Written evidence submitted by NHS Providers (DEL0137)

NHS Providers is the membership organisation for the NHS hospital, mental health, community and ambulance services that treat patients and service users in the NHS. We help those NHS trusts and foundation trusts to deliver high-quality, patient-focused care by enabling them to learn from each other, acting as their public voice and helping shape the system in which they operate.

NHS Providers has all trusts in voluntary membership, collectively accounting for £84bn of annual expenditure and employing more than one million staff.

Key messages

The NHS has worked at speed to transform services in the face of COVID-19, providing care for those suffering from the virus by scaling up capacity, as well as continuing to care for patients with other conditions. However, this has inevitably impacted on core services, which have had to be de-prioritised in the short term to ensure capacity for COVID-19. NHS trusts have done all they can to manage this impact, particularly prioritising the most clinically urgent patients.

Trusts will need to be prepared for further waves of COVID-19, and it will be necessary to retain ‘surge’ capacity in order to address possible future demand.

However, retaining surge capacity and the staffing required to support this, will clearly have an impact on the NHS’s ability to manage ‘ordinary’ demand. Trusts are keenly aware of their responsibilities to restart ‘ordinary’ business but managing day-to-day demand alongside a stream of COVID-19 patients, and maintaining surge capacity, will be complex, difficult and challenging, and will require effective prioritisation.

We welcome recent correspondence from NHS England and Improvement (NHSEI) on moving towards the second phase of the NHS’ response to the pandemic, which outlines some clear national prioritisation, while allowing considerable local flexibility for trusts to make decisions around which services they are able to resume safely and when.

However, it is vital to ensure providers maintain the flexibility to make decisions which work for their local trust and their patients. The pandemic has affected different areas of the country in different ways, at different times: a one size fits all approach will not be suitable when it comes to resuming services.

Community service providers and mental health providers have played a key role throughout the pandemic, harnessing innovation to deliver for patients in their own sectors, as well as freeing up space for critically ill patients. However, we need to be aware of the pressure facing these services, particularly given the pent-up demand that the NHS is going to face when services resume. Whilst the initial wave of demand has lessened in acute hospitals, capacity is hugely stretched in community services and mental health providers are already beginning to report a significant increase in demand.

Testing is key to managing the spread of the virus, avoiding further spikes in cases and resuming core services. The Government needs to urgently update its 4 April testing plan so trusts can be clear what is required of them. While the situation is improving, the flow of Personal Protection Equipment (PPE) to trusts is still not as consistent and reliable as it needs to be.

It will be vital to ensure the NHS is sufficiently prepared to manage pandemic related demand alongside the flu season and typical winter pressures.

Achieving an appropriate balance between coronavirus and ‘ordinary’ health and care demand

On 17 March, NHSEI wrote to NHS bodies asking them to enact a number of measures to free up capacity to cope with the unprecedented demand caused by COVID-19.[1] To implement this, many trusts postponed core services, such as non-urgent elective care, in order to look after critically ill patients. Acute trusts also rapidly discharged significant numbers of patients to create the required COVID-19 capacity. On 29 April, NHSEI once again wrote to NHS bodies to set out its response to the second phase of COVID-19 asking them to assess their capacity for “at least” some routine non-urgent elective care.[2]

Now that the NHS has successfully negotiated the initial peak of COVID-19 related demand, the NHS will need to strike the right balance between coping with COVID-19 related demand and meeting ‘ordinary’ healthcare demand. Trusts have worked hard throughout the pandemic to ensure that both those with, and without COVID-19, continue to receive the care they need. Trusts are acutely aware that ordinary healthcare demands have not simply vanished while the country is dealing with this virus. However, we need to be realistic both about what trusts can deliver and how quickly, acknowledging that re-starting services is going to be more complicated than stopping them and focussing on creating emergency capacity in crisis mode. It will not be possible for trusts to do everything at the speed we would all like: effective prioritisation will be key.

We are aware of several key challenges, which are inherent in achieving an appropriate balance of care between coronavirus and ‘ordinary’ healthcare demand:

The NHS is going to have to deal with unknown, ongoing levels of COVID-19 related demand at the same time as fully restarting ‘ordinary business’. It is unclear at the moment what COVID-19 related demand will look like given the uncertainties involved – for example, how lockdown will be eased and how any easing will actually work, given that it is impossible to accurately predict in advance how people will react to any particular lockdown easing measure. Trusts will need to be prepared for further waves of COVID-19 and it will be necessary to retain ‘surge’ capacity (for example, ensuring there are enough beds to cope with another wave and that staff vital to managing COVID-19 demand can be redeployed again).

On a practical level, the need to treat ongoing COIVD-19 demand and retain surge capacity present real constraints to restarting planned care. For example: hospitals may need to divide their physical space between COVID and non-COVID demand which will restrict capacity in many trusts. Wards and operating theatres may need to be kept aside for surge capacity – whilst it is possible to quickly turn areas into, for example, critical care capacity, it is not possible to keep switching capacity in an unlimited way.

Trusts will need to allow staff the opportunity to recover from the first wave of demand and they may want to retain staff in reserve for surge capacity.

COVID-19 is hitting different regions at different times and in different ways, with trust leaders reporting significant variations in the way the virus is affecting their trust. It is clear that returning to the “new normal” will vary from trust to trust. While some national guidelines will be helpful in setting out how providers move on to the next phase of resuming services which have been paused since the outbreak, it is vital to ensure providers have the flexibility to make decisions which work for their local trust and their patients rather than a one-size-fits- all national approach. Some trusts will be able to resume ‘ordinary’ care quicker while others will be more constrained due to the need to treat COVID-19 patients and keep surge capacity.

Maintaining surge capacity and delivering ‘ordinary’ care will be a challenge for trusts, so it will be vital to have a clear approach to capacity planning, including regional surge capacity plans. It would be helpful for trust leaders to be given more clarity on how and when the extra new surge capacity at Nightingales across the country will be used. Trust leaders are also keen to have more information regarding the best way to use extra capacity in the private sector. Extra staff, equipment and beds have been made available following a blanket contract agreed between the NHS and the independent hospital sector. We believe there is a strong argument to contract this capacity for a further period and trusts recognise their responsibility to ensure this capacity, if it is contracted for a further period, is used to best effect.

Additionally, it is vital to recognise the needs of frontline NHS staff, who are working tirelessly to care for COVID-19 patients every day. Trust leaders are acutely aware that many of their frontline staff are exhausted from dealing with the first wave of the pandemic. While it is vital to ensure patients who need care can access it, this must be balanced with a need to support an exhausted healthcare workforce. Trust leaders are concerned that it is unrealistic and unfair to expect healthcare workers to go from coping with one crisis to working flat out to manage the backlog of care that has arisen during the pandemic. Steps must be taken to ensure, protect, and maintain staff resilience: consequently, trust leaders are doing all they can to ensure support is available for staff.
Trusts are also concerned about a difficult confluence of any potential spike in COVID demand with traditional winter pressures. Preparations for winter demand will soon be underway and so trust leaders are urging the Government to consider factors such as winter and the flu season when planning their longer-term strategy. Avoiding another spike in the virus at this time will be crucial to trusts’ ability to cope with the normal stresses and strains of winter. Alongside these winter pressures, providers will need to manage the backlog of non-urgent elective surgery which was put on hold at the outset of the pandemic.

Meeting the wave of pent-up demand for health and care services that have been delayed due to the coronavirus outbreak

Trusts are deeply concerned at the marked drop in demand for key services such as A&E attendances, cancer diagnostics, neurosurgery and urgent cardiology services. Trusts are receiving fewer referrals from general practice for conditions such as suspected cancer. For example, one trust chief executive told us their trust would normally diagnose around 20 colorectal cancers a month; however, in March, they diagnosed none. Latest figures also show there was a 29% fall in the number of A&E attendances in March 2020 compared with the same time last year, suggesting people are staying away from A&E, either because of fears of catching the virus or because they do not want to overburden the service.[3] Trust leaders are concerned that decisions not to seek help could lead a delay in diagnosis and deterioration in people’s overall health.

The drop off in demand since the outbreak of COVID-19 is not limited to the acute sector. Mental health trusts have also seen a significant fall in the number of referrals for services such as CAMHS and IAPT. However, there has been a rise in the number of people presenting in crisis. One mental health trust told us they had seen a reduction in referrals from GPs, but a rise in young people presenting in crisis or having attempted suicide.

Trusts recognise that the “pent up demand” from patients who are not currently presenting or being referred, means they will see significant numbers of patients come forward in the future. The fact that it is very difficult to plan for when these patients will present / be referred is another significant problem in effectively managing the restart of planned care. Trusts welcomed the launch of NHSEI’S launch of the “Help us help you” campaign to make sure people know the NHS is there for those who need it during the pandemic, encourage them to seek help if they are unwell, and avoid delays in getting treatment for serious conditions.[4] We would encourage further national level communications with the public on this issue to assure the public it is safe to use the NHS.

Meeting extra demand for mental health services as a result of the societal and economic impacts of lockdown

Trusts are anticipating a significant increase in the demand for mental health services, as people grapple with the economic consequences of the virus, as well as the social and psychological impact of a prolonged, and as yet, undefined period of lockdown and social distancing.

Mental health providers have been quick to adapt, supporting the acute sector by providing intermediate care wards for those recovering from the virus, and setting up mental health A&Es to help ease pressures on emergency departments whilst ensuring people in crisis are still able to access the support that they need. Discharges have been accelerated, admissions have been avoided through enhanced crisis, and home treatment models and clinical services have been moved online.

Although COVID-19 has presented a number of challenges for mental health providers, the pressures also present opportunities to accelerate new ways of working and drive innovation. For example, extending physical healthcare skills in the mental health sector and making greater use of digital, volunteers, and the third sector.

Key to meeting the extra demand for mental health services will be ensuring appropriate funding is available. Mental health trusts have consistently expressed concern that extra mental health funding has not reached the front line in the way intended and it will be vital to ensure that the required expansion in service provision is fully and promptly funded, on a sustainable basis.

Meeting the needs of rapidly discharged hospital patients with a higher level of complexity

Community services providers have taken a leading role during the pandemic, enabling the NHS overall to manage the surge in patient demand and care for the most critically ill in acute settings. The NHS has adapted its discharge procedures to deliver a rapid discharge to assess operating model in the face of COVID-19. Thanks to the work of community and mental health trusts, social care providers and local Government, the NHS has been able to discharge thousands of medically-fit patients swiftly, which has freed up beds for COVID-19 patients.

However, this has meant that community service providers are now caring for a considerable number of extra patients with complex conditions who have been rapidly discharged from hospital. In the short term, community and mental health trusts, as well as social care providers, are concerned that the reintroduction of services which were de-prioritised at the start of the crisis will overwhelm them, particularly given the extra support they are already providing, and will have to provide, to COVID-19 patients through rehabilitation. Community service providers also have a key role, alongside GPs, to play in supporting a social care sector that is under huge pressure.

Now that the first peak of COVID-19 demand has passed, trust leaders are concerned that community services are facing the biggest potential mismatch between capacity and demand given the NHS’s historic under funding and lack of priority given to these services.

Steps taken by the NHS and social care providers to rapidly discharge patients has demonstrated that once this pandemic has passed, there is a real opportunity to build on the progress made during this period, allowing more medically fit patients to be discharged more promptly, rather than remaining in hospital for a prolonged period. But we must acknowledge the true cost of this shift and resource community services and social care accordingly.

Providing healthcare to vulnerable groups who are shielding

Trust leaders are expecting to see a significant increase in demand for community services as some day to day services, such as routine elective care resume, and they support those recovering from coronavirus alongside a sharp increase in the need for other support closer to home.

The NHS has an effective shielding policy in place, with support from the national bodies, trusts and primary care to identify and contact those individuals thought to be at greatest risk. The list of people advised to shield themselves has inevitably grown as more conditions have been added.

Providing healthcare to vulnerable groups who are shielding will add yet more pressure on community services, given that these patients will likely have a number of complex health needs and may have experienced a deterioration in physical or mental health due to prolonged isolation. Vulnerable patients may require a range of different support to regain their mental, physical and economic wellbeing during the pandemic and beyond to enable them to return to full independence. This will require multi-disciplinary working between colleagues in NHS community services, social care, primary care, other colleagues in local authorities and the need for rehabilitation support.

Community care services are cohorting staff into hot/cold COVID teams who then support groups of shielded patients. Effective cohorting is difficult in any setting and depends on an effective and comprehensive testing capacity, and the availability of sufficient PPE.

Supporting mass testing and vaccination once they become available

Given the UK’s testing capacity is spread across organisations, and information on the virus is continually evolving, it is vital that we have a coordinated approach to rolling out mass testing and that clear lines of responsibility are established. NHS trusts have played a key role in supporting the national testing effort so far, but trust leaders need clarity on the Government’s approach of test, track and trace as we enter the next, arguably more challenging phase of easing and ending the lockdown. Currently, there is little detail available about how this will work and how the NHS will be involved. Trust leaders need to know what role trusts, and their workforce, will play in the delivery of this.

As well as playing a role in mass community testing, it is likely that trusts will have to test all of their staff on a regular basis in the interests of infection control: it is vital that we see the right measures put in place to ensure regular, frequent testing of all staff and patients. Currently, some trusts are still unable to get regular, consistent access to tests for all staff and patients with symptoms, leaving people either without tests or waiting too long for results.

Alongside this, trusts need clarity on what role testing laboratories, including NHS laboratories for which they are responsible, will play in the next phase of the testing approach.

Ensuring that positive changes that have taken place in health and social care as a result of the pandemic are not lost as services normalise

As we look to the future, and a return to the “new normal”, trust leaders are keen to keep the positive changes brought about by the pandemic. We have seen significant amounts of health care provision moved online, including GP appointments, outpatient appointments and basic consultations. This demonstrates the progress that can be made when digital transformation is prioritised and funding made available.

We have also seen how the introduction of a rapid discharge to assess model has helped the NHS manage increased demand throughout the system, discharging tens of thousands of medically fit patients from hospital into social and community services, demonstrating how quickly care can be integrated. However, it is important to recognise that although we will see lasting benefits from some of the reconfiguration we have seen since the outbreak of COVID-19, these decisions have been taken at speed and without the usual consultation.

We believe that a more flexible approach to regulation and reporting has also helped the NHS to adapt and react quickly, and is a positive change brought about by the crisis, which trusts would like to maintain in future. Clearly, some level of regulation will always be necessary given the risk that healthcare provision carries, but flexibility has helped.

We have also seen how local trusts have been empowered to make decisions in the best interests of their trust, their patients and their staff. Coronavirus has highlighted the speed at which the NHS can change when the whole system is working towards a clear objective. In some instances, the pandemic has accelerated system working with regard to planning and pooling of resources, but we are yet to see these systems as a unit of delivery for the NHS. Going forward, we believe the role of and accountability of trust boards must be sustained, including in any future legislative changes.

Finally, the NHS has been well supported by various partners throughout the pandemic, including other public services, the army and volunteers. Thanks to these relationships, the NHS has been able to live up to the challenges presented by coronavirus. It is vital for the health service to maintain these new relationships in the future.

May 2020