29 / 04 / 2020
NHS England and NHS Improvement (NHSEI) chief executive Sir Simon Stevens and chief operating officer Amanda Pritchard have written to NHS organisations across the country to outline a second phase of the response to COVID-19. This follows their letter of 17 March, which outlined how services needed to adapt to manage the significant pressures brought about by the pandemic.
This briefing summarises some of the key issues outlined in the letter, specifically those which stray from previous guidance. It also sets out the NHS Confederation’s view on the direction of travel set out for the health and care system, ahead of our launch this week of our programme aimed at ‘resetting’ health and care.
NHSEI has asked all NHS local systems and organisations to ‘fully step up’ non-COVID-19 urgent services as soon as possible over the next six weeks. Urgent and time-critical surgery and non-surgical procedures should be provided at pre-COVID-19 levels of capacity. NHSEI has also appealed for local support for the national campaign to encourage people who should be seeking emergency or urgent care to do so.
The ask from NHSEI is not simply in regard to urgent care, however. Services are also urged to make judgements on whether there is further capacity for at least some routine non-urgent elective care, too.
With regards to cancer services, referrals, diagnostics (including direct access diagnostics available to GPs) and treatment must be brought back to pre-pandemic levels at the earliest opportunity. Cardiovascular care, including heart attacks and stroke, is also listed as an area for hospitals and secondary care services to prioritise.
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NHSEI states that there should be an inclusive approach to educational material, testing and appropriate protections for all staff, reiterating that a safety and learning environment for all staff is vital as ‘diverse and inclusive teams make better decisions, including in the COVID-19 response’.
The letter indicates that increased testing capacity means that the offer of regular testing will now be able to be extended to asymptomatic staff. It recognises the emerging UK and international data suggesting that people from black, Asian and minority ethnic (BAME) backgrounds are being disproportionately affected by COVID-19, stating that ‘employers should risk-assess staff at potentially greater risk and make appropriate arrangements accordingly’. However, it does not direct any specific protections for BAME staff.
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NHSEI warns that we are going to see increased demand for COVID-19 aftercare and support across these services. Community services should prepare to support the increase in patients who have recovered from COVID-19 and been discharged from hospital. In mental health, all-age open access crisis services and helplines should be established and enhanced psychological support should be made available for NHS staff who need it. In primary care, cancer, urgent and routine referrals to secondary care should be made as normal and populations should continue to be stratified, with proactive contact made to those in the ‘shielding’ cohort of patients.
A full list of the activities that community, primary care and mental health providers are expected to prioritise can be found in the annex of the letter.
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All patients being discharged from hospital to a care home should continue to be tested for COVID-19 and, under the direction of local resilience forums (LRFs), local authority public health departments and CCG infection control nurses can help ‘train the trainers’ in care homes about Public Health England’s recommended approach to infection prevention and control.
To further support care homes, NHSEI will bring forward a package of support to care homes drawing on key components of the Enhanced Care in Care Homes service, to be delivered as a collaboration between community and general practice teams.
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NHSEI argues that services need to retain their ability to quickly repurpose and create ‘surge’ capacity locally and regionally, should it be needed again. All STPs and ICSs are therefore asked to plan for the service type and activity volumes that they think could be needed beyond the end of June. This will inform discussions during May about possible contract extensions with the independent sector.
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The NHS Confederation is supportive of several measures set out in the letter. While it must be stressed that the fight against COVID-19 is far from over, we have heard concerns from members about the growing backlog of elective procedures and significant drops in emergency attendances. Now is the right time to resume operations and other treatments delayed due to COVID-19 in a measured and responsible way. Equally, NHSEI is right to highlight the likely surge in demand for community health services, primary care, and mental health. These services will be crucial in providing aftercare associated with the pandemic and we must ensure that they are not overwhelmed.
The Confederation has long been supportive of local systems and partnerships being given the authority to make decisions according to local need, and so we are pleased to see an emphasis on local systems’ role in planning how to resume to ‘normal’ levels of activity across primary and secondary care.
The focus on care homes is welcome. We know that care homes across the country are facing unimaginable pressures and they will prove to be a key battleground in the fight against coronavirus over the coming months. Our members, including within CCGs, are already supporting them to train staff and minimise cross-infection. Care homes will need significant support, including provision of proper PPE and testing, as they work to minimise the spread of the virus among their residents. This is an issue the NHS Confederation will continue to press NHSEI on.
The move towards recommending that employers risk-assess staff and employ any mitigation strategies accordingly is encouraging. Guidance is being produced by NHS Employers, which is part of the NHS Confederation, to help employers to carry out workplace risk assessments with their teams.
The Confederation is also pleased to see NHSEI addressing the opportunity to ‘lock-in’ beneficial changes we have seen across health and care services since the outbreak of the pandemic. We are this week launching a programme focused on how we can ‘reset’ health and care and ensure that we do not revert to ‘business as usual’. Capturing the innovation we have seen across the system will be key to this.
That said, there are issues not covered in the letter that must be taken into consideration. One is that many staff across the health and care sectors are understandably exhausted. While the letter mentions mental health support for NHS staff, there will need to be extensive evaluation of staff’s needs as we look ahead.
In addition, while the letter refers to a ‘Test, Track & Trace’ service, further detail will be needed on how the virus will be monitored as aspects of ‘normal service’ begin to recommence. This will, no doubt, require close coordination across primary, community and secondary care services, as well as local government.
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