Covid-19 has disrupted, and in some cases overwhelmed, the functioning of healthcare systems across the world. It has led to new forms of healthcare prioritisation, including the reduction, suspension, or re-organisation of routine services. While resource allocation conflicts are inherent features of the UK’s National Health Service (NHS), allocation – particularly of intensive care beds and ventilators during the initial acute phase of the Covid-19 pandemic have proved particularly controversial.
Some have questioned whether clinical ethicists should have a role in these resource allocation decisions, or whether they should not, and others have sought to clarify what is legally and ethically required in terms of consistency and fairness. But in asking ‘who should we treat?’, the position of non-Covid services in the queue for funding and service reorganisation/reprioritisation has been contentious. Avoidable deaths, greater complications, and reduced quality of life for patients with non-Covid related conditions have undoubtedly resulted. The initial prioritisation of Covid-19 services was unsurprising given the immediate impacts and potentially devasting consequences for individual patients, health professionals, and the health service. A rapid response in the acute phase of the pandemic was essential if the NHS was to cope with the influx of acutely ill patients, and funnelling resources (including personnel) to provide Covid-related care was a key part of this response. Pausing routine non-urgent care both released resources for this response and helped to limit the spread of Covid-19 via hospital attendances.
As we move from the acute phase of the pandemic and start to reset health services (variously called the recovery or restart phase), fairness dictates that policy-makers, politicians, health professionals and others consider how services are (re)organised and resources (re)allocated for Covid and non-Covid care. New kinds of ethical issues and dilemmas arose in the acute phase because of changes in healthcare resourcing and working practices (e.g. physical distancing, wearing masks and other PPE) – including for non-Covid services – and these will continue as we reset. 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.
A key question facing healthcare providers is how to prioritise and reset services. It might be expected that direction would be found in guidelines and policies, but while many of these exist for the Covid-related response, they are more limited, yet still essential, for non-Covid services. And although 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, there is no such comparator on which to base decisions relating to providing non-Covid services in the reset phase. The ethical framework underpinning, and values contained within, documents relating to resetting non-Covid services are thus 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’.
Furthermore, while there is a large body of literature on ethical frameworks for healthcare decision-making, including during pandemics, and discussions of ethics support, there is limited empirical research on how these frameworks are applied in practice. Given the unexpected and unprecedented halt to, and restart of, some non-Covid services, it is timely to be integrating ethical assessment of how policies are applied to reconfigure services. These assessments are essential because such decisions may result in unfairness, complaints and, ultimately, litigation, if they are contested. These decisions may also cause moral distress and stress for health professionals.
The Covid-19 pandemic has injected urgency into these matters, and 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 account for the risk of subsequent waves of Covid-19 cases, as is being seen in some parts of the UK currently experiencing local lockdowns. At this time of rapid change, we must learn from our experiences and reset non-Covid services in ways that balance the priorities of healthcare providers, patients, and wider communities, while ensuring adequate protection from the potential harms caused by Covid-19 and limiting the effects on treatment pathways for other diseases. To achieve this, a fair and transparent ethical framework must guide policymakers’ and NHS decision-making, ensuring that patients and communities can 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 focus is on maternity care and paediatrics, two areas non-Covid care which have been significantly affected by the response to the pandemic, as highlighted by professional and patient organisations. We are conducting an ethical analysis of current policies and processes guiding the reorganisation of NHS maternity and paediatric services, and will collect the experiences of healthcare providers reconfiguring and resetting services, those delivering care, and 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 are supported when making such critical decisions.
This project is funded by the Arts and Humanities Research Council (AHRC) as part of UKRI’s Covid-19 funding