcare systems with better resourced out of hospital services. So, can the model work in the English NHS? It is critical to view efforts to introduce ‘call before you walk’ in the wider policy context. The move is part of a far wider radical overhaul of emergency care pathways broadly designed to address the dangerous overcrowding seen in EDs in recent years.

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RCGP says the plans should contain: costed proposals for additional funding for general practice solutions for how the current GP workforce capacity can manage new and pre-existing pressures commitments to continue the reduction in regulatory burdens and ‘red tape’, which has enabled GPs to spend more time on frontline patient care during the pandemic a systematic approach for identifying those patients who are likely to require primary care support; and proposals for how health inequalities will be minimised to ensure all patients have access to the necessary post-COVID-19 care.