Welcome This is the last issue of the COVID-19 Evidence Alert in its current format. Since the first issue in June, we’ve been scanning for evidence on a range of prioritised themes to support the COVID response. As Phase 3 recovery plans within England are being finalised, it seems an opportune time to reflect on the evidence we’ve found so far and how this might inform reset and recovery.
The final three issues offer some brief reflections on the evidence we have scanned along with links to some of the studies which we think offer particularly interesting perspectives. These are organised by the following themes:
Our full range of evidence scans, alerts, trackers and live searches is available online. We have also curated a Wakelet collection of useful web resources on COVID and Coronavirus.
We will be updating the trackers as quickly as we can, so each tracker provides a one-stop collection of the evidence we’ve found since June. Our searches are by no means exhaustive so the trackers won’t be comprehensive - but they will provide you with a useful core collection of evidence and insights to inform planning and provide a baseline for future analysis, research and evaluation.
We welcome your feedback. Did we miss any important themes in our approach? How could we improve on our scans and alerts? Please share comments with us via email@example.com.
Analytical Collaboration for COVID-19
As previously described the collaboration is using its expertise to focus on questions that the NHS may lack the immediate resources to look at, which may be more medium-term, cut across sectors, or benefit from independent analysis. We are gradually publishing analytical outputs so keep an eye on these pages for useful findings. You can keep up to date by following @strategy_unit on Twitter.
Early on in the pandemic, it was recognised that rehabilitation would be needed for some Covid-19 patients with ongoing physical, psychological and functional needs. As the pandemic progressed, it became clear that many patients, even those who were not hospitalised, were experiencing symptoms for some time (Long COVID 1, 2, 3, 4).
There is some transferable evidence related to rehabilitation needs from previous pandemics and incidents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11. Evidence is beginning to emerge 1, 2 on the rehabilitation needs for Covid-19 patients specifically. We found several recurring themes in the literature: Kawasaki-like syndrome in children: Early in the pandemic, it became clear that some children were affected by Kawasaki-like symptoms 1, 2, 3, 4, 5, 6, 7.
Support across the pathway- Given the diversity of symptoms 1 (neurological 1, 2, 3, 4, 5; cognitive 1; musculoskeletal 1, 2; psychological 1, 2; cardiovascular 1, 2; respiratory 1), evidence suggests different patients require different types of services-both physical and psychological, across ICU, hospital wards, step down facilities and the community 1, 2, 3, 4, 5.
Risks for prolonged inpatient stay- Cognitive impairment, paralysis, and those requiring a ventilator or dialysis are among factors associated with a greater risk of prolonged inpatient stays 1.
Multidisciplinary teams- Papers suggest rehabilitation is best delivered by specialists supported by multidisciplinary teams 1, 2, 3 to address the psychological, functional and physical aspects of recovery. Multidisciplinary care can offer effective co-ordination of care and avoid unnecessary duplication of services. There is however an important role for rehabilitation specialists 1.
Personalised care- Studies have shown patients will require different services at different stages in their recovery. A personalised service based on individual needs has proved useful and good communication with patients and family members regarding next steps and treatments are suggested 1, 2, 3. There is a particular risk in older people of deconditioning 1, 2, 3.
Centres of excellence- Provision of rehabilitation support facilities referred to as “Centres of Excellence”, for those who survive but need care and cannot return to their own homes have been recommended. The repurposing of unused buildings 1 could rapidly expand the supply of space.
Mental and physical support- A range of fatigue, depression and mental health problems are reported 1, 2, 3. A combination of physical interventions such as physiotherapy, respiratory and graded exercise programmes and psychological interventions 1, 2, 3 are suggested.
Technology- Studies have shown the widespread application of remote rehabilitation and tele-rehabilitation to reduce the need for in-person care including live consultations, or pre-recorded sessions for generic material 1, 2. However, virtual care is reported to have many limitations which should be reviewed before implementation 1.
As the pandemic has progressed, there has been an increasing emphasis on research and analysis to inform the delivery of health and care beyond the first peak as well as the implications of social distancing and other measures to reduce spread. The recovery phase is likely to take time, not least because there is a mental health impact on and risk of burnout amongst health and care workers. There is also the impact in care homes and wider social care to consider in addition to preparedness for a future peak. Planning will need to address infection control; identifying and addressing unmet needs, particularly within vulnerable groups; engaging with the public; meeting workforce needs; and sustaining innovations made under pressure.
Many services moved towards remote consultations as a means of delivering care whilst protecting staff and patients from infection. The urgency of the pandemic response has helped overcome some long-standing barriers, however there are potential risks of widening inequalities, as some people are disadvantaged by the “digital divide”.
As well as these general lessons, there are issues specific to different services and settings:
Primary care: the changes in demand 1, 2, 3 and increase in virtual consultations has been a focus for some studies 1, 2, 3. Another model which has been tested is the use of Community Health Workers 1 to conduct home visits. Primary care is also seen as having an important role in admission avoidance for non-covid care during the recovery phase 1, 2. There are accounts of interventions to help people deal with the impact of COVID including virtual group interventions 1 and social prescribing 1. There is also emerging evidence on the impact on health visiting 1.
Long Term Conditions (LTCs) Management: there are multiple impacts on patients with LTCs, including delayed diagnosis, diversion of health care resources; interrupted care; interrupted supply of medication; increased stress and lower activity 1, 2, 3, 4, 5, 6. Usage of health services has decreased which may be due to restricted access or a fear of infection. There are implications for continuity of care and providing support remotely. International research shows that telemedicine and triaging are the mitigation strategies most often used to overcome disruptions to care for people with long-term conditions. Rehabilitation has been shown to be the most commonly disrupted service which will potentially lead to consequences in the future.
Outpatient Care: virtual consultations have been used to deliver outpatient care, however, there are considerations around sustaining the use of technology, including co-design, changes to workflows and practices 1, 2, 3, 4, 5, 6. Examples span urology 1, 2, orthopaedics 1, 2, 3, 4, dermatology 1, neurology 1, 2, radiology 1; cardiology 1, 2, 3; oral and maxillofacial surgery 1; ophthalmology 1.
Elective Care: the impact on capacity and waiting lists is significant 1; the need for increased infection control will affect the volume of patients scheduled, with implications for patients, clinicians and commissioners 1, 2. It is suggested that a number of factors will need to be considered, including epidemiological conditions in the community, patients' health, the COVID‐19 status of all members of the surgical team, the facilities and resources available 1, 2, 3, 4. There are specific examples from orthopaedics 1, 2, 3, 4; obstetrics and gynaecology 1, 2, 3; neurosurgery 1, 2; cardiac surgery 1.
Emergency Care: the decrease in emergency activity during lockdown 1, 2, 3 raised concerns, particularly in relation to stroke, heart failure and heart attacks 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and trauma 1, 2, 3, 4, 5, 6 given the severity of consequences if not treated.
Screening and Immunisations: the response to the pandemic has also affected preventative services, including decreased screening and childhood vaccinations, which will have longer term implications 1, 2.
Mental Health Services: the delivery of mental health care has predominantly shifted from face-to-face contact to virtual media (e.g. video, phone) 1, 2. There are specific concerns about the impact 1, particularly on children and young people 1 and patients suffering substance abuse 1, 2 who may be particularly vulnerable. There is also discussion on options for delivery of care for people with serious mental illness 1.
Cancer Services: guidance has been issued by professional bodies to help clinicians to prioritise patients for treatment during the pandemic 1, 2 in the light of estimates of the impact on morbidity and mortality 1, 2, 3. Analysis suggests adverse outcomes 1, 2, 3, 4, 5, 6 from disruptions to treatments such as chemotherapy, the impact of lockdown measures and a decrease in symptomatic diagnosis 1. Priorities for restarting services include: expanded testing; social distancing; telemedicine 1. Some examples focus on particular cancers, including breast cancer 1, 2; oesophago-gastric cancer 1; head and neck cancers 1; pancreatic cancers 1.
End of life care: A rapid review 1 suggests hospice and palliative services have an essential role in the response to COVID-19 by responding rapidly and flexibly; ensuring protocols for symptom management are available, and training non-specialists in their use; being involved in triage; considering shifting resources into the community; considering redeploying volunteers to provide psychosocial and bereavement care; facilitating camaraderie among staff and adopting measures to deal with stress; using technology to communicate with patients and carers; and adopting standardized data collection systems to inform operational changes and improve care. The barriers to advance care planning has also been addressed 1.
Analytical outputs from the Strategy Unit offer useful insights into the impacts on waiting lists and on changes in healthcare activity. The Analytical Collaboration has also shared analysis throughout the pandemic to inform recovery planning:
This alert has formed part of a national evidence update service, provided by the Strategy Unit, as part of a collaboration to provide analytical support to the health and care system to help inform the initial response to COVID-19. Thank you for the very helpful feedback we have received since we published the first issue back in June. We’ll be updating the evidence trackers on our web site to include all the links from the weekly alerts. In response to feedback, we’ll be adding sub-themes to the trackers on rehabilitation needs, impacts on health outcomes, and impacts on non-Covid care, to help you navigate evidence to date.
The Strategy Unit is hosting a 6-week festival of virtual events, called Insight 2020, exploring some of the challenges facing decision-makers in health and care in 2020 and beyond; emerging models of practice to make best use of analysis to inform decision-making; and some of the exciting work that is already happening in this area.
Insight 2020: a festival of analysis and learning for the NHS, Local Government and our partners will run from 28 Sep to 13 Nov 2020. The festival will comprise a mixture of events, workshops and panels, representing conversations at a local, national and international level. For example, our festival launch session includes Ben Goldacre talking about ‘How open approaches can revolutionise health data science in the UK’ and Andi Orlowski on “Dangerous analytics…and how local analysts can save you!”, with Q&A hosted by Professor Mohammed A Mohammed. We will also be running a session on the COVID Evidence Conundrum, featuring a range of perspectives from people who have been involved in generating, using and applying evidence on COVID discussing what this means for how we use evidence to inform decisions.
Who is Insight 2020 for? We’ve collaborated with inspirational people and organisations across the sector to bring together a programme which has something for everyone who is involved with decision-making in health and care.
What will Insight 2020 look like? Sessions will be varied and flexible. People can commit as little or as much time as they’d like, and most of the sessions will be recorded so you can fit them into your schedule in a way that suits you. Every session is free.
Each week will focus on a central theme, starting with a ‘headline’ presentation on the Monday. This will be supported by targeted sessions and the week’s speakers will convene each Friday for an interactive panel discussion and Q&A to respond to the key debates raised during the week. The festival themes are:
Week 1: Our decision-making context in 2020
Week 2: The role of the Midlands Decision Support Network
Week 3: The analytical priorities of the Decision Support Network
Week 4: Building momentum around addressing health inequalities
Week 5: The decision-making toolbox
Week 6: Making the most of our decision-making resources