Written evidence submitted by NHS Providers (DEL0318)
NHS Providers report
Recovery position: What next for the NHS?
The NHS entered the COVID-19 pandemic with 100,000 vacancies (NHS Digital, 2020), A&E performance at an all-time low (NHS England, 2020a), a growing waiting list for elective care (NHS England, 2020b), increasing demand for mental health, community and ambulance services, and a social care system in a fragile state. This makes the achievements trusts, and their local system partners, have delivered to transform care within the first weeks of the coronavirus outbreak all the more remarkable. From creating sufficient critical care capacity to avoid the service being overwhelmed, to implementing community ‘discharge to assess’ models, accelerating the use of digital technology and creating ‘mental health A&Es’ to support those in need, their achievements are significant.
However, we all recognise that the priority to protect the public from COVID-19 came at the cost of suspending some services in the early weeks of the outbreak and delivering others in a different way. Trusts are now seeking to restart more services and exploring how they will balance the competing demands of retaining capacity to treat COVID-19 patients, cater for unknown future waves of the outbreak, and restart services in a way which keeps both their staff and patients safe.
This briefing shares the results of the first NHS Providers survey carried out with the chairs and chief executives of trusts since the COVID-19 pandemic began. It offers a snapshot view of the sector’s position as trusts emerge from the first peak of the outbreak and move towards a ‘new normal’. It shares the different approaches trusts have put in place to continue caring for non-COVID patients, highlights the work they are doing to return to a sustainable level of services, and demonstrates the complexity of calculating what a sustainable level of service provision should be.
On 14 May, NHS Providers published a briefing Spotlight on... The new normal (NHS Providers, 2020) and submitted evidence to the health and social care select committee session on the same day. During the session, Rt Hon Jeremy Hunt MP, chair of the committee, asked us to survey trusts to help gain a greater insight into the challenges around balancing COVID-19 and non-COVID care, particularly as the NHS works towards restoring services that had been paused as part of the rapid operational response to the outbreak.
The outbreak of COVID-19, and the task of treating those seriously ill with the virus, presented an unprecedented challenge for trusts and the wider health and care system. Prior to the pandemic, NHS trusts were already grappling with rapidly growing demand for healthcare. The NHS was facing its longest and deepest financial squeeze in NHS history with over 100,000 workforce vacancies in the trust sector alone and staff exhausted after coping with year-round levels of ‘winter’ demand. Despite treating record numbers of patients, acute trusts were recording their lowest results against performance standards in elective surgery and emergency care in over a decade. Community, mental health and ambulance services were under similar pressure.
NHS Providers conducted a short snapshot survey of chairs and chief executives between the 21 - 31 May. The survey aims to capture the views of the sector on:
The survey received 158 responses representing 126 trusts, or 58% of the provider sector, with all regions and trust types represented in the data.
Trusts are rightly proud of their achievements in rapidly transforming care since lockdown began, and trusts have seen a dramatic change in the way they deliver services. Almost all (99%) of trusts agreed that they had seen rapid innovation.
Despite the challenges, trusts have developed innovative ways of managing demand and are putting in place measures to increase the volume of services they provide while keeping people safe.
“In mental health and community services online consultations are working very well. We are doing around 8,000 per month now in addition to telephone work. The workforce like it and generally so do patients and carers. There are some cases it’s not working for, but 80% of the time it’s great and the clinicians do not want to go back.” - chief executive, combined mental health/learning disability and community trust
“We have set up a trust-wide change programme, based on IHI Quality Improvement principles, to plan for and implement recovery and restoration. This will determine what of our old practice we will let go or restart, and what of our new practice we will stop or adopt/adapt (John Wright model). This model is also being used across our ICSs.” - chair, combined mental health/learning disability and community trust
Trusts have expressed confidence in their boards’ and workforces’ commitment to returning to a place of being able to meet all their patients’ needs, but stress the importance of ensuring realism in the conversation about how quickly they will be able to do so, given the ongoing constraints.
The COVID-19 outbreak has had a significant impact on the public’s behaviour in terms of whether and how they seek advice, treatment and care.
However, although trusts report reduced demand for services during the lockdown period overall, many have seen a rise in the number of late, urgent or severe presentations, especially mental health crises:
“In mental health referrals were down but activity remained high and we have been able to work more intensely with our caseloads and work through waiting time backlogs. We are seeing a steady increase in referrals. We expect a surge of referrals for CAMHS as kids go back to school.” - chief executive, combined mental health/learning disability and community trust
“We shall strive hard to meet the needs of all of our patients over time, but what that timescale will be is less clear, even in a community trust we have waiting lists and these have built up. The way that we deliver some services will change radically - talk before you walk - but whether all patients will be satisfied with this will be variable. BAU will not be business as we know it and we shall be supporting many in our communities who have been very badly affected by COVID and will be for time to come.” - chair, community trust
“I'm concerned that whilst the trust is ready to continue to innovate and create the 'new normal' primary care is struggling both practically and behaviourally. It is essential the new PCN contract is asserted toward true and open collaboration and integration. Further it is essential that the expectations and needs of needin care homes and domiciliary care functions is reviewed and supported to fully integrate meaningfully into the place-based care systems.” - chief executive, community trust
Trusts are almost unanimous in their concern for their staff, with 92% agreeing with the statement “I am concerned about staff wellbeing, stress and burnout following the pandemic”. All combined trusts and mental health trusts agreed with this statement, while 78% of specialist trusts agreed, reflecting the differential impact of the virus on different types of trust, but it is clear that the strain of the outbreak on NHS staff is top of mind for trust leaders, with implications for how they go about restoring services.
The impact of COVID-19 on staff has been substantial and wide-ranging. Trust leaders cite high levels of staff absence (70%), and said staff will need a chance to take leave over the summer to recover, with many concerned about the impact on staff should there be further waves of the outbreak. In order to support their staff, trusts have been engaging with them, such as via virtual listening events, to ensure their views are heard as part of the return to providing normal services.
“Many staff are still experiencing the pandemic…We have focussed on learning this past two weeks. We had a week-long learning week [with] 32 virtual events focus on staff wellbeing, hearing their experiences and getting to what we/they have learnt, what to keep etc. We had 700-plus staff involved and 132 service users over the week and it looks like it has gone very well…Staff also fed back they felt heard and supported and validated in the process.” - chief executive, combined mental health/learning disability and community trust
In March, many staff were also redeployed to support the COVID-19 response, and the process of restoring services will also entail these staff returning to their prior areas of work. This will only be able to take place when the need for COVID-19 specific resource is substantially reduced and will also require regular testing of these staff to ensure they can safely work with non-COVID-19 patients. As part of the ongoing need to maintain surge capacity, 78% of trusts have undertaken workforce reconfiguration to redeploy staff or create more flexible roles and are committed to supporting their workforce with this process.
Since being asked to resume providing some non-emergency services, trusts are putting in place measures to ensure they can do this safely. However, important questions remain about how quickly trusts will be able to return to the levels of productivity and the range of services they were able to offer before the pandemic, with significant IPC restrictions still in place and uncertainty about a potential second peak:
Trusts cited a range of factors which will enable them to resume providing elective and non-emergency services, including improved testing regimes, access to PPE, and streamlining of services in line with IPC measures. Trusts have expressed some concern about the limitations created by a lack of available testing capacity and are clear this forms a critical part of the process of restoring non-COVID-19 services.
“We…do not have a lab facility to do our own testing which is tricky. We have been discussing using Optigene to assist with our testing regime alongside the government's test, track and isolate.” - chief executive, acute specialist trust
“Clarity around the testing and clear IPC guidance, aligned with royal colleges are the key limiting factors. To increase elective capacity and start to reduce waiting times we will need long term use of the independent sector and also some additional theatre capacity.” - chief executive, acute trust
However, they also emphasised how conditional their response is on the myriad variables impacting on the capacity of ‘day-to-day’ services, in particular the timing and magnitude of any future peaks in cases. Many said that they wished government would make more information available about the likelihood and timing of future outbreaks and localised spikes in the number of cases to assist with planning. There was also a widespread view that trusts need funding to meet surge demand and reconfigure estates to support social distancing where required.
“We have reduced bed numbers for infection control reasons. We have 20% staff ill or isolating. Staff need to don and doff etc increasing time needed with each patient. Getting our waiting lists down for both RTT and cancer will be a major focus but will require additional capacity if we are to do it quickly. It also requires the changes seen in primary care to continue and the willingness of clinicians to continue going the extra mile.” - chair, acute trust
“It is not clear yet how significant the "surge" in mental health demand will be. National modelling has to date focussed on the acute demands. The innovation that has occurred will aid meet increased demand, but we cannot be confident at the moment whether there will be sufficient capacity to meet the anticipated increased demand.” - chief executive, combined mental health/learning disability and community trust
Some trusts expressed concerns that services may not return to a level patients are treated as quickly as they would like, and expressed a need for nuance in conversations between government and the national bodies, and with the public, about which services would resume, and when.
They estimate that on average, they are operating at 53% capacity for non-COVID services, anticipating a rise to 70% in three months’ time, and 83% within six to 12 months. Again, ambulance trusts and mental health trusts estimate their current level of capacity to be higher than the acute sector (97% and 87%, rising to 100% and 99% respectively). Community trusts and acute trusts have lower current capacity (43% and 53%, rising to 77% and 88% within 6-12 months).
Trusts are clear that they have continued to offer services where they can and are confident that they can meet the needs of all patients who have urgent requirements. However, while some services will be able to resume quickly, particularly with the continuation of remote and digital care, many respondents conceded that services were unlikely to return to a level comparable to before the pandemic, for all patients as capacity is necessarily reduced due to the need for social distancing, PPE and infection control requirements, keeping COVID-19 and non-COVID patients apart, and the need to retain surge capacity within the system to guard against future potential spikes of the virus:
“COVID-19 will have impacted inequalities further and many of the vulnerable, at risk groups may not seek care and will be socially isolated and economically impacted. The NHS' recovery needs to prioritise resources to the invisible patients… and this is a good opportunity to reframe what our priorities are.” - chief executive, combined acute and community trust
“I am confident that we will meet the needs of all patients who have urgent requirements. But such is the backlog I suspect it will take us to the end of the year to clear the backlog before taking new routine referrals.” - chief executive, combined acute and community trust
Respondents named a number of factors they need to take into account as they plan the return of services; one pointed out that in surgical theatres, there are now 20 minute waiting periods before and after intubation and between patients, reducing capacity by one hour per patient. Others are factoring in winter planning, pressures on social care and other services. Mental health trusts are factoring in a new and unknown level of mental health need as a result of the outbreak on top of existing demand. Ambulance services have to pause to deep clean vehicles after a suspected COVID case, however it is clear that it is acute trusts facing the greatest difficulties in restoring services quickly.
“We will not be able to do major elective procedures anytime soon as COVID-19 is having a significant impact on productivity in theatres and bed spaces are significantly reduced with required social distancing.” - chief executive, acute trust
“I am concerned that we may not have the staffing capacity to resume business as usual alongside the additional workload we have taken on in relation to supporting shielded patients, supporting recovering COVID patients in the community post discharge. We will look to new ways of working including use of technology to increase our productivity but that may not be sufficient.” - chief executive, community trust
A small number of respondents (12%) said that their trust would not be able to return to its previous level of service. This varied considerably by sector, reflecting the differential impact the pandemic has had on different types of services:
“We have continued throughout to deal with the demands on service that have presented through 111, 999 and clinical assessment. The ambulance sector has never been in a stronger position in terms of performance and this is a strong indicator that when the sector is adequately resourced to meet demand it can heavily influence the success across other elements of pathways for patients.” - chief executive, ambulance trust
There is also some regional variation, with trusts in London more likely to feel confident in returning to a normal level of service immediately (16%) compared to the Midlands (0%) and the North West (0%). This underscores the need for a regional approach to restoring services in reflection of the different pace at which the COVID-19 outbreak has progressed across the country. Areas with fewer active cases are more likely to be able to arrive at a new normal way of working than those with ongoing virus spread and existing high pressure on COVID-19 areas but remain vulnerable to further spikes in cases.
“Here in [south coast] we are clearly likely to have several surges because of summer visitors. Hotels are currently reporting up to 80% bookings for July and August, and holiday rentals up to 100%. The issue here is that the visitors may not be ill but be carriers and there is little indigenous immunity in [south coast] as our numbers have been relatively low to date. So we are preparing to bring more services on line relatively fast, using our different sites for trauma and orthopaedics, COVID and non-COVID and ED on our main site, the local private hospital for all cancer ( since early May) and opening a new site in the north of the county some 100 miles of small roads from the centre.” - chair, acute trust
For many trusts, there is a challenge in defining ‘normal services’, and some question whether the pre-COVID level of service is a desirable comparison given many were struggling to meet demand at the time.
“Arguably we were not meeting the needs of all patients before COVID-19, and unless the vaccine becomes available it could be a couple of years before we can return to what we were doing before COVID19, although arguably we wouldn't want to simply return to that position.” - chief executive, combined acute and community trust
“It is clear that there are different categories of "restoration" - there is that which is straightforwardly about replacing services in the same format with added COVID-19 safeguards, and on the other hand services where experience or strategies/discussions pre-COVID have demonstrated that services should be provided in a different way and they need more work to set up in new sustainable format.” - chair, acute trust
“Mental health services faced a massive treatment gap prior to COVID-19 - the Five year forward view target for CAMHS was 35% coverage. COVID demand, especially young people, is on top of that. The workforce is already extremely stressed from overwork. This will make that worse.” - chief executive, combined mental health/learning disability and community trust
Overall, trusts are clear that they are committed to returning to a sustainable level of services which meets the needs of as many patients as possible, but emphasise that this may look different to before the coronavirus outbreak, and will rely on continued innovation and sustaining the new ways of working implemented to cope with the outbreak.
“The geography of the site makes it more challenging for doubled up services whilst keeping people separate with COVID-19/ suspected COVID-19/ non-COVID needs. New ways of working have meant some waiting lists have improved, others have grown. More planned operations are becoming more urgent. We have already seen people who have left it for too long before seeking help and are too far progressed in their illness to aid recovery, which is heart breaking.” - chair, combined acute and community trust
Trusts have emphasised the complexity of the task they face in planning their journey towards a ‘new normal’. When asked about the challenges they face in returning to a level of service comparable to pre-COVID-19, trusts agreed that they continue to face a number of constraints:
- Patients will need to be more spaced out on hospital wards, reducing bed space. Average bed spacing in hospitals ranges between 1.6m in older buildings and 1.8m in newer hospitals, and space between staff around beds must also be taken into account. Trusts estimated that the 2m rule reduced bed space by up to a third, and a change to the rule reducing the distance to 1m, when supported by PPE and testing, is a welcome boost to capacity.
- A&E departments will face similar restrictions with a need to provide adequate distance between patients in waiting areas and treatment bays, raising questions for trusts about how they will accommodate all those who need treatment.
The majority (89%) of trusts expect to see an increased backlog of people waiting for care, with a knock-on effect on their ability to return to a normal level of service. Some trust leaders responding estimated that it would take a year to clear waiting lists for outpatient services, elective surgery, but also immunisation programmes, children’s services, health visiting and safeguarding caseloads. This is coupled with the likelihood of a surge in the number of people needing care following the easing of lockdown measures. Mental health services in particular are already seeing a rapid rise in need among those who have experienced mental health problems either during, or as a direct result of, the coronavirus outbreak and lockdown. Community trusts are faced with a number of patients who have been critically unwell with COVID-19 and will need support and rehabilitation.
“The problem is our previous capacity was already outstripped by unmet and unfunded demand, because of the treatment gap, and the post-COVID mental health surge will compound that. We have kept a remarkable amount going through the pandemic; we will need well over 100% to keep pace afterwards and staff are tired and in chronically short supply, especially the highly trained people we need for more complex cases - and that is what we are seeing.” - chief executive, combined mental health/learning disability and community trust
Trusts emphasise the complexity of the modelling required to project the capacity required to meet demand from new and existing patients over the coming months. The combined effect of a long pause in normal service provision, a backlog of new demand, lockdown-generated demand, and a reduction in normal capacity, is likely to be significant.
Further impacting on capacity is the need to retain surge capacity to deal with an unpredictable level of COVID-19 demand, with 80% of trusts agreeing that this has a bearing on how long it will take to return to full capacity.
While cases continue to fall, trusts are alive to the possibility of future waves of the outbreak as social distancing measures are eased. The rapid response to the outbreak in March entailed a highly disruptive process of switching off services, cancelling planned care, redeploying staff and repurposing wards and operating theatres to scale up ICU capacity. Not wanting to go through this process again, trusts are cautious as to how quickly, and how closely, they return to business as usual without compromising their ability to retain surge capacity.
PPE and COVID-19 testing capacity remains a concern with more than half of trusts agreeing each of these is an issue (53% and 57% respectively).
The ongoing insecurity of PPE supplies coupled with new guidance that all staff in NHS trusts must wear masks at all times, leaves trusts with uncertainty about the volume of care they will be able to carry out, and similarly as trusts scale up services the need for the capacity to test patients and staff increases so that the integrity of COVID-19 and non-COVID areas can be maintained. Trust leaders have also raised the challenge of the lack of availability of fit testing for FFP3 masks for community trust staff in particular.
While trusts talk about a surge in demand for care as well as the increased level of need created by a pause in services, they are also concerned that people remain reticent to receive care in hospital due to the risk of catching COVID-19 as an inpatient, and are looking to provide the reassurance patients need to feel safe in receiving care in hospital and mitigate the risk of harm created by delayed treatment. One trust estimated 25% of their patients offered surgery have declined it.
“Though we regularly review the longer waiters I am clear that there will be a building level of harm as people do not present and secondary care do not refer. These referrals are a fraction of previous levels.” - chief executive, acute specialist trust
“Many of our services are provided for older people who might be reticent about accessing services in the current circumstances which means we need to ensure we can accommodate their concerns appropriately.” - chair, community trust
Trusts are committed to returning as quickly as possible to meeting the needs of all their patients and service users. However, it is evident from their responses to this survey that the task of restoring services which were paused as part of the early response to COVID-19 is complex.
Reconfiguring the NHS to respond to the pandemic was a monumental effort, and there is further complexity inherent in modelling demand, prioritising according to need, ensuring the workforce is available to provide services, managing the need for testing and isolation of patients as well as separating COVID-19 and non-COVID-19 patients, which makes restoring services a lengthy process.
Trusts have made clear that the ‘return to a new normal’ will not mean returning to the way the NHS operated before the COVID-19 pandemic. NHS providers and their staff have already undertaken rapid innovation, often working together and with other local partners in systems to prepare for COVID-19 and continue to provide non-COVID care in the most urgent cases. Trusts are not looking to return to the old ways of working where helpful recent innovations could be embedded. But there are challenges which must be addressed, including around capacity, changes in the volume and profile of demand, and uncertainty surrounding the future behaviour of the virus and the potential for further outbreaks.
This means trusts need sustained realism from government and the national bodies about how they will return to full operation, and over what timeframe. While the public should have full confidence that the NHS is there to treat and care for them when they need it, we also need a much more open conversation about the differences we will all see in how that care is delivered for some time to come.
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