Which ethical values underpin England’s National Health Service reset of paediatric and maternity services following COVID-19: a rapid review

Objective To identify ethical values guiding decision making in resetting non-COVID-19 paediatric surgery and maternity services in the National Health Service (NHS). Design A rapid review of academic and grey literature sources from 29 April to 31 December 2020, covering non-urgent, non-COVID-19 healthcare. Sources were thematically synthesised against an adapted version of the UK Government’s Pandemic Flu Ethical Framework to identify underpinning ethical principles. The strength of normative engagement and the quality of the sources were also assessed. Setting NHS maternity and paediatric surgery services in England. Results Searches conducted 8 September–12 October 2020, and updated in March 2021, identified 48 sources meeting the inclusion criteria. Themes that arose include: staff safety; collaborative working – including mutual dependencies across the healthcare system; reciprocity; and inclusivity in service recovery, for example, by addressing inequalities in service access. Embedded in the theme of staff and patient safety is embracing new ways of working, such as the rapid roll out of telemedicine. On assessment, many sources did not explicitly consider how ethical principles might be applied or balanced against one another. Weaknesses in the policy sources included a lack of public and user involvement and the absence of monitoring and evaluation criteria. Conclusions Our findings suggest that relationality is a prominent ethical principle informing resetting NHS non-COVID-19 paediatric surgery and maternity services. Sources explicitly highlight the ethical importance of seeking to minimise disruption to caring and dependent relationships, while simultaneously attending to public safety. Engagement with ethical principles was ethics-lite, with sources mentioning principles in passing rather than explicitly applying them. This leaves decision makers and healthcare professionals without an operationalisable ethical framework to apply to difficult reset decisions and risks inconsistencies in decision making. We recommend further research to confirm or refine the usefulness of the reset phase ethical framework developed through our analysis.

readjustment of services due to a pandemic. Recognising that the reset phase requires different decision-making to the acute phase, we have adapted the framework by drawing upon two interlinked national documents (a letter on "Third phase of NHS response to Covid", 31 st July 2020 (Stevens & Pritchard, 2020); and the National Voices "Five principles for the next phase of the Covid-19 response", published June 2020 (National Voices, 2020)). These adaptations aim to reflect the particular ethical considerations relevant to the "reset" phase. We recognise that this adaptation creates a tension between the rapid review methodology and findings, which we discuss alongside the revised framework below. In our analysis we will draw upon the systematic review of reasons approach (Strech & Sofaer, 2012) to facilitate explicit consideration of ethical values being applied to inform decision-making in non-C19 maternity services, and paediatric critical care and surgery services during the C19 reset phases in England.
This rapid evidence review forms the first stage of a larger project, providing a snapshot of ethical decision-making in maternity and paediatric care to inform subsequent stages of the Everyday and Pandemic Ethics study. Review findings will be available as immediate recommendations for ethical best practicefor example by examining the transparency of written policies against standards in the 2016 Pandemic Flu Policy -for paediatric and maternity services delivery during the C19 reset phases.

Objective
The objective of this review is to answer the question: what ethical values guide decision-making in non-C19 paediatric critical care and surgery and maternity services during the C19 reset phases in England? Achieving this objective will entail exploring a range of decision-making factors, such how are involved in decision-making, what decisions have been made, and how decisions are justified, identifying implicit and explicit ethical values.

Methodology
To ensure a rigorous review methodology, we have drawn upon the ENTREQ guidelines for qualitative research synthesis (Tong, Flemming, McInnes, Oliver, & Craig, 2012) and the systematic review of reasons approach developed for normative review questions (Strech & Sofaer, 2012). Integrating these approaches address the critique that literature reviews exploring normative considerations often fail to clearly report the methodological approach taken (Mertz, Strech, & Kahrass, 2017).

Inclusion and exclusion criteria
Inclusion criteria This review will consider sources developed to guide non-C19 paediatric critical care and surgery services and maternity services during the reset phases of C19; or that discuss the application of ethical values to paediatric critical care and surgery services and maternity services during the reset phases of C19.
The review will include sources relating to England, including national policies (that include England), and policies from Trusts and individual hospitals across England, including our case study sites (in North West England and the Midlands). We will be restricted to sources written in the English language, and published after 29 th April 2020.

Exclusion criteria
Sources published prior 29 th April 2020, that discuss healthcare delivery broadly; or that discuss maternity or paediatric critical care or surgery services during the acute phase of the C19 pandemic in England (defined as the start of lockdown on 23 rd March until the 29 th April 2020) will be excluded.

Data sources
The review will include the following data sources: BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2021-049214 :e049214.
 National policies guiding the implementation of non-C19 maternity services, and/or paediatric critical care and surgery services; and/or providing an ethical framework or decision-making tools for healthcare reorganisation of these services during the C19 reset phases;  Local trust and hospital policies guiding the implementation of non-C19 maternity and paediatric critical care and surgery services; and/or providing an ethical framework or decision-making tools for healthcare reorganisation in these services during the C19 reset phases;  Guidelines and statements from Royal Medical Colleges relating to the implementation of non-C19 maternity and paediatric critical care and surgery services and/or providing an ethical framework or decision-making tools for healthcare reorganisation in these services during the C19 reset phases;  Working papers and committee reports discussing the re-orientation of non-C19 maternity and paediatric critical care and surgery services during the C19 reset phases;  Evidence reviews and primary qualitative and quantitative research on the re-orientation of non-C19 maternity and paediatric critical care and surgery services during the C19 reset phases;  Peer-reviewed commentaries and grey-literature discussing experiences of non-C19 maternity, and paediatric critical care and surgery services during the C19 reset phases.
All sources will be obtained from online platforms, or via e-mail for Freedom of Information requests and stakeholder contributions.
To complement academic databases, and recognising the scope of the research question, we will also search grey literature sources including the websites of NHS Trusts (including our case study sites), the UK Government (gov.uk), and websites of professional bodies (e.g. Academy of Royal Colleagues and the Royal College of Paediatrics / Midwifery and NICE). We will also search clearinghouses of C19 related grey literature such as policy documents, for example the Health Foundation C19 Policy Tracker (https://www.health.org.uk/news-and-comment/charts-and-infographics/covid-19-policytracker).

Study screening methods
We will review all identified sources and any duplicates removed. Two members of the research team (AC, PB, CR, SF and LF) will double screen all identified results. Screening will be based on title and abstract / summary (where available). Where these are not available or no definitive decision can be made about whether a source meets the review inclusion criteria based on title and abstract/summary screening, additional full text review will be undertaken. To operationalise the inclusion criteria we applied the following scoring system: 0. Not included 1. Included: Identifies the approach taken to decision making (e.g. discusses a decision-making tool or framework) 2. Included: Identifies what decision has been made 3. Included: Identifies a justification for the decision taken Where a source meets more than one of the inclusion criteria, all will be identified. Disagreements in double screening will be resolved through discussion with a third member of the review team (HD) not involved in initial screening to reach a consensus decision about inclusion or exclusion.
We will document all searches and screening assessments in a flow chart, with an accompanying narrative explanation, including explicit reasons for study exclusion.

Using the Freedom of Information Act 2000
The Freedom of Information Act 2000 (FOI) imposes two main duties on public authorities: one to proactively provide information, and the other to respond to requests for information. A model 'publication scheme' has been produced which public authorities are obliged to follow in making relevant information available. The model publication scheme sets out various classes of information, which are tailored to different authorities by a 'definition document' for each type of organisation.
The classes of information are as follows:  Who we are and what we do  What we spend and how we spend it  What our priorities are and how we are doing  How we make decisions  Our policies and procedures  Lists and registers  The services we offer To aid access to NHS Trust information we will review Trusts' Freedom of Information Act Publication schemes and submit freedom of information (FOI) requests. Our publication scheme reviews and FOI requests will target our case study sites, as well as additional NHS Trusts with Clinical Ethics Committees as listed on the UKs Clinical Ethics Network. Both the reviews and the FOI requests will explicitly focus on sources (e.g. meeting minutes, policies, or decision-making tools) guiding maternity services and paediatric critical care and surgery services developed for the reset period. FOI requests will be submitted to individual hospitals and NHS Trusts, as well as at regional and national decisionmaking levels. To mirror database searches, we will repeat the publication scheme reviews and the FOI requests prior to publication of the review for the inclusion of additional sources. After the initial searches, publication scheme reviews and results from FOI requests, we will share results with Trust and project stakeholders to conduct a completeness check and request additional missing sources be identified for screening and potential inclusion. We will furthermore search citations of included sources for snowball sampling.

Appraisal of sources
Given the reviews focus on normative values, we will apply the PROGRESS Plus tool 1 to identify the extent to which sources consider characteristics recognised to affect health equity (https://methods.cochrane.org/equity/projects/evidence-equity/progress-plus). This tool covers factors including place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, and social capital (O'Neill et al., 2014); as well as "plus" factors such as age and disability, relational features (such as single parent household), and timedependent relationships (e.g. receiving in-patient care). Assessing sources against these will identify the extent to which sources are systematically considering various aspects of health equity.
In addition, for peer reviewed literature we will apply the relevant CASP checklist 2 (https://caspuk.net/casp-tools-checklists/), and for policy sources the AGREE-II tool developed for assessing healthcare practice guidelines (Brouwers et al., 2010).

Data extraction and management
We will report the following characteristics of included sources:  Publication type (e.g. policy, report, professional body guideline, peer reviewed article, commentary piece, decision-support tool, etc);  Month and year of publication;  Population (maternity or paediatric services);  Source scope (national, regional, trust, hospital, etc);  Where relevant for primary research we will also report: the primary research question, methodology, number of participants, and analysis approach.
Sources will be analysed against a coding framework. This coding framework has been developed by modifying the Ethical Framework embedded in the Government's Pandemic Flu policy (UK Government, 2017). The Ethical Framework in the Pandemic Flu Policy is guided by the fundamental principle of equal concern and respect, accompanied by 8 embedded principles designed to be applied as a checklist to help ensure that the full-range of ethical issues are considered in decision-making processes. It is the only framework explicitly intended to guide all UK NHS decision-making during the rapid readjustment of services due to a pandemic. However, recognising that the reset phase requires a different decision-making to the acute phase, we adapted the framework by drawing upon two interlinked national documents: (1) a letter from the NHS Chief Executive and Chief Operating Officer on "Third phase of NHS response to Covid", dated 31 st July 2020 (Stevens & Pritchard, 2020), and (2) the National Voices "Five principles for the next phase of the Covid-19 response" published in June 2020 (National Voices, 2020). Our coding framework retains the Pandemic Flu 8 embedded principles, but adjusts their specification according to how they are operationalised in these two documents. We recognise this adaptation creates a methodological tension in our review as our coding framework is based upon a Framework adapted according to ethical documents relevant to the review scope and purpose. We believe this approach is justifiable given the lack of an overarching framework tailored to the reset phase, and the need for a coding framework for the review that reflects the ethical specificities of this phase.
Extracting information from sources in relation to each of these adapted principles will identify whether the source engages with the normative values identified as important when making decisions during the C19 reset phase. The principles (retained from the national pandemic flu policy) and adapted sub-domains are as follows: Recognising that the reset phase may incorporate responding to second waves of C19 infections, for example through localised lockdowns (as provided for in the UK Governments Covid-19 Contain framework: https://www.gov.uk/government/publications/containing-and-managing-localcoronavirus-covid-19-outbreaks/covid-19-contain-framework-a-guide-for-local-decision-makers), the principles and sub-domains within this assessment framework may be inductively revised on the basis of the sources reviewed. We will report any development of the framework as an outcome of the rapid review. We will apply a scoring system to assess the inclusion and application of each principle domain. This will entail a 2-stage process, first answering "yes/no" to its inclusion and, secondly, rating application of each domain on a scale of 1-3, where: 1. ethical principle(s) inferred or mentioned but not clearly applied; 2. ethical principle(s) identified and its application described; and 3. ethical principle(s) application is discussed in-depth, including balancing against other principles.

Data synthesis
To further explore the data, we will conduct further analysis of sources from our case study sites (North West England and the Midlands) to conduct a thematic synthesis (Thomas & Harden, 2008) 3 . This approach will draw upon the review of reasons where the data is explored to identify reasons for adopting particular normative positions, and the consistency of these reasons across sources and settings (maternity or paediatrics). This will help to surface the range of reasons informing decisionmaking processes, and experiences of these decisions by those affected.
Data synthesis will be led by AC and PB, with regular review and discussion with the wider research team to ensure rigor of the approach to analysis.

Reporting
We will report this rapid review as brief reports summarising the approach to paediatric critical care and surgery services, and maternity services, during the reset phase of the C19 pandemic. This will identify the ethical values informing paediatric critical care and surgery services, and maternity services, during the reset phase of the C19 pandemic, and highlighting case study examples that explore the reasons for adopting a particular normative position. The report will be disseminated in the form of a short brief, shared with our stakeholder group comprised of representatives of National bodies, case study Trusts and Hospitals, and other relevant parties. We will also disseminate the review findings via social media (e.g. Twitter) and our project website (https://www.liverpool.ac.uk/population-health-sciences/departments/health-servicesresearch/key-projects/resetethics/). We will also develop a rapid review publication reporting the full results. It will go into more depth than the brief report about the methodology, and will offer an in-depth description of the response to planning for the reset phase of maternity services and paediatric critical care and surgery services in England. We will explore examples of good practicesuch as where specific sources have engaged with the full breadth of ethical considerations, or where there is transparency in descriptions of ethical engagement and decision-making processes. From this, we will make recommendations for addressing areas where the normative basis of adopting specific approaches to service planning and delivery are unclear.

FILE 2: PUBMED SEARCH STRATEGY
Columns 1 and 2 describe the conceptual structure of the search input into PubMed. Column 3 provides an indicative example of how PubMed translated the natural language terms for each query by generating MeSH terms and using the natural language for all fields in the PubMed record. In addition to the below, in PubMed the date filter of "last 1 year", and language filter "English" were applied.

FILE 3: PUBLICATION SCHEME SEARCH STRATEGY
The publication scheme search focused on case study hospital Trusts. The focus of the search was the 'How we make decisions' and 'Our policies and procedures' sections of the Trust's Publication Scheme.
As with the review, sources listed in the publication scheme were excluded if either: a. they were dated before April 29 th , 2020; or b. their focus and content was on a period prior to April 29 th , 2020 (for example an annual report for a financial year to 31 st March); For sources included, a high-level review was then carried out to identify any references to policies or other documents of interest (for example supporting documents or reports prepared for board meetings