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For patients will all types of conditions, the pandemic has led to significant challenges around their care, with treatment backlogs and elevated risks from the virus. However, particularly for those with long-term conditions, there has been notable disruption to their regular care, with stakeholders from across all aspects of the healthcare required to play a role in the recovery.Speaking with consultant rheumatologist and Chair of the British Society of Rheumatology’s Clinical Affairs Committee, Dr Elizabeth Macphie, and Todd Manning, General Manager at AbbVie UK, the scale of the challenge before us is vast, but spread disproportionately from service to service, and specialty to specialty. This has created unique challenges, but equally opportunities to innovate around the care being provided, to meet the local needs and desires of these services’ patients.Dr Macphie, who alongside her BSR role is a consultant rheumatologist based in Preston within a community rheumatology service as part of an integrated musculoskeletal (MSK) service, explains: “I’ve come into this with the local knowledge of what’s happened to our service as a result of the pandemic and how things have changed, but [myself and colleagues] have also been listening to that national voice of what is happening to colleagues and departments up and down the country.“We’re recognising that rheumatology services are very different, and the impact of services has been quite varied.“How these services are now getting back to the ‘new normal’ as we hear being talked about so often, is again very different for services up and down the country.“With respect to the NHS restart, I’ve always wanted to look at the positives. The pandemic has resulted in huge changes across the NHS, with lots of activity put on hold, but I think the change that has happened within the NHS [around new mindsets] needs recognition.“Particularly for services dealing with patients with long-term conditions, there has been so many situations where there were lots of discussions happening before the pandemic about where remote consultations fit [in the offering] for these patients. The pandemic has pressed the fast-forward button on all of that.“It has meant we’ve all had to adapt to new ways of working very rapidly, and now we must capture those new models of care.”But responsibility for those building those improvements in services doesn’t just fall on the clinicians’ shoulders. Rather, all those involved in health have a role to play; with AbbVie’s Todd Manning adding: “We believe very strongly that we have a responsibility to healthcare systems in the UK and around the world to play a really active role in the recovery coming out of the Covid-19 pandemic, to the same level we believe we played during the acute phase of the pandemic.“We have a specialisation in medicines and vaccines, but we also have a wealth of expertise in developing initiatives and tools which can help support the efficient and optimised deliver of care for patients, through existing and new channels.“We [equally] have a broad network which we can utilise, bringing stakeholders together to stimulate debate around key issues that are affecting patients. In these types of ways, I think that we can play a role beyond the rules that our medicines can play to help the NHS recover as quickly as possible for patients.”But, for all of the want to spark discussion and collaboration, what do some of the new ways of working and innovative approaches which the likes of Todd and Dr Macphie are championing look like?One recent aspect of research conducted by AbbVie was based around better understanding the impact of Covid-19 on these patients with long-term conditions, helping to understand and qualify the scale of the issue. Evidence showing a sharp drop in GP appointments, referrals and outpatient appointments were not surprising to them, Todd explains, but did demonstrate the concerning breadth of the situation.For example, using modelling techniques, there was estimated to be a staggering 124,000 patients who may have had some kind of misdiagnosis of their conditions.Importantly, as a caveat, many of these have not been given final incorrect diagnoses, but rather saw the pandemic limit further discovery, testing or appointments which might have revealed a different condition. Other patients, due to delays in treatment, have been left without a diagnosis, with many – particularly those with long-term conditions – likely to present in the future with more severe instances of their disease, having more complex care needs and potentially requiring more invasive or potent treatments.Getting the response right will directly impact these patients. As Todd emphasises: “These are patients whose lives are going to benefit from the way the NHS responds.“There is clear evidence that the earlier you treat the disease, the better outcomes that you have in the long term. So there is a risk [regardless of the pandemic] but we may see more individuals presenting with more severe forms of a condition – like rheumatoid arthritis, for example – than we would have pre-pandemic.”And one important, potentially significant way of improving the treatment provided to those patients is to involve them more extensively in their own care decisions; often utilising a method known as shared decision making. That way, for those with long-term conditions, they are choosing models of care which best meet the needs and aspects of their life which matter most to them.As Dr Macphie describes: “I think shared decision making is absolutely pivotal to any sort of healthcare professional conversation.“One of the things that we see is the ethos behind moving from that paternalistic view of medicine where, as the doctor we know best, to this concept of shared decision making that is now well-embedded, particularly in the care of long-term conditions.”Suddenly, by taking a conscious effort to involve the patient within the decision making process around their condition – particularly when most treatment plans involving long-term conditions are related to mitigation rather than curing the disease – the quality of that consultation increases, the clinician is able to provide more effective and efficient care by getting straight to addressing the root concerns which matter most to the patient, and there is a more positive experience had by the patient too.“It is about recognising that we don’t lose some of the GAME we’ve had with making sure patients are involved in shared decision making.“The other aspect is making sure that patients are provided with options in such a way that they realise the full breadth of what is available to them. Sometimes, I think it’s very difficult, as a consultant, to say to patients that one of the options is that we don’t do anything.“Yet, one of the things I’ve learned over the years as a consultant is that, actually, it’s very helpful sometimes to be very open and honest with the patient. To let them know that is an option.“It puts clinicians in a safe zone to say, ‘Look, I’m here to help guide you through the choices available to you’ and quite often some patients will come back and say ‘What do you advise? You’re the specialist, what is your advice?’ and I think if you’re very open and honest to patients, that there is a number of options, when they put that question to you, you can then assess them with [a level of trust].“But it does take a lot of confidence. I think it is something you really have to work on as a clinician. You have to be in the right mindset to be able to have those discussion with patients. We all benefit from ongoing learning in this area, and I think it is one of the things that a collaboration with industry can help with because it is something [which can improve services] across all specialties.”It was a statement echoed by Todd too, with AbbVie UK’s General Manager saying: “For shared decision making to work, you need a really dedicated clinician, a person that is going to share all of the options with the patient, and you need a willing patient for it to work too.“But when it does, it has been shown that those patients who do take an active role and take responsibility for the decisions affecting their care have more positive outcomes.“Shared decision making [and giving patients this opportunity to take responsibility for their care] is something that we’re particularly passionate about.“Pre-pandemic, I think shared decision making was quite focused on the treatment pathway, whereas post-pandemic in the recovery phase, it’s about the treatment pathway, but also about the development of care services and how that will develop into the future.”There will be a lot of changes in the near future in healthcare as we restore services and rebuild capacity, but there are also opportunities to reimagine some of our traditional ways of working, to increase the quality and efficiency of care, and to empower patients and clinicians alike. Shared decision making, particularly around long-term conditions, seems to be one of the opportunities of real growth we’re already seeing benefits from.