Health and social care integration in the context of the COVID-19 outbreak in England

March to July 2020


1.     Context: integrating care

The current separation of responsibilities for health and social care services dates back seven decades, to the very foundation of the NHS.

Whilst efforts to overcome resulting fragmentation in the experience and outcomes of care can be traced back at least to the 1980s 1 both anecdotal evidence and formal evaluations suggest the experience of most people living in England today remains fundamentally dis-integrated.2

There are multiple transitions or “hand-offs” between separately organised, funded and run services including within and between:

In recent years, the health and care landscape in England was shaped through Health and Social Care Act 2012, with the abolition of Strategic Health Authorities and Primary Care Trusts; establishment of the new National Commissioning Board (NHS England); transfer of Public Health responsibilities to local government; formation of Clinical Commissioning Groups (CCGs) covering all areas of England; and Health & Wellbeing boards designed to support joint system-leadership.

All of these developments have been set against ongoing growth in demand and increasing financial pressures across the public sector: with a number of further strategic and policy interventions, including the 2013 Better Care Fund, the 2014 NHS Five Year Forward View, and 2019 NHS Long Term Plan, all designed in part to respond through co-ordinated action to develop preventative, person and community centred care closer-to-home.

The NHS Long Term Plan published in January 2019 represented a further shift in the organisation and delivery of health services, as significant than the Health & Social Care Act 2012.

It presents new opportunities for those working in and alongside the health service, as well as new challenges.

Integration is central to the Plan and exemplified by a move to:

      Integrated Care Networks / Partnerships (ICPs) and

      Primary Care Networks (PCNs) planned to operate at the 30,000 to 50,000 population level.

In May 2020 another four areas were designated by NHS England as integrated care systems, bringing the total to 18 which now cover half of the population of England.3

However, even in the most advanced Integrated Care Systems, practical integration across the NHS and local partners remains very much work-in-progress.








1 Shaw, Rosen, Rumbold (2011) What is integrated Care? Research Report, Nuffield Trust.

2 Kumpunen, Edwards, Georghiou, Hughes (2019) Evaluating integrated care: why are evaluations not producing the results we expect? Briefing, Nuffield Trust.

3 Six million more to benefit as NHS locks in the benefits of stronger partnerships (11th May 2020), NHS England and NHS Improvement (available online, accessed 16th July 2020)




2.     Mobilising in response to COVID-19: protect the NHS, save lives

In late January 2020 the first confirmed cases of COVID-19 were reported in the UK.

On 11th March 2020, with 456 confirmed cases, and 8 deaths following positive tests, the Chancellor stated, “Whatever extra resources our NHS needs to cope with coronavirus – it will get.”

On 23rd March, the Prime Minster announced the start of a national lockdown, accompanied by an appeal for people to "Stay home, Protect the NHS, Save Lives".

The COVID-19 outbreak represented the biggest challenge to the NHS since 1948 and led to a full- scale mobilisation of resources in response.

On 17th March 2020 the Chief Executive and Chief Operating Officer of NHS England & NHS Improvement wrote to Chief executives of all NHS Trusts and Foundation Trusts, CCG Accountable Officers, GP practices and Primary Care Networks and Providers of community health services; copied to Chairs of NHS trusts, Foundation Trusts and CCG governing bodies, local authority chief executives and directors of adult social care, Chairs of Local Resilience Forums, Chairs of ICSs and STPs, NHS Regional Directors and NHS 111 providers.4

The letter outlined next steps to be taken by the NHS in response to COVID-19 to:

Against reports of hospitals in the north of Italy being overwhelmed with COVID-19 patients, NHS organisations were instructed to take immediate steps to free up 30,000 (or more) beds from the 100,000 general and acute beds in the NHS in England, though:

a)      postponing all non-urgent elective operations

b)      urgently discharging all hospital inpatients medically fit to leave

c)       making use of independent hospital staff and facilities, and within a fortnight freeing up community hospital and intermediate care beds to make available up to a further 10,000 beds.

Additional measures included steps to ensure adequate provision of Personal Protective Equipment (PPE) to the NHS, refresher training for all NHS clinical and patient-facing staff, segregation of all NHS patients with respiratory problems (including presumed COVID-19 infected patients), targeted NHS staff testing, and a move to remote (online and telephone based) consultations.

Across the NHS in England, “Gold”, “Silver” and “Bronze” commands were rapidly established with regular meetings to co-ordinate this activity and cascade decisions at a national, regional, ICS / STP and local / organisational level. We witnessed the resulting response at all levels from national to local neighbourhoods.









4 Next Steps on NHS Response to COVID-19 (17th March 2020), NHS England and NHS Improvement (available online, accessed 16th July 2020)


3.     Impact of the response across the NHS

In March 2020 there were significant levels of anxiety across society and at all levels of the NHS. This was driven in part by modelling of potentially overwhelming levels of demand for critical care beds as a result of COVID-19. However, many of those we spoke to in the service in this period also voiced a sense of liberation.

The letter from NHS England & NHS Improvement of 17th March 2020 included the directive to “remove routine burdens”, including a cancellation of routine CQC inspections, deferring of national and local strategic planning processes, and a suspension of requirements on GP practices and community pharmacists to enable a singular focus on responding to COVID-19.

These measures were combined with assurance of income protection and substantial additional funding (within a month the Treasury had allocated the NHS an extra £6.6bn), protection of primary care income, and a suspension of the Payment by Results (PbR) system under which commissioners only pay providers for each patient seen or treated, based on nationally determined currencies and tariffs.5

The start of 2020 had seen significant concerns raised by GPs around the new GP contract framework, associated requirements of Primary Care Networks (PCNs), and proposed funding.

In parallel, many partnership and NHS Trust board discussions were dominated by discussions about ongoing and substantial NHS financial deficits and the necessary actions to address these.

The focus on achieving financial balance was arguably the biggest single driver of local strategies and plans across England in this period.

The COVID-19 outbreaks brought together PCN clinical directors, community, mental health and acute trust executives, and ICS teams in new ways and with a clear sense of shared purpose; with a mandate to make immediate decisions; and supporting funding to make resulting changes happen.

We saw correspondingly high levels of collaboration, and rapid innovation, in the period from March 2020, across primary, community and acute services, including but not limited to the adoption of digital technologies to enable remote consultations, and significant improvements in information sharing across organisational boundaries.

One senior clinician described the key success as being not just a shared approach at a system leadership level, but:

The investment of the NHS in Emergency Preparedness, Resilience and Response (EPRR) and the ability to put this rapidly into practice undoubtedly helped saved lives, as did a huge commitment from those working on the frontline.

In the end, despite over 300,000 lab-confirmed cases of COVID-19 in the UK by the end of June 2020, critical care capacity was not overwhelmed; rows of empty beds at the Nightingale Hospital in London, at the height and the epicentre of the pandemic, were in many ways testimony to the resilience of existing NHS services and the effectiveness of their response.

This success was nonetheless achieved at a significant cost.

By July, when it was judged that England had achieved stage three in the government’s timetable (linked to control of the virus) for easing lockdown measures and at which re-opening of… higher-risk businesses and public places” could begin, ONS data shows that cumulative excess deaths had




5 Chancellor provides over £14 billion for our NHS and vital public services (13th April 2020), HM Treasury (available online, accessed 17th July 2020)


exceeded the five-year average by over 50,000.6 Whilst NHS services were successfully protected, over 170 NHS staff had also died.

In thinking about how to reconcile the pride felt across communities in the NHS and its performance, with the heavy loss of life, it is important to consider the environment within the NHS was operating, prior to and in the early stages of the outbreak; alongside the decisions which were subsequently taken and the impact of those decisions, on both the NHS and other public services.

A number of these issues are-well documented but were no-less real and impacted both the NHS and (as the next section of this submission describes in more detail) broader care services responding to the pandemic at the same time.

      Existing national stockpiles of PPE proved insufficient, and it took many weeks to resolve supply issues and for the required COVID-19 testing capacity to be available.

This created an environment where a lack of available PPE and testing meant that managers were asked to make decisions around where to prioritise the resources that were available; decisions which would inevitably impact on lives within and outside the service.

Whilst shortages were evident in hospitals, availability of PPE and testing for NHS primary and community services and for those being looked after in the community (identified as an issue in March) was significantly worse, even as infection rates in the community rose and protecting care homes was recognised as an increasing necessity.

These concerns persist today, in the context of preparations for mitigating and managing any

“second wave” of COVID-19.

      Based on modelling showing the scale of the mismatch between critical care capacity and a surge in demand7, the development of the first “Nightingale” facility as a critical care temporary hospital with space for 4,000 beds was a justifiable response.

Opening such a facility by 3rd April 2020 was a significant achievement for the NHS and all those involved. It nonetheless represented a significant actual and opportunity cost, focussing time and resources in a facility which treated a total of 54 patients before being put on standby in May; with a number of questions raised during its first weeks of operation around its ability to treat the more complex cases which ultimately resulted from the pandemic.

      In parallel, on 21st March 2020 the NHS in England announced an emergency agreement to secure around 8,000 private sector hospital beds, together with nearly 1,200 ventilators, more than 10,000 nurses, 700 doctors and 8,000 other clinical staff. This would not only be available to treat coronavirus patients, but will also help the NHS deliver other urgent operations and cancer treatments”. 8

The block-booking of almost all private sector hospital capacity in England represented a huge increase in the resources available to the NHS. However, a number of those working in these facilities have reported that through to the end of June 2020 they were left with little to do, with many beds left empty and clinical staff paid to undertake admin tasks. There are significant questions around what impact access to this capacity had, in the context of the level of “pent-up” demand now being experienced across NHS service providers due to the lockdown.




6 Number of deaths registered in England and Wales, including deaths involving the coronavirus (COVID-19) pandemic (7th July 2020) Statistical Bulletin, Office of National Statistics.

7 Ferguson et al. (2020), Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand, Report 9, Imperial College London.

8 NHS block books almost all private hospital sector capacity to fight covid-19 (21st March 2020) Health Service Journal (available online, accessed 17th July 2020)



It is easy to see how the NHS was in an impossible position in March 2020, having to make often life- or-death decisions from the starting point of insufficient capacity and resources, a lack of data and a need to rely on modelling assumptions many of which turned out to be incorrect.

There was nonetheless a feeling within the NHS at the time that the centralised “command-and- control” approach risked mis-directing the response towards those things which could be readily managed through such structures - such as construction of new hospitals, securing of additional critical care beds and capacity - at the expense of services no less critical to the health and wellbeing of individuals and communities, but more complex to organise in a top-down way.

For large parts of NHS community and mental health services, the pandemic saw an immediate cessation of routine activities; and even within the large acute hospitals, it is clear that there were two pandemics: one experienced by those working in critical care, at the constant point of being overwhelmed; and one experienced in those areas providing often life-changing and life-saving planned care, where similar to many private healthcare staff and the hundreds of thousands of ordinary people who volunteered to help (“Your NHS needs you9) individuals wanting to help found themselves with comparatively little to do.

The ability of primary care to adapt and continue to provide help and support was a notable exception to this process but hinged significantly on the relative autonomy that GPs and practices enjoy within the health service, and their ability to support each other through existing local relationships, federations and the emerging Primary Care Networks.

People living in England now face significantly-lengthened waiting lists as services struggle to respond to pent-up and new demand; and potentially significantly worse outcomes, both for those whose existing conditions have worsened, as well as those now presenting for the first time at a higher level of acuity due to delays in being able to access help at an earlier stage.

Working within the NHS command structures in this period was often a traumatic and exhausting process.

Rightly or wrongly, many senior NHS managers and non-frontline staff continued to convene in person to help plan and co-ordinate the response, and as a result a number became infected with COVID-19 themselves.

The expectations on staff led to people working unsustainably long hours, in the context of having to make daily life-or-death decisions, and with a high-risk of long-term impacts on mental and physical health and wellbeing.

However, many also reported a strong sense of mission and purpose. Without their dedication the immediate consequences of the outbreak for the NHS, and the communities it serves, could have been significantly worse; but it is important to also recognise the toll that this took, on both the individuals concerned, and also on the wider health and care system.

The concept of building a hospital in nine days; or of widespread digitisation of primary care, promised for years, achieved in weeks; is a highly seductive one and an argument which has already been heard for extending the emergency structures and powers, which were designed to provide short-term, critical responses, into the broader running of the NHS (and potentially social care as well).

Yet there are also clear limitations to this model and significant risks to its application.







9 ‘Your NHS Needs You’ – NHS call for volunteer army (24th March 2020) NHS England (available online, accessed 17th July 2020)


4.     Impact of the response on Social Services

The pandemic posed an unprecedented challenge to the social care sector. It had a significant impact on the social care workforce and placed teams under extreme pressure to protect vulnerable people in extremely challenging circumstances.

As Public Health England found, the impact was disproportionate across the population, including across different ethnic groups and by those living in areas of deprivation.10 The following section relates substantively to the experience of adult social services but that is not to diminish either the immediate or longer-term effects experienced as a result of similar issues impacting services supporting Children & Young People.

In order to protect the NHS and free-up capacity within hospitals to manage the expected surge, discharge procedures were radically overhauled in March 202011 and, as a result 6,500 people were discharged from hospitals into the care of local social services teams from 26th March to 12th June 2020 in London alone, which equates to 25% of the care home capacity in London being filled over a 10-week period.

This was against a national backdrop where, in the first half of March 2020, the number of patients discharged to care homes was higher than in the previous year and the proportion of hospital discharges to care homes increased as the month went on before starting to reduce moving into April.

Discharged patients required a variety of care settings, from nursing homes through to community support at home and, in addition to providing this support at unprecedented levels, care staff were also required to take responsibility for a significant proportion of “shielding” residents – those identified by NHS England or clinicians as being at greater risk for contracting the virus and therefore asked to remain at home, with support from local teams, for an initial 12 week period. In some London boroughs, there were over 20,000 shielding people identified as requiring support.

The pandemic presented an extraordinary challenge to a care workforce already under extreme pressure.

The decision to protect NHS services and to ensure adequate provision within a clinical hospital setting, whilst understandable, had consequences for the teams delivering services outside that setting. In the strategic context, this decision was modified as the pandemic developed when it became clear that the level of infection and the mortality rates being suffered within care homes was leading to tragic outcomes for many residents.

At the outset of the pandemic, the majority of infections were identified within a clinical hospital setting. In the week ending 20th March 2020, 4% of those confirmed as dying from COVID-19 nationally were care home residents. The figure had grown to 31% in the week ending 17th April 2020.

At the peak of the pandemic within care homes (which took place later than the peak within hospitals), nationally 44% of weekly fatalities occurred within care home residents. A report by Laing & Buisson on total excess deaths resulting from the pandemic estimated 57% will have been care home residents.12

In addition to the requirements to support the shielded population and manage rapid discharge into care settings, social care teams also had to manage the broader challenges created by the pandemic.


10 Disparities in the risk and outcomes of COVID-19 (June 2020), Public Health England available online, accessed 7th August 2020)

11 COVID-19 Hospital Discharge Service Requirements (19th March 2020), DHSC & NHS England (available online, accessed 7th August 2020)

12 Article published in LaingBuisson’s online journal Care Markets (7th June 2020), William Laing (available online, accessed 7th August 2020)


This was done in the context of diverse populations, and the clear disparities in the risk and outcomes of COVID-19 on people living in deprived areas and people from Black and Minority Ethnic (BAME) groups.

These challenges included supporting families affected by the closure of services for those requiring non-residential care; managing the ongoing domiciliary care of non-COVID vulnerable people without adequate PPE and with reduced staffing numbers due to absence and illness; supporting vulnerable households and children through the experience of being confined to a domestic setting and providing ongoing support to families in crisis.

Finally, social care teams worked alongside council colleagues as part of the whole council response in areas such as rough sleeping and food distribution.

There were some excellent examples of collaborative working between NHS and social care colleagues strategically and locally, ranging from regional joint-work on demand and capacity modelling to local solutions to move forward on PPE and testing ahead of national responses.

However, the pandemic nonetheless represented an extraordinarily difficult and tragic moment for care clients and their families, as well as for the staff and commissioners of social care.

Access to PPE and testing has been a major challenge throughout the pandemic. Initially, as the majority of infections were in a clinical setting, PPE and testing for NHS staff was prioritised. This meant that often staff in care homes or in home care settings were working without PPE and without knowledge as to whether either they, or their clients, were infectious.

Over the course of the pandemic, locally-led arrangements and procurement solutions helped to bring more reliability and organisation into the system, and represent a potential model of practice moving forward in the space of PPE and testing.

Nationally, the mortality rate amongst social care staff and healthcare workers became a growing concern.

The impact on social care staff has been particularly severe. The death rate amongst the social care workforce has been calculated as 23.4 deaths per 100,000 for males and 9.6 deaths per 100,000 females, compared to 10.2 deaths per 100,000 men and 4.8 deaths per 100,000 women for health workers.

COVID-19 has had a significant impact on social care staff, and further research will be required to understand how to mitigate this risk in future.

Across England, social care teams mobilised to protect and support their local populations, working collaboratively with colleagues in the voluntary and community sector, deploying local volunteer assets as well as drawing down on the local knowledge and insight about specific communities and support requirements that is a key part of social care provision.

This involved:


Financial support was made available to care homes from local authorities, to meet the increasing and unexpected costs, and innovative work took place across health and care in order to develop better systems of discharge and support to care homes.

A key element of future planning will be to make sure positive developments including in better discharge to and provision of mental and physical heath support within care homes are embedded.

Detailed preparation took place within local areas to free up capacity and ensure that the peak predicated hospitalised population could be discharged and new patients admitted. This was a huge task. It involved re-providing care for many existing recipients in conjunction with the care sector, voluntary organisations, charities and their families and creating step down facilities to support COVID positive residents and protect care homes; and preparing huge range of facilities from hotels to hospices, to charity retreats and conference centres to meet anticipated demand.

The acceptance by the NHS that resources directed via them would be used to pay for higher levels of discharge was essential – as it remove the usual debate and argument about responsibility and payments, thus enabling focus on action.

However, an ongoing risk presented by the crisis is that care and support can often be ‘overprescribed’ at the point of hospital discharge and there is a sense in London that rapid discharges led to some people being on the wrong pathway, without sufficient support to rebuild their strength and capacity, thus leading to a drift into needing long-term care that could have been avoided (with associated costs adding to pressures on already overstretched local authority services).


5.     Conclusions

Both the NHS and social care in England were placed in a hugely challenging position through the pandemic.

Many of the changes in policy introduced nationally (such as greater access to PPE and testing within the care workforce, improved discharge protocols for suspected COVID positive patients, and the development of effective isolation protocols within care homes) were developed only as a result of failings in the early stages of the pandemic where the toll on both staff and service users was unacceptably high.

Staff worked collaboratively to manage the effects of the pandemic, and many have taken time to reflect and learn from the experience in order to be in a stronger position for the future.

Social care has been, historically, less well understood by the public than many of the health-focused professions. The lack of knowledge presented a challenge at the outset of the pandemic, with decision- makers often unaware of the principal role of care homes as places of residence (people’s homes) and social interaction; and therefore often unsuitable and unequipped to apply the same infection control approaches as used in hospital settings.

The pandemic has magnified a range of ongoing realities within the care home sector.

Composed of independently run organisations, and operating within growing public funding constraints, this is a highly fragile sector; and the success or failure of these organisations has a direct impact on the lives of residents and the scale of demand faced in turn by the NHS (with the hospital sector in particular having to deal with the consequences).

In the development of integrated care systems, the role of independent care providers has often

been seen as “too complex / for the future” or the responsibility of local authorities to resolve.

The pandemic has shown how untenable this position is, in a world where many of those services are seeking to integrate around do not fit into neat “health / local authority” or even “public / privately provided” support boxes.

Any changes to the delivery of care home support, including segregation, infection control measures associated with staffing levels, restricting movements and pay and the provision and use of PPE, has a direct impact on the costs borne by providers, which will need to be passed on to funders, whether in the public sector or self-funders.

These extraordinary costs have, rightly, been recognised and provided for within the NHS but the position in relation to care services remains precarious.

A more preventative approach has the potential to avoid demand in the NHS, and to safeguard the wellbeing of some of England’s most vulnerable people.

This, at its essence, requires a commitment to allocate resources to prevent infection in care homes and elsewhere – otherwise we will continue to invest in expanded hospital capacity to deal with the avoidable consequences of disease.

This period has led to a rapid increase in understanding of the reality and value of integrated approaches to care, where organisations work together as part of a co-ordinated system in a local setting.

In this brief window of respite, it is critical we build on that understanding to create local models for treatment and care than ensure people and staff are equally protected and prepared, both for ongoing and longer-term challenges to health and wellbeing.


August 2020