SVL0012

Written Evidence submitted by BMA (British Medical Association)

About the BMA

The BMA is a professional association and trade union representing and negotiating on behalf of all doctors and medical students in the UK. It is a leading voice advocating for outstanding health care and a healthy population. It is an association providing members with excellent individual services and support throughout their lives.

1. Summary

1.1 The BMA welcomes the opportunity to response to the Public Accounts Committee’s inquiry on COVID-19: Supporting the vulnerable during the lockdown. Since the development of the Government’s shielding programme in March, there have been issues with the identification and definition of people who should be considered clinically extremely vulnerable and clinically vulnerable; unclear communications and repeated changes in guidance resulting in confusion and anxiety among people who are shielding; and inadequate supply of consistent support throughout the pandemic, such as deliveries of food and medicine.

1.2 At the outset of the shielding programme, GPs, already under significantly increased workloads due to the COVID-19 pandemic, undertook the considerable task of identifying patients for shielding lists. People who have been shielding throughout the pandemic have faced enormous challenges and uncertainty. For many, including clinically vulnerable doctors and doctors caring for people who are shielding, this had included disruption to training, career development, isolation from their peers, job insecurity, as well as practical challenges around remote working.

1.3 The Government must now engage proactively and thoroughly with clinically vulnerable people and groups representing people shielding, to learn the lessons from their experiences and respond to their concerns. It is particularly important that the needs of clinically vulnerable people are considered when working through strategies for exiting lockdown. Many people in these groups have been shielding and isolated for months, with all the associated economic and health issues that entails. It is important that lockdown exit strategies are not predicated on curtailing personal liberty for people in this group.

1.4 Outcomes from the Government’s Everyone In programme have been widely welcomed and the scheme has shown how support can be successfully delivered to a vulnerable population. It is now vital that lessons are learnt from the positive outcomes of this scheme and this learning embedded in future approaches to supporting people who are homeless.

2. Definitions and guidance on people identified as clinically vulnerable

2.1 Initial Government advice on shielding was not particularly clear and caused widespread confusion and anxiety to shielding individuals. Disability groups advised the Government in March 2020 that conditions listed which deemed people to be ‘clinically vulnerable’ were not comprehensive enough. These concerns remained unaddressed when later shielding guidance was published in October as the UK entered the tiering system.

2.2 The BMA raised concern that the initial lists of people advised to shield provided by NHS England/Improvement to GP practices were not comprehensive and resulted in considerable additional workload for practices and confusion for patients. A survey by general practice publication, Pulse, found that GP practices in England were spending an average of 26 hours a week reviewing whether patients should be shielding during the pandemic. Commenting at the time, Chair of the BMA GP Committee Dr Richard Vautrey said:

‘Ensuring the list of shielding individuals is accurate is extremely important to ensure the most vulnerable in society are protected. It is a complex and timely process that required the input of GPs, patients and NHSE England and Improvement, including clinical and non-clinical systems to ensure it is accurate and maintained. It is vital that NHSEI factors in the time needed for GPs to make adequate patient assessments so as not to add to the additional workload burden being placed on GPs at this time.’

2.3 This is emphasised in the NAO’s recent report, which highlights difficulties in drawing up shielding lists, pointing to problems extracting data from both hospital and GP NHS IT. The report recommends that “DHSC should ensure that healthcare data systems allow easy, but secure, access to healthcare data.” The BMA has persistently pushed for changes to NHS IT systems for solutions that are more streamlined, yet secure for patient data.

2.4 From June onwards, when the first lockdown was eased, the sudden lifting of restrictions served to compound confusion and anxiety among people who were shielding. Disability groups raised concerns over the way the relaxation of restrictions on 1 June was communicated to people who had been advised to shield for 12 weeks until 30 June. A survey by Disability Rights UK found that 85% of people shielding felt unsafe going outside since the relaxing of the lockdown rules, whilst only two-fifths had the confidence to leave home since the regulations around shielding were eased.

2.5 The Women and Equalities Committee’s report on the impact of COVID-19 on disabled people concluded that:

“The way the Government has communicated with disabled people has, on occasions, caused confusion and compounded already keenly felt anxiety. The chosen method and timing of communications with people categorised as clinically extremely vulnerable, and therefore likely to be living under very considerable stress, has sometimes been poorly thought out, with insufficient consideration given to the psychological effects on recipients and their families.”

2.6 When the country entered the tiered system of restrictions, services which were initially ringfenced for disabled people in the first lockdown, such as food and medicine deliveries, were no longer ringfenced, causing access issues. Despite the 2.2 million people advised to shield in March being told to stay “one step behind” their area’s three-tier standing, little support was provided to help them to do so.

2.7 The reintroduction of national restrictions in November brought led Government to allocate local councils £14 per clinically extremely vulnerable person to ensure they have access to essential supplies. However, concern has been raised that this has been done without evidence of any assessment of vulnerable people’s needs.

2.8 The NAO report concludes that DHSC is unable to say whether shielding led to fewer deaths and less serious illness in CEV people than would have otherwise been the case, although it is likely to have helped. It is nonetheless highly concerning that, despite the Government’s shielding programme, there have been a disproportionate number of deaths among disabled people.

2.9 Analysis by the ONS found disabled people accounted for 6 in 10 of all COVID-19 deaths for 24 January to 20 November 2020. It also shows a continued higher COVID-19 mortality risk for disabled people. Among men defined by the ONS as more-disabled the risk was 3.1 times higher, whilst for more-disabled women it was 3.5 times higher. This fell to 1.9 times higher risk among less-disabled men and two times higher risk among less-disabled women. Adjusting for personal and household characteristics, a smaller but statistically significantly raised risk of death remains unexplained for some groups. It is vital that the Government proactively engages with disabled people to ensure lessons from the pandemic are learnt and that their needs are fully considered in any strategies for exiting lockdown.

3. Impact on shielding healthcare workers

3.1 Doctors who have been shielding throughout the pandemic have faced enormous challenges and uncertainty, including disruption to training, career development, isolation from their peers, job insecurity, as well as practical challenges around remote working. Shielding has impacted on doctors’ emotional wellbeing with many feeling guilt, embarrassment, frustration, anxiety, and loneliness.[1] In addition, staff may have had to discuss elements of their health conditions with their employer and colleagues, which they may not have felt comfortable doing. Many have also not felt fully supported. The BMA’s July COVID-19 tracker survey found that of 560 respondents who reported shielding 30% said they felt unsupported or the support was not satisfactory.

3.2 When the shielding programme in England and Northern Ireland was paused from 1 August, the BMA raised concern over how healthcare staff who are clinically vulnerable or who are caring for others who are vulnerable will be able to safely return to their usual clinical duties. This included highlighting that taking on board and implementing existing guidance on shielding from the government, employers, and national public health bodies, could cause confusion, particularly with regards to the use of PPE (personal protective equipment). We called for a clear and consistent approach that included clear guidance and protocols on how workplaces could be made safe for staff who had been shielding.

4. Learning lessons from shielding programmes

4.1 Going forward, it is vital that the Government engages proactively and thoroughly with people who are clinically vulnerable and the groups that represent them to learn the lessons from their experiences and respond to their understandable concerns that government has not adequately supported them throughout the pandemic.

4.2 It is particularly important that the needs of clinically vulnerable people are considered when working through strategies for exiting lockdown. Many people in these groups have been shielding and isolated for months, with all the associated economic and health issues that entails. It is important that lockdown exit strategies are not predicated on curtailing personal liberty for people within this group, including disabled people.

4.3 There are also lessons to be learnt from the success of the Everyone In initiative, which by May 2020 had seen more than 90% of rough sleepers and those in unsuitable accommodation offered self-contained accommodation by local authorities.

4.4 As well as housing so many rough sleepers in such a short amount of time, another positive development of the homelessness response to the pandemic in has been improved collaboration at a local level between Clinical Commissioning Groups (CCGs), public health, local authorities and housing departments in England. For example, public health and local authorities working with their CCG to find funding for specialist homeless clinical practices to provide additional COVID-19 outreach and screening.

4.5 It is vital such new ways of working are not lost and allow homeless people to continue to be better served in their health needs by public services. Practices that have seen effective cross-sector collaboration during COVID-19 must be embedded and built upon beyond the pandemic.

February 2021