Letter dated 27 August 2020 to the Chair of the Committee from Celia Ingham Clark, Medical Director for Professional Leadership and Clinical Effectiveness, NHS England (CVD0038)

Dear Caroline,

Thank you for inviting me to give evidence to the Women and Equalities Committee on Wednesday 22 July as part of your inquiry into coronavirus, disability and access to services. As agreed, I am writing back to the Committee to provide further information on blanket Do Not Attempt Resuscitate (DNAR) notices. NHS England and NHS Improvement remain clear that the blanket application of DNARs is unacceptable and that standards and quality of care should be maintained, even in pressurised circumstances.

As outlined in my evidence, NHS England and Improvement have taken steps to communicate this to the system throughout the COVID-19 emergency period:

• On 24 March, NHS England-Improvement published specialty guides for the active management of patients with suspected and confirmed COVID-19 which include specific guidance on the management of people with a learning disability and people who are autistic.[1]
• National Director for Mental Health Claire Murdoch, National Clinical Director - Learning Disability and Autism Dr Roger Banks and Medical Director for Primary Care Dr Nikki Kanani wrote to all Acute Trust CEOs, Community Trust CEOs and our primary care distribution list on 3 April. This letter strongly recommended clinicians refer to that guidance and made clear treatment decisions should not be made on the basis of the presence of learning disability and/or autism alone.[2]
• On 7 April, Chief Nursing Officer Ruth May and National Medical Director Steve Powis 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 on the inappropriateness of blanket DNAR notices.[3]
• This message has been further reemphasised through our April and May primary care bulletin, which reaches teams across General Practice.

The NHSE/I Palliative and End of Life Care team are currently developing public facing information which explains how a patient or their representative can raise concerns if a DNAR order has been made without their knowledge or if disagree with it. This will be relevant for all people, not just people with a learning disability or who are autistic and will be shared with a range of voluntary sector stakeholders.

As noted in our 9 July 2020 letter to General Practice we have agreed with the General Practitioners Committee of the BMA that the QOF Quality Improvement (QI) Domain requirements for 2020/21 will be recast to focus upon restoration of services for the remainder of this financial year. Improving the care of people with a learning disability is a QI topic for 2020/21. As part of the revised requirements, practices will be required to review the records of patients on their learning disability register to identify those recorded as DNAR and confirm that this decision remains appropriate or to amend as clinically indicated. Practices will additionally be asked to declare that they have a process in place to review DNAR instructions via their annual contract declaration which takes place in the autumn.

I hope you find this information helpful.

Yours sincerely,

Celia Ingham Clark

Medical Director for Professional Leadership and Clinical Effectiveness