THE RICHMOND GROUP OF CHARITIES - WRITTEN EVIDENCE (PSR0029)
House of Lords Public Services Committee inquiry on public services: lessons from coronavirus
About The Richmond Group of Charities
The Richmond Group of Charities brings together a range of major national charities who are all key players in England’s health and care system, investing many millions as significant delivery partners for the NHS and other public services. Together we hear the concerns of and provide advice and information to millions of people. This aspect of our work has accelerated enormously during the pandemic. Our purpose and credibility flow from the shared insights we generate from our substantial individual contributions, through direct service delivery and our own staff and volunteers, our support for NHS services and staff, and our funding for research.
The Group has a particular focus on the needs of people with long-term conditions – especially multiple conditions. We aim to use the power of our united voice to enable better value for money in the health and care system, helping decision-makers understand how to achieve the best outcomes for the people we support. We are striving, in a changing world, to develop our own services and activities so that together we can support people with multiple needs more collaboratively with services that recognise and respond to the realities of people’s lives and model the changes we want to see in others’ policy and practice. We are committed to contributing to the long-term recovery from this pandemic.
Q4 - Did workforce pressures preceding the crisis, such as difficulties in the recruitment or retention of workers, limit the ability of public services to meet people’s needs during the lockdown? How effectively, if at all, have these issues been addressed during the Covid-19 outbreak? Do public services require a new approach to staff wellbeing?
1.1 There were significant workforce challenges prior to the Covid-19 outbreak. These issues have not gone away and will have been exacerbated as a result of the crisis. Many experienced healthcare professionals are set to retire over the next 10 years, and there were already 40,000 nursing vacancies in health and care settings in England. As the priority during the immediate crisis was treating people with COVID-19, many staff were redeployed to support this effort.
1.2 This meant NHS staff working in new ways and in new settings across primary, secondary and community care. Some staff were redeployed out of their current role, which will have disrupted how teams have been working. This led to depletion of specialist skills in the community in many areas, as they were particularly valuable for ITU work. This had knock on effects for the support people could access outside of hospital for their condition.
1.2.1 Over 400 Macmillan health professionals who normally deliver cancer care and support, were redeployed into other roles in order to boost the ability to support the COVID-19 effort.
1.2.2 Access to a range of specialist services in the community was reduced due to redeployment of staff for the Covid-19 response, particularly specialist nurses. In line with this, Richmond Group members reported an increase in calls to their helplines from people who were struggling to access support in the usual way.
1.2.3 In order to free up capacity within general practice, NHS England amended some parts of the GP Contract including permitting practices to suspend annual reviews and medication reviews, including for with asthma, diabetes and COPD, until the end of June.
1.3 Prior to the pandemic, 4.4 million people were already on a waiting list for elective procedures, the highest figure since the referral to treatment pathway began in 2007. Around 700,000 people would normally receive elective procedures each month, most of which have stopped. Many people living with long term conditions will be represented in these numbers. At the same time, many services that they would normally rely on may be side-lined in efforts to address those waiting for surgery. There are significant workforce implications in meeting these challenges, both in maintaining capacity to clear the backlog while also operating differently to make sure people requiring appointments for routine management of long-term conditions are not left behind.
1.3.1 For example, there will be a huge backlog of breast screening appointments with thousands of appointments cancelled during the pandemic. However, there is a workforce crisis within the diagnostic and imaging service. Prior to the pandemic, only 18% of breast screening units were adequately resourced with radiography staff in line with breast screening uptake in their area and over the next five years a quarter of consultant breast radiologists are forecast to retire.
1.4 In response to the outbreak many NHS employers have been much more flexible in their approach to workforce planning and utilising skills. This flexibility has included things like easier movement between Trusts for health care professionals and better communication between different parts of the system. This good practice should continue as the NHS returns to operating in more normal times.
1.5 Without the additional support of volunteers and the wider VCSE sector overstretched NHS resources would have struggled to meet the high levels of need caused by the crisis. As services are restarted, any planning for the future needs to consider how the system is supported by the VCSE sector.
1.6 The redeployment of clinical staff to respond to COVID 19 provided the NHS with significant flexibility. At the same time this has resulted in clinical reviews, education and support being unavailable, which has caused greater variation in availability of services and support across the country. Where care has not been available or not seen to be available, this has acerbated existing inequalities in access to services. In addition, there are now immediate pressures on staffing capacity to respond to increased clinical need because care hasn’t been available or perceived not to be available during the lock down. We need to keep a close watch on the emerging evidence and impact on outcomes that the redeployment and new ways of working have had.
The relationship between central Government and local government, and national and local services
Q19 - Would local communities benefit from public services focusing on prevention, as opposed to prioritising harm mitigation? Were some local areas able to reduce harm during coronavirus by having prevention-focused public health strategies in place, for example on obesity, substance abuse or mental health?
2.1 Local communities would benefit from a focus on prevention by public services. The Government should respond to the consultation on the Prevention Green Paper, outlining how they will tackle the significant challenges the pandemic has shown many communities are facing.
2.2 Public service providers will need to understand the ways in which existing health inequalities have been exacerbated during this crisis and the impact that will have on the health and well-being of those living with multiple conditions.
2.2.2 We know that almost a third of all patients critically ill with COVID-19 were from Black, Asian and Minority Ethnic (BAME) backgrounds – despite making up just 13% of the UK population, and in order to tackle the impact of this, the Government will need take an intersectional approach and examine how health and economic inequalities are interlinked and the impact it has on the health of these communities.
2.2.3 Understanding the impact of post-COVID-19 recovery will also be important, as there is some evidence of people living with long-term effects of the virus. Asthma UK and British Lung Foundation have set up the Post-COVID Hub to support people left with breathing difficulties after COVID-19.
2.2.4 Our work in partnership with the Royal College of General Practitioners and the Guy’s and St Thomas’ Charity in the Taskforce on Multiple Conditions has identified the clear links between deprivation and the prevalence, earlier onset and faster progression of multiple conditions.
2.2.5 Likelihood of multimorbidity is consistently associated with levels of household wealth, sense of control over one’s life, physical activity and loneliness. Examples of social risk factors that impact people’s health are meaningful work, financial health and housing. Those communities with higher levels of multimorbidity are more vulnerable generally and at higher risk in the case of a second wave or future pandemic. A focus on the wider determinants of health must drive NHS reset conversations.
2.2.6 The PHE report Disparities in the risk and outcomes of COVID-19 discusses the need to better understand the link between obesity and COVID-19. Emerging evidence from the Intensive Care National Audit and Research Centre (ICNARC) has shown a relationship between high BMI and death from COVID-19. The Government already has an evidence-based plan to address obesity, including recommendations set out in the Prevention Green Paper, and there should be a focus on these measures.
2.2.7 Smoking cessation services experienced increased demand due to potential links with worse COVID-19 outcomes. It is important to restore these services and to learn from innovation in service improvement. The commitment within the Long-Term Plan that by 2023/24, all people admitted to hospital who smoke will be offered NHS-funded tobacco treatment service must be resumed.
2.2.8 We know that people living with a long-term physical health condition are twice as likely to develop a mental health condition. This large cohort of people (15 million) has now grown further to include people who are living with the long-term health consequences of coronavirus.
2.2.9 People living with physical and mental health conditions are twice as likely to be inactive (do less than 30 minutes of physical activity a week) compared to people without health conditions. This is despite evidence (as stated in the Chief Medical Officer’s Physical Activity Guidelines of 2019) that physical activity supports self-management of at least 20 chronic conditions and symptoms such as pain and fatigue, as well as reducing the risk of many conditions by up to 40%.
Role of the private sector, charities, volunteers and community groups
Q20 - What lessons might be learnt about the role of charities, volunteers and the community sector from the crisis? Can you provide examples of public services collaborating in new ways with the voluntary sector during lockdown? How could the sectors be better integrated into local systems going forward?
3.1 Richmond Group members saw an unprecedented increase in demand for their information, advice and support as the crisis hit, and a high level of need from the public which was not being met elsewhere by the wider system. Calls to helplines and other enquiries from many thousands of people daily rose to three, four or even five times their usual levels.
3.2 Charities played a vital role in information sharing and dissemination to the public. There was a need to relate the various updates Government issued during the outbreak to individual conditions, explaining what the impact would be on individual groups, particularly around shielding guidance. The flow of information should be maintained as lockdown measures ease, and we move into a new phase.
3.2.1 British Heart Foundation and the Stroke Association worked closely with NHS communications teams on the NHS campaign to address the dramatic drop-off in emergency admissions and reach the people affected.
3.2.2 Richmond Group members have also sought to gather new insight and data on lived experience of those with long-term conditions during the crisis, and want to share this information with health systems to support service improvement and design during the recovery, and to add some richness to patient experience information beyond the usual audit figures.
3.2.3 Richmond Group members were also able to use the rich insight they have about their beneficiaries to articulate problems in the system that national teams are less aware of as there is not good data available. Members were able to reach out to services to understand the impact of the outbreak on them and then feed this information up to Government and the NHS. Ensuring that high quality data is collected and available should be a priority as services are resumed.
3.3 Alongside the wider VCSE sector, Richmond Group members have invested significant resources as delivery partners for the NHS, as well as expertise, to support the COVID-19 national effort. This contribution has been vital in helping to address the broad range of needs people have been experiencing as a result of this outbreak. It will also be critical to address longer term needs as a result of the pandemic, and there needs to be an open and strategic conversation between Government, the NHS and the sector about financial sustainability of this support.
3.4 Services were rapidly redesigned to be delivered through telephone and online platforms, as well as work undertaken to adapt existing information and support which addresses how COVID-19 impacts on their specific health condition(s), and to answer the concerns of their beneficiaries. Below are some examples of how our members were able to innovate their systems to meet the needs of their beneficiaries, as well as reacting to new and arising needs caused by the lockdown.
3.4.1 Alzheimer’s Society – Dementia Connect Companion Call: The Alzheimer’s Society set up their Companion Call service in just three weeks as a temporary addition to the long running Dementia Connect service to provide help to people with dementia and their carers so they feel more connected and less lonely during the COVID-19 crisis. Regular calls are made to people to simply have a chat about everyday things like the garden, what is on TV or events like VE day. Alzheimer’s Society recruited 800 volunteers in rapid time, and by the end of May around 7,500 companion calls had been made with many people requesting them once or twice a week.
3.4.2 Age UK: Age UK worked closely with DEFRA to increase access to home delivery of shopping for older people and those with disabilities who are struggling, including an offline option, secure methods for volunteers or friends to buy shopping for others and help for those who didn’t have others to shop for them and didn’t know where to turn. By working together, they could join up services and coordinate so that support reaches those who need it most.
3.4.3 Stroke Connect: Stroke Association worked with the NHS to deliver the Stroke Association Connect Service. During the COVID-19 pandemic, people affected by stroke have been discharged from hospital sooner. The Connect Service reaches out to stroke survivors by telephone and provides essential reassurance and information for people affected by stroke about the support available to help them rebuild their life after stroke.
3.4.4 We Are Undefeatable Campaign: The Richmond Group organises the We Are Undefeatable campaign, led by 15 health and social care charities, funded by the National Lottery and supported by Sport England. It aims to support people living with health conditions to be physically active. The campaign worked quickly to generate new content for the website (weareundefeatable.co.uk) and to rework advertisements and promotional materials, such as a booklet with easy to follow exercises at home, to provide support for people living with health conditions to remain as active as possible.
3.4.5 Rethink Mental Illness – Clic Service: Rethink Mental Illness, as part of the Mental Health UK partnership, launched Click, a new UK-wide online community to support people’s mental health. Clic offers an online chatroom which is moderated 24 hours a day. Public Health England provided the funding for further development. Feedback received from users so far is that people feel less isolated, have experienced improvements in mental health, and are more confident in discussing their illness.
3.4.6 National NHS diabetes clinical helpline established working in partnership with Diabetes UK and pharmaceutical companies: this was set up quickly to respond to challenges people with diabetes were having in accessing clinical advice when sick due to diabetes clinical teams being redeployed to respond to COVID-19 demands in hospitals. Diabetes UK’s Helpline refers people to the clinical advice line staffed by clinicians employed by the NHS and pharmaceutical companies, who were not required to or able to work due to the pandemic and reprioritisation of services. This partnership provided a new way of integrating clinical and emotional support within a single pathway and using a single telephone number. It also provides direct support to reduce pressure on local, stretched NHS teams as a key response to the disproportionate risk to people with diabetes of COVID-19.
3.4.7 The NHS Volunteer Responders Scheme has been delivered in partnership with the Royal Voluntary Service, and when it launched over 750,000 people signed up in just four days, three times the original target. This demonstrated that volunteers will step forward for the NHS in very large numbers, but in order to maximise their contribution, it is important that volunteers are given the right support and training and what they can contribute is clearly set out.
3.4.8 The NHS Volunteer Responders Scheme provides a new way for people to volunteer and meet an identified need. Given the large pool of volunteers the system can cope with them individually selecting when they want to be on duty. There are approximately 200,000 on duty at any one time, and the system for cascading requests down a chain of available volunteers means that the system can work dynamically.
3.4.9 The NHS needs to think broadly and creatively about the volunteering workforce, recognising the value volunteering adds for people, staff and the volunteers themselves, as well as ensuring there is a permanent offer of joined up volunteering support available.
3.5 During this outbreak, large parts of the bureaucracy which has constrained the NHS from integrated working has been removed. The same willingness to remove bureaucracy needs to be applied to charities who want to work in partnership with the NHS. By working in partnership, the NHS, Local Authorities and the voluntary sector can develop the integrated approach required to effectively meet the future demand. There needs to be a change in mindset by NHS and Local Authority Leaders about how they work and collaborate with the VCSE sector, and this renewed relationship needs to be based on an equal partnership.
 The Richmond Group of Charities brings together the following members: Age UK, Alzheimer’s Society, Versus Arthritis, Asthma UK and British Lung Foundation Partnership, Breast Cancer Now, British Heart Foundation, British Red Cross, Diabetes UK, Macmillan Cancer Support, Rethink Mental Illness, Royal Voluntary Service and Stroke Association