BRIRISH MEDICAL ASSOCAION (BMA) – WRITTEN EVIDENCE (PSR0071)

MEMORANDUM OF EVIDENCE TO THE HOUSE OF LORDS SELECT COMMITTEE ON PUBLIC SERVICES INQUIRY ‘PUBLIC SERVICES: LESSONS FROM CORONAVIRUS’ 

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.

This response to the House of Lords Select Committee on Public Services sets out the BMA’s views on lessons from COVID-19 for the healthcare sector, the increasing use of technology, workforce challenges across the NHS and the Government’s response to the pandemic. 

Overview

• The government’s initial response to the COVID-19 pandemic made some positive steps but was more broadly marked by a failure to adequately prepare and conflicting and unclear guidance.
• Shortages of personal protective equipment and delays to provide comprehensive population testing and tracing including priority testing for healthcare workers, have caused significant issues and impeded attempts to slow transmission rates.
• Successes in developing innovative approaches to delivering remote primary and secondary care, including investment in technology and a cutting of bureaucratic processes should be maintained and built upon in the future.
• It was initially positive to have sufficient critical care capacity and enough ventilators, but this also had significant drawbacks, as a shift in NHS prioritisation from core services to critical care, resulted in a backlog of referrals, which will need to be tackled as normal NHS service resumes. It is crucial that enough support and resource is made available to ensure that this backlog can be addressed in a timely process.
• There is a demand for both good data and for good modelling. A lack of local data on COVID-19 and the lack of transparency on the impact of COVID-19 on BAME patients and staff. Have both significantly impacted services and increased risk unnecessarily. 
• COVID-19 has exposed structural inequalities that persist throughout the UK. Action must be taken to improve the reach of health services to BAME communities and to mitigate the impacts of the lockdown so that existing health inequalities are not widened.
• Recommendations within the PHE’s report on the impact of COVID-19 on BAME communities must be urgently implemented and an action plan published that clearly sets out roles and responsibilities for taking these recommendations forward.
• The pandemic has exacerbated underlying stress factors for healthcare workers. A BMA survey found that 66% are seeing an increase in workload during the crisis. To address this, it is crucial that staff wellbeing and mental health support is adequately provisioned for.
• Employers need to ensure that staff are able to take time off, or to work flexibly and are supported to do so. It is important to ensure that those who have worked for an extended period during the pandemic are able to take a break when they need it most. 

1. General

What have been the main areas of public service success and failure during the Covid-19 outbreak?

‘Successes’

In our view there has been some areas of positive learning developed across the NHS during the COVID-19 pandemic. These include:

-          Creating increased capacity in critical care beds

-          Increasing workforce capacity

-          Improving the use and availability of technology across the NHS, particularly in primary care

-          Reducing bureaucratic processes, to free up more time to support patients

-          Support for individuals who are shielding

Prior to the pandemic, there was insufficient NHS critical care capacity to cope with the potential increases in demand. Following the outbreak of COVID-19, Sir Simon Stevens expressed an intention to free up capacity and increase this availability[1]. Data shows that this approach was successfully achieved, with critical care capacity expanded from a baseline of approximately 3,667 beds open daily across England (8.33 per 100,000 population) at 80-85% occupancy at the end of February[2] to approximately 7,000 beds, excluding Nightingale hospitals, (15.9 per 100,000 population) in early May[3].  Overall, this ensured critical care services were not overwhelmed during the initial peak of the COVID-19 outbreak in England. However, it is also important to note that this unprecedented shift of NHS resource from other core services towards critical care came at the expense of those other parts of the NHS. It is also important to note that while capacity was increased in some areas this led to significant understaffing, which may have the potential to impact the delivery of care. These points are further explored in section two of this response. So, while we consider the expanding of critical care capacity to be a success in terms of pandemic planning, it cannot be considered a success in wider terms of NHS delivery because of its impact on wider NHS services.  

Since the outbreak of the pandemic, general practice has seen a ‘fundamental shift’ in how it operates, effectively moving to a ‘digital front door’ model overnight. A significant number of consultations can now be delivered by telephone, online and via video, with face-to-face consultations either in the practice or at home only when clinically necessary. This process of innovation and change was undertaken in the absence of much of the regulatory or contractual requirements that were previously placed on GPs. Similarly, when the need for additional support for patients in care homes was recognised, practices, often working together with local community care teams, responded quickly and effectively and without the need for contractual change. The response from GPs to COVID-19 is compelling evidence of what can be done when practices are afforded the trust, autonomy, flexibility and freedom to act as the leaders of the profession in their local communities and acting in the best interests of their patients. With the removal of layers of bureaucracy, and greater support to roll out technology from central government, GPs have been empowered to work in an environment that has actively encouraged problem solving using clinically led solutions. We believe this success must be built upon by continued investment in technology and the reduction of unnecessary ‘red tape’ across primary care.

We are also encouraged that Government was able to identify, contact and support potentially vulnerable individuals, advising them to shield. This includes offering support for those shielding in their homes, supporting the mobilization of volunteer programmes and allowing for local contact points for residents to easily report if they had concerns about family, friends or their neighbours. Should this process for identifying and sharing the details of vulnerable members of the community be retained, it has the potential to be used to ensure that these type of higher risk individuals are provided a more rounded and integrated support package spanning community and secondary care. This would of course need to be done in a manner which also ensures the necessary protections were afforded for personal data.

As part of the lockdown planning there was a concerted effort by local authorities to find homes for people sleeping rough, including using hotels which were unoccupied at the time. We believe that momentum on tackling homelessness should not be lost when the pandemic recedes, and that these individuals now identified should be supported to prevent a return to rough sleeping.

Failings

The key flaw in the Government’s approach was the delay in recognising the scope of the coming problem, to observe learning from other countries and then in implementing an effective response, particularly with regards to testing and personal protective equipment for public sector workers. A summary of areas we consider to be key failures are included below:

-          A failure to plan

-          Significant issues with stockpiling, procurement and distribution of personal protective equipment (PPE)

-          Unclear and regularly changing guidance to healthcare workers and other public sector workers

-          A lack of public guidance on face coverings

-          Delays to initial priority testing and significant shortfalls in the current test and trace programme

Failure to stockpile enough PPE at the outset of the pandemic was a crucial issue for healthcare workers. This was further exacerbated through significant delays to procuring additional PPE, with reports of some batches sent into the NHS being faulty or past its expiry date. There were missed opportunities regarding the potential to join the EU scheme to procure PPE, which the Government ruled out applying for, even though the UK was still entitled to participate[4]. In addition, there was frustration at the daily Government briefings referring to there being sufficient PPE, when that was not the experience of our members on the ground.

The BMA received reports of the PPE supply chain being inefficient, examples include hospitals warning of critical shortages even when Government maintained they had sufficient supplies; GP practices receiving multiple PPE packages that were either short of the number of PPE that they had requested or missing key items such as eye protection. While the dedicated phoneline to resolve such shortages was a good idea, in practice it did not seem to be able to prevent these regular shortfalls. There were also issues with different masks being provided to the ones which workers had passed fit tests with, leading to the need for repeated fit testing and instances where a healthcare worker may pass a fit test with one type of mask, but then fail with another, leaving them unable to safely work in certain environments. The BMA also received reports that the masks were often designed in a way that was unsuitable for many female healthcare workers or those from certain ethnicities. In future we would like to see masks specifically designed with all healthcare workers in mind, and available in sufficient numbers for all those who need them[5].

The lack of appropriate PPE was clearly demonstrated by a BMA survey, in April 2020, of over 6000 doctors[6] showing that:

• around half of doctors working in high risk areas said there were shortages or no supply at all of long-sleeved disposable gowns and disposable goggles, while 56% said the same for full-face visors
• in general practice, more than a third of GPs said they had no eye protection, with a further third saying there were shortages
• just under a third of doctors said they were sometimes pressured to work without adequate protection.

The lack of priority COVID-19 testing for healthcare workers, led to doctors and other healthcare workers self-isolating needlessly, with the impact of this being felt significantly in staffing levels. Our members reported to us significant frustration that they were obligated to stay at home, when a test would have determined their ability to work in a timely manner.

The guidance produced by Government for healthcare workers was also a cause of significant concern amongst BMA members, both in its variance from international WHO guidance but also in its seemly constant changes. Many guidelines had updates which contradicted the previous version(s), leading staff to feeling unsure of the correct approaches, and raising concerns about the safety of both staff and patients. Examples of this include the use of aprons rather than gowns, which was published on 18 June 2020[7], and advice offered to pregnant healthcare workers. Messaging around appropriate PPE was also undermined by comments from senior NHS figures, including the Health and Social Care Secretary, referring to a need not to ‘overuse’ PPE[8]. In our view it is not appropriate to encourage the rationing of protective equipment, which has the ability to save lives.

Government advice on the use of public face coverings was also an area of concern and varied from other European countries. The BMA believes that the wearing of face coverings by the public in areas where they cannot socially distance is beneficial to reducing transmission. To complement this approach the Government should also have ensured a supply of face coverings were made available to the public, in a similar way to practices in other nations The ambiguity of recent advice to the public is also a source for concern, people are more likely to follow rules if they are able to understand how they work and the rationale behind them. 

Finally, the initial and ongoing public policies in relation to availability of testing and tracing fell far short of what was needed. This resulted in the infection spreading unchecked through a policy of self-isolation, as Government did not have the capacity to test more widely, its 10, 000 test a day target was delayed. This situation continues as ongoing delays to the NHS tracking app remain an area of serious concern, particularly as we face the possibility of a second wave of the virus. 

How have public attitudes to public services changed as a result of the Covid-19 outbreak?

Research published by the Health Foundation has found public attitudes towards public services have substantially shifted since the COVID-19 pandemic. Nearly 9 in 10 people (86%) now believe the national government has a ‘great deal’ or ‘fair amount’ of responsibility for ensuring people generally stay healthy, significantly up from 61% in 2018. Similarly, 76% see local government as having responsibility for people’s health (up from 55% in 2018)[9].

Simultaneously, members have reported to us that they have generally perceived an uplift in public support of healthcare workers and a greater recognition that the both the services themselves and the staff within them need to be better funded. However, we have still received instances of staff being poorly treated including reports of doctors struggling to find accommodation, due to a perceived concern regarding transmission.

It is also worth noting that because of the emphasis put on dealing with COVID-19, many members of the public have not been accessing core NHS services, either for fear of taking up valuable NHS time in a health crisis or for fear of catching the virus. This may well lead to poorer overall health outcomes and an increase in the NHS workload in the longer term as the health service tries to catch up with the backlog of cases and deal with untreated conditions that have become emergencies needing urgent treatment as a result. So while it has been helpful in some respects that public perception and value of the NHS resource has increased, there now remains a need to ensure the public are more aware of those occasions when it is crucially important to access NHS care and made to feel able to do so, regardless of the circumstances at the time.

2. Resource, efficiency and workforce

Did resource problems or capacity issues limit the ability of public services to respond to the crisis? Are there lessons to be learnt from the pandemic on how resources can be better allocated and public service resilience improved?

Prior to the pandemic, there was insufficient NHS critical care capacity to cope with the potential increases in demand facing services due to COVID-19, for comparison, per 100 000 Italy and France had almost twice the per population critical bed availability as the UK[10].

As outlined in section one of this submission to the Committee inquiry, the NHS achieved a significant increase in critical care capacity through redeployment of resources, and it ensured that critical care services were not overwhelmed during the initial peak of the pandemic. Despite this critical care services have undoubtedly come under intense pressure during this period. Some of these pressures were due to capacity not always being in the ‘right place at the right time’, for example one North London hospital had to declare a ‘critical incident’ in March due to its critical care wards being full, it had to request to transfer patients elsewhere in London[11]. Better coordination was needed across the country to move ICU patients around to make best use of critical care capacity - the first ‘wave’ of the pandemic was characterised by some areas using surge ICU with low nurse: patient ratios and anaesthetic machines as ventilators, while other areas had plenty of spare “normal standard” ICU capacity that went unused.  Learning must be taken from this to better use critical care resource in the instance of another such pandemic.  

More broadly, across the country services have come under intense strain because much of the ‘extra’ capacity was achieved through stretching resources more thinly. Staffing ratios were significantly diluted in order to expand capacity, potentially compromising patient safety and creating an extremely stressful working environment for staff. Guidance from the Faculty of Intensive Care Medicine usually advises that intensive care (also known as level three critical care) requires a registered nurse/patient ratio of a minimum 1:1, this guidance was amended to a minimum of 1:6 during the pandemic[12].  The necessity of these dilutions highlights the large, well-documented staff shortages endemic to the NHS. A lack of trained staff also hampered efforts towards use of NHS Nightingale London as it had to refuse patient transfer requests from other hospitals on up to 30 occasions due to ‘staffing issues’, namely a lack of critical care nurses[13].  

As highlighted in section one, the unprecedented resource shift towards critical care to prepare for the COVID-19 outbreak, came at the expense of other parts of the NHS. This included postponing all non-urgent elective operations, urgently discharging hospital inpatients medically fit to leave, and block-buying capacity in independent hospitals[14]. There was also a large shift in workforce and technical capacity from other clinical areas towards critical care. This has had far-reaching effects on both patients and the health and social care workforce.  In a recent BMA survey, 40% of respondents said that the longer-term impact of the pandemic on patient clinical demand was their top concern[15]. Recent reports also suggest that the cancellation of elective operations could mean more than seven million patients will be on hospital waiting lists by the autumn[16]. It will take years before a thorough analysis can be done of the external effects of the pandemic on non-COVID-19 mortality and morbidity. Any return to ‘normal’ levels of care post-COVID will be slow and difficult. To tackle this shortfall, it is crucial that investment in the NHS workforce is prioritised and a plan published to address this unprecedented care backlog.  

Increasing critical care capacity also involved discharging large numbers of patients into the community, which resulted in a significant impact on care homes, GP practices and other community services. This meant that patients were transferred to settings where they were not shielded in the same way as they would have been if in a medical setting. Care homes were burdened with a large volume of patients yet were apparently not prioritised for testing or PPE.  This situation must not be repeated should a similar situation arise in future. As non-COVID care restarts, it is vital that the NHS is supported to provide care to these patients, especially those who need urgent support for time-sensitive conditions such as cancer. Ultimately, the NHS will only be able to cope with balancing COVID and non-COVID work if there is an accompanying strong focus on tracking and containing the virus in the community, tackling the immense backlog of untreated non-COVID community conditions and if local public health services are supported to lead this.  

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? 

Latest national statistics show that[17] the equivalent of 88,347 full-time vacancies still persist across secondary care settings in the NHS. Staffing shortages exist across both medical specialities (8,338 doctors) and nursing (36,083). A survey by the Royal College of Physicians found that 53% of consultants and 68% of trainees said that there were ‘frequently’ or ‘often’ gaps in hospital medical cover that raised significant patient safety issues[18]. We also lost the equivalent of 334 full-time qualified GPs between December 2019 and March 2020, which is a decline of 1,418 GPs since September 2015[19].  This is despite numerous workforce initiatives, including the 2015 GP Workforce 10 Point Plan and the 2016 GP Forward View, that we believe were not significant enough to arrest the decline in GP hours available to the NHS.  Trends in the losses of GP partners (down 3,778) and the increase in salaried and sessional GP working (up 2,361) over the past five years demonstrate the impact unmanageable workload and a desire to work more flexibly to control work-life balance and preserve wellbeing has had on the GP workforce. In secondary care

These shortages undoubtably contributed to the pressure faced by the NHS workforce during the COVID-19 pandemic. In order to address these significant shortages, the government appealed to doctors who had left the NHS, including those who had retired, to return and provide their support for a fixed period. Government also employed final year medical students on NHS contracts. While these approaches did increase capacity, they demonstrate the severity of current NHS understaffing. It is vital that learning here is not lost and the Government explores how it may retain some of those returning healthcare workers.  Improved and increased recruitment and retention of NHS staff must now take place to meet the needs of patients across the NHS. 

It is clear that the COVID-19 pandemic has exacerbated underlying stress factors for healthcare workers, including increased exposure to death and suffering. Recent BMA surveys [20] found that:  

• 41% of doctors were suffering with depression, anxiety, stress, burnout, emotional distress or another mental health condition relating to or made worse by their work, with 29% saying this had got worse during the pandemic.
• 22% feel they do not have the access to help that they need.  
• 66% are seeing an increase in workload during the crisis – with staff redeployed to new roles, covering for sick colleagues or directly dealing with the surge of COVID-19 patients  

Following these intensive levels of high workload and pressure, it is crucial that staff wellbeing is adequately provisioned for and that staff have access to tailored mental health support. Past studies of pandemics have shown a higher mental health burden on healthcare workers, and so support will need to be comprehensive both during and after the crisis.[21] While initiatives brought in to support NHS staff wellbeing during the COVID-19 pandemic there are concerns that these will only be available for the short-term. As the UK eases lockdown and the number of COVID-19 cases decrease, NHS workers will continue to be at the frontline of the pandemic. Any support offer for staff should be enhanced and maintained for the long-term, particularly as take up may not be immediate. There are also additional services which need to be resourced in the here and now, such as the comprehensive occupational health and specialist mental health support. With NHS mental health services facing an increase in demand healthcare staff may not be able to have access to timely support.  

Employers have a responsibility to provide a safe working environment and take preventative action to protect staff from developing poor health and wellbeing in the first place. The impact of the pandemic of the workforce demonstrated the vital role health services play in ensuring staff are appropriately risk assessed. Yet accessibility of OH services is inconsistent across the UK.[22] The BMA has long called for a fully funded, comprehensive, accessible OH service for NHS staff.  

Employers need to ensure that staff are able to take time off, or if they would like to work flexibly are supported to do so. A consistent and fair policy for staff using annual leave entitlement is needed which ensures that those who have worked for an extended period during the pandemic are able to take a break when they need it most. Staffing rosters must have cover for annual and sick leave built in to prevent unrealistic expectations of service capacity being built up.  

More broadly, healthcare workers also need clarity on their future contractual status and working arrangements. Many doctors and other healthcare workers have had to change their working patterns as part of the NHS’s response to COVID-19. Some of these changes, because they were in response to a true emergency, have been extraordinary, including prolonged periods of duty, short notice changes without any predictability and involving extended periods away from home life, and most junior doctors having their training effectively put on hold. Where contractually agreed elements of doctors’ roles have been temporarily suspended due to the pandemic – including vital elements of education and training, academic research, study leave, and professional development, these should be reinstated. 

As we emerge from the worst aspects of the first wave of the pandemic, workload intensity will increase above pre-COVID levels as the NHS resumes all services and deals with the three-month backlog of non-COVID patient need. This is why the NHS must continue to get “whatever resources it needs”[23] both now and in the future, particularly in light of the continuing need for staff to follow strict safety, hygiene and infection control protocols, to ensure all patients can receive the care they need in a timely and safe fashion for both themselves and the NHS staff who care for them. 

The impact of a decade of cuts were felt during the pandemic. According to the latest NHS workforce statistics, there were the equivalent of 616 full-time public health medicine doctors and trainees in March 2010. This had decreased to 132, a reduction of 484, in March 2020[24]. Of these, the number of public health consultants, essential during a public health crisis, reduced from 331 to 19 (-312). These cuts meant that by mid-March there was not sufficient capacity or resources to coordinate and establish testing and tracing of all cases of COVID-19. The cuts to the public health laboratory service, coupled with a failure to identify alternatives, meant that tests couldn’t be processed quickly enough either. The lack of sufficient consultants in communicable disease control has resulted in insufficient capacity when it is most needed too.  To better safeguard in case of future pandemics and other public health crises, e.g. diabetes, heart disease, smoking cessation, obesity, sexual health etc, it is crucial that funding cuts to public health services are entirely reversed swiftly.  

Why have some public services been able to achieve goals within a much shorter timeframe than typically would have been expected before the Covid-19 outbreak – for example, the increase in NHS capacity? What lessons can be learnt? 

Government’s focus has been on tackling the pandemic which has resulted in timely advancements and red tape being reduced, including a suspension of appraisals, revalidation and CQC visits, and a willingness to provide increased resource where it is needed. A good example of this is in general practice where remote consultations have rapidly become standard practice, coupled with a reduction in bureaucratic processes, which has resulted in GPs having more time to spend treating patients. These are both areas which the BMA had previously called for greater investment and reform in but was not prioritised, when patients could no longer access surgeries then the necessity of such approaches hastened their development. The same can also be shown with the increase in critical care capacity outlined preciously in this response.   

3. Technology, data and innovation

Has the delivery of public services changed as a result of coronavirus? For example, have any services adopted new methods of meeting people’s needs in response to the outbreak? What lessons can be learnt from innovation during coronavirus? 

When given the freedom to innovate without artificial targets and undue bureaucracy, NHS staff can achieve a huge amount. General practices and secondary care have adopted the use of video and telephone consultations, while enhanced access to the summary care record and greater remote working have changed the way some secondary care services are delivered.  This provision of remote access to GPs has been beneficial to the many patients who would struggle to attend GP surgeries. This adaption amongst GPs should be further expanded in future to better join up with the care sector. Should such technology have been in place across the care sector prior to COVID-19 it would have resulted in a more direct route to better support the care of patients in these settings. For example, health care workers in care homes can be supported virtually to undertake health indicator checks, such as blood pressure, changing dressings or oxygen probe monitors for patients with suspected or actual COVID-19. When supported by appropriate functioning technology this can streamline the provision of care, and also free resource within the wider NHS.  

How effectively have different public services shared data during the outbreak? 

Interim data sharing arrangements between primary and secondary care, primary care and central bodies (NHSD, X) and the acceleration of data sharing agreements already underway within primary care have been launched with the aim of reducing the burden on primary care clinicians and providing all clinicians across both settings with access to the information required to treat patients. Though temporary, the BMA is working with arm's length bodies and stakeholders to establish what is worth taking forward, what is not and when these measures should be stepped down. One such measure, a fortnightly extract of GP data sets for planning and research has drastically reduced the time GPs have spent reviewing applications for data and preparing data for this purpose, thereby freeing up more time to spend with patients. 

In General Practice relatively little data around COVID-19 testing was received in the early stages of lockdown and GPs reported often having to ask their patients what their COVID-19 status is or if they have been tested. Although this has now been remedied with an appropriate solution allowing the flow of test results into the GP record, it is concerning that this was not prioritised earlier.  They also face a significant delay in getting usual communications, such as discharge letters or clinic letters.  As such there have been significant delays in finding out serious diagnoses (in some cases GPs were unaware of deaths in a timely fashion) which seriously impaired the ability to function effectively.  

Did public services have the digital skills and technology necessary to respond to the crisis? Can you provide examples of services that were able to innovate with digital technology during lockdown? How can these changes be integrated in the future? 

General practices were provided with hardware to enable them to embrace virtual connectivity and consultations. However, there were some issues with the equipment provided. For example, the laptops provided had screens that were too small to load an entire summary at once, which meant that clinicians could write notes but not click the ‘ok’ button to save them. This rendered the laptops effectively useless for this purpose without the purchase of additional auxiliary screens. In future, ensuring that the equipment provided is fit for purpose will facilitate its appropriate use and avoid unnecessary future spending to correct deficiencies. Broadly this rapid increase in the use of technology across primary care has been welcomed.  

For secondary care, governance rules concerning how technology is used and approval mechanisms for funding for new equipment were lifted during the pandemic providing an ability to better streamline care and the delivery of services through increasing access to needed technology. We would again support the continued use of this approach.  

4. Inequalities

Have public services been effective in identifying and meeting the needs of vulnerable groups during the Covid-19 outbreak? For example, were services able to identify vulnerable children during lockdown to ensure that they were attending school or receiving support from statutory services? How have adults with complex needs been supported?

The advice on shielding was ‘trickle down’ and came far too late for many vulnerable medics.  It was also often open to interpretation, for example advice for pregnant women came out in several versions. The first version made no mention of pregnant healthcare workers, the second suggested they work remotely, the third said that if they were under 28 weeks they could ask to work remotely if they chose to. The result of this lack of communication the advice was lacking or conflicting and meant that many healthcare workers were compelled to work in unsafe conditions. 

While there may be varying approaches for identifying vulnerable groups (e.g. it was not immediately apparent what level of severity of asthma should put someone into a shielding category) in the situation of a totally novel virus it will never be possible to demonstrate lack of teratogenicity or safety with regards to adverse pregnancy outcomes (especially miscarriage) until at least 40 weeks from the origin of the virus (so women infected in very early pregnancy could have given birth in order to assess pregnancy outcomes).  It should be accepted policy to recommend shielding for pregnant healthcare workers for any novel virus in pandemic conditions.

Were groups with protected characteristics (for example BAME groups and the Gypsy, Roma and Traveller community), or people living in areas of deprivation, less able to access the services that they needed during lockdown? Have inequalities worsened as a result of the lockdown? If so, what new pressures will this place on public services?

The COVID-19 pandemic has had a disproportionate impact on BAME people, both within the wider community and the healthcare workforce. Current data shows that BAME people are more likely to have higher rates of severe illness and admission to critical care, as well as mortality from COVID-19. ICNARC data (22 May) which covers clinical care units in England, Wales and Northern Ireland has shown that BAME people make up 33.2% of admissions. This is significantly higher than the 14% of BAME people in the England and Wales population[25].

As highlighted in the PHE report[26], BAME people have a higher morbidity rate from COVID-19 even after accounting for the effect of sex, age, deprivation and region. Analysis from the ONS shows that after accounting for different age profiles, Black men and women are for times more likely to die from COVID-19 than White men and women. After accounting for socio-demographic factors and self-reported health, people of Black, Bangladeshi and Pakistani ethnicities were still almost twice as likely to die from COVID-19. This may be in part due to that fact that people from lower socioeconomic backgrounds and BAME people were not as able to stay home, due to the type of work they may be employed in, such as healthcare or other public sector roles.

Within the healthcare workforce, 61% of 200 workers who have died have come from BAME backgrounds. Among doctors, over 90% of those who have died have been BAME, more than double the proportion in the medical workforce as a whole[27].

With social isolation recommended for older and vulnerable people, some older generations of BAME people, particularly those for whom English is not a first language, may also experience greater problems in accessing routine healthcare and advice because they could be more distanced from other family members or carers who often act as advocates for them.

We are also deeply concerned that incidences of domestic abuse have increased significantly during lockdown. For example, Refuge, reported a 120% increase in calls to its helpline, and a 700% increase in website traffic, in a single day[28]. Many victims of domestic abuse will be living with their abuser during the lockdown and will have restricted access to support networks. Women from BAME communities may face additional barriers in accessing support, due to language barriers or cultural pressures and expectations. It is important that culturally sensitive services are available. Disabled women are also more likely to be victims of abuse.

In future an increase in unemployment will exacerbate deprivation and poverty. Our report Health at a Price - Reducing the Impact of Poverty[29] outlines the significant health impacts of living in poverty, whilst the recent Marmot Review – Ten Years On[30] highlights an increased likelihood of living in poverty for some BAME groups (e.g. 46% of individuals from a Pakistani and 50% of those from a Bangladeshi background are living in poverty after adjusting for housing costs). This is also echoed in the PHE review showing that those from a deprived area are twice as likely to die should they contract COVID-19.[31] A report by the Trades Union Congress in 2017 found that BAME people are persistently disadvantaged in the labour market and therefore more economically vulnerable. For example, it found that BAME people are more likely to be on zero-hours contracts or other forms of insecure work, including self-employment.

As the UK faces an historic economic recession as a consequence of COVID-19, ongoing financial and other additional support needs to be targeted at those who are living in poverty or insecure employment. Adequate financial support such as immediate access to adequate sick pay will also help ensure that people who should be shielding or isolating for their own and others’ health are not forced to work by economic necessity.

The COVID-19 pandemic has exposed structural inequalities that persist throughout the UK. Action must be taken to improve the reach of health services to BAME communities at the moment, including to migrants and their families, and to mitigate the impacts of the lockdown so that existing health inequalities are not widened. Over the longer term there must be a determined public health focus on interventions to narrow the longstanding inequalities that COVID-19 has brought to the fore.  

Are there lessons to be learnt for reducing inequalities from the new approaches adopted by services during the Covid-19 outbreak?

The COVID-19 pandemic has brought to the fore longstanding structural inequalities that persist within the UK and our public services. However, it has also exposed where action is needed to address these.  Recommendations within the PHE’s report on the impact of COVID-19 on BAME communities must be urgently implemented and an action plan published that clearly sets out roles and responsibilities for taking these recommendations forward.

The Equality and Human Rights Commission recently announced that it is suspending its compliance work to enforce the specific duties that support the PSED and require public bodies to annually report equality information about their workforce and among service users during the COVID-19 pandemic[32]. We believe this may have caused confusion about the status and priority to be given to equality at present.  Public bodies must be clear that the Public Sector Equality Duty remains in force through the current crisis and must continue to gather data and assess the impact on equality of their policies and practices. Equality monitoring should continue throughout the pandemic and steps taken to identify and mitigate health inequalities and disparities of experiences and outcomes as they arise.

5. Integration of services

Are there any examples of services collaborating in new and effective ways as a result of Covid-19? Are there lessons to be learnt for central Government and national regulators in supporting the integration of services?

We believe that the pandemic has demonstrated the need to empower doctors, as local clinical leaders. During the pandemic we have seen greater collaboration between hospitals, such as the leadership shown by clinicians setting up the Nightingale hospitals and a shift from payment by results type practices, as well as increased support from CQC as it moves away from undertaking appraisals and inspections. In primary care this leadership could be achieved by strengthening and resourcing the development of primary care networks and giving them the necessary flexibility to use available resources, workforce and partnerships within their area. This means being at the heart of decision making, particularly at a time when all NHS and care services review their way of working to deliver care whilst reducing risks of COVID-19 infection to patients and the workforce

Such an approach would improve local join up and help to promote social prescribing. We have heard examples from members of the value of community groups and volunteers during the pandemic. One member described in their area, the local council coordinated COVID-19 Volunteers, which had over 4,000 residents volunteering to deliver food to shielded residents, managing befriending calls and carrying out deliveries. Alongside this ‘Scrub hubs’ were set up by residents to make PPE for GP practices and local hospitals.

In Stockport it was reported that the local out of hours service provider was able to step up to run day-time clinics to assess those who may have COVID-19. This commissioned service was built on the organisations existing infrastructure and worked well. These types of examples show that by increasing local join up and empowering local leadership can yield valuable results.

June 2020