Delivering Core NHS and Care Services during the Pandemic and Beyond

The pandemic has presented an unprecedented challenge to the NHS and the Government. Whilst we have no doubt that often communication to patients was as effective as could reasonably be expected in the context of a pandemic, this was not always the case. As we set out in our letter to Rt Hon Matt Hancock and Sir Simon Stevens on 21 July 2020, the patient experience for some has been unacceptably poor, leaving them feeling like they have been left in “limbo” or “in the lurch”. Unnecessary anxiety and stress has been caused to those patients due to poor communication not just from their local hospital about the scheduling of appointments or access to treatments, but from national bodies, and on key items of guidance such as on shielding. Some sections of the public have been left thinking the NHS is not working on routine non-COVID conditions, this in conjunction with the fear of some patients about going into hospitals where there could be a risk of catching COVID-19, is having a significant impact and needs addressing.

Notwithstanding the actions taken to date, we recommend that NHS England & Improvement review, as a matter of priority, the directions given to NHS Trusts about how to communicate with patients about the progress of their treatment and important medical guidance in any future spike or second wave. As part of this review, NHSE/I must ensure that patients are always treated with dignity and compassion. We ask that as part of that review, NHSE/I makes an assessment of its and hospitals’ communication with patients—and provide us with an update by the end of October 2020. We also ask, as part of this review, that NHSE/I address how they will communicate to the general population to ensure that the public gets the message that the NHS is open, and that those who have fears of catching COVID-19 in medical settings are not discouraged from accessing medical treatment. (Paragraph 22) Waiting times and managing the backlog of appointments

The pandemic has placed an unprecedented burden on the delivery of core NHS and care services. This has resulted in the delay, suspension or cancellation of services which in turn has inevitably led to a significant increase in waiting times, the backlog of appointments and pent-up demand for medical treatments. We are concerned that this has, in part, been created as a result of many individuals being too scared to access the medical treatment they require because they are uncertain as to whether NHS services are safe to use.

We recognise the commitment of policy makers and the NHS leadership to restoring core NHS services and the ongoing efforts to manage the backlog. We are also grateful for the hard work of all staff and the use of innovative methods to support core NHS services during the pandemic, including: the creation of cancer hubs, Urgent Dental Centres and COVID-light facilities. We are concerned, however, that despite such innovations many core health services have been unable to continue or Delivering core NHS and care services during the pandemic and beyond 63 have continued with very limited capacity. In March 2020, Sir Simon Stevens issued an instruction that cancer services should not be stopped, but it is clear that this instruction was not always adhered to.

During our session on 30 June 2020, Sir Simon Stevens told us that he “expects” waiting times for and referrals to core health services to “go up quite significantly over the second half of the year.” We also heard from Sir Simon, Amanda Pritchard and Professor Steve Powis of the importance of restoring core services for patients. It nevertheless remains unclear to us what practical steps the Government and NHSE/I are taking and are planning to take to reduce waiting times, meet the backlog of appointments and prepare the NHS for addressing pent-up demand. The absence of a public plan to address these issues may be contributing to the inability of local trusts to inform patients when they can expect to receive a long-awaited medical procedure. Nevertheless, we do also recognise the significant difficulty in planning ahead when the risk of a second spike remains unclear.

We recommend that the Department of Health & Social Care and NHSE/I provide an update on what steps they have, individually and collectively, taken and are planning to take to quantify and address the overall impact of the pandemic on waiting times, the backlog of appointments and pent-up, and as yet unknown and unmet patient demand for all health services, specifically across cancer treatments, mental health services, dentistry services, GP services and elective surgery. We also ask the Department and NHSE/I to provide a comprehensive update on what steps are being taken and what steps will be taken in the future to manage the overall level of demand across health services. We request this information by the end of October 2020.

We also recommend that NHSE/I provides us with a more broader update on what positive innovations or changes have taken place in the NHS during the pandemic, and how it seeks to ensure all the positive changes that have occurred are captured and potentially implemented across the entire NHS. We expect this information by the end of 2020.

We further conclude that the delivery of dental services in England has been significantly hindered by the pandemic. This has been largely due to the need to protect both patients and staff from COVID-19 which has, in turn, presented financial challenges to both NHS and private dental practices. We welcome NHSE/ I’s continued efforts to support the restoration of dentistry services in England.

We are concerned that there does not appear to be a plan for the restoration of dental services in England. We recommend that Sara Hurley (Chief Dental Officer for England) sets out her assessment of the challenges facing dentistry services in England, and clarifies what steps will be taken to ensure dentistry services are able to continue to be restored to meet patient demand in the safest possible way whilst also remaining financially sustainable. (Paragraph 68) 64 Delivering core NHS and care services during the pandemic and beyond Issues facing NHS and care staff: PPE and testing Personal Protective Equipment (PPE)

We recognise the unprecedented scale of the challenge facing the Government and NHSE/I to keep NHS and care staff safe during the pandemic. As in other countries facing the pandemic there were, however, persistent failures with the procurement and supply of appropriate personal protective equipment (PPE) to some NHS and care staff, particularly during the early stages of the pandemic. It is important to recognise that different staff will require different types of PPE and there is a need to make sure that the PPE available is suitable for a diverse work force. We welcome the appointment of Lord Deighton as adviser on PPE to the Secretary of State for Health and Social Care. Lord Deighton’s evidence gave us confidence that the issues relating to PPE which have been raised with us will be prioritised and addressed.

We request an update from the Department of Health & Social Care by the end of November 2020 on what steps are being taken to ensure that there is a consistent and reliable supply of appropriately fitting PPE to all NHS staff in advance of the onset of winter and a potential second wave. (Paragraph 87) Routine testing of all NHS and care staff

We are grateful to Professor Chris Whitty (Chief Medical Officer) and his expert colleagues for their continued and constructive engagement with our work. We also recognise that the Government, following the advice of the Chief Medical Officer and others, has taken a considered approach to implementing the SIREN study. We note that the Government aims to utilise the SIREN study to better inform the frequency at which, and under what circumstances, the testing of NHS staff for coronavirus ought to take place.

We accept the advice we have received from many eminent scientists that there is a significant risk that not testing NHS staff routinely could lead to higher levels of nosocomial infections in any second spike. We therefore urge the Government to set out clearly why it is yet to implement weekly testing of all NHS staff.

We note that Professor Chris Whitty has said that the testing of asymptomatic staff may be necessary in the future and that if there is a “surge in winter” of coronavirus cases then he would be likely to advise that routine testing of NHS staff should take place. However, we are concerned that contrary to this advice, routine testing of asymptomatic NHS staff appears not to have been introduced where the virus is already surging in the North East and the North West, perhaps due to capacity constraints.

We ask that Professor Whitty sets out to what extent testing capacity has impacted the advice he and his colleagues have provided to the Government on routine testing of NHS staff. We further ask Professor Whitty to clarify whether he has advised the Government to introduce routine testing of all NHS staff in the current virus hotspots and if not why. (Paragraph 123) Delivering core NHS and care services during the pandemic and beyond 65

We conclude that the case for routine testing of all NHS staff in all parts of the country (including clinical staff as well as cleaners, porters and so forth) is compelling and should be introduced as quickly as capacity allows and before the winter-flu season begins. Those who—either directly or indirectly—provide treatment to patients should not be put at any further unnecessary risk of catching or spreading COVID-19. We urge that steps be taken to expand capacity rapidly to make this possible.

We recommend that, by the end of October 2020, the Government and NHSE/I set out: i) what current capacity there is for testing all NHS staff, ii) what further capacity (if any) will be required and iii) how long it is likely to take to secure sufficient capacity to offer routine tests to all NHS staff. (Paragraph 125) Issues facing NHS and care staff: fatigue and “burnout” NHS and care workforce wellbeing during the pandemic

We are extremely grateful to all NHS and care staff for their hard work and dedication in trying to meet patient needs in such exceptional circumstances. This includes those who have returned to the NHS (such as clinicians returning from academia, retirement and other industries); students who have left their training early to do so, and staff that have been redeployed to manage capacity constraints in other areas of the NHS. We share concerns that some NHS and care staff are suffering from fatigue, exhaustion and a general feeling of being “burnt out” and that the wellbeing of staff (particularly their mental health) is at significant risk.

We are grateful for NHSE/I’s continued support of NHS staff and welcome the further measures set out in the People Plan (July 2020) for the 2020–21 period. In particular, we welcome the important and ambitious measures set out in the People Plan which show a clear desire to address workforce fatigue and provide mental health support to NHS staff. However, given the pressures on recruitment and retention of staff, we are concerned that the People Plan does not set out future workforce recruitment objectives, therefore failing to address one of the biggest concerns that many staff have, namely whether there will be enough of them to give high quality care to patients. We also believe more must be done to support the mental wellbeing of staff. Helplines, apps, webinars and managerial training will all be of value but with many members of staff facing much more severe and sustained pressures on their mental health, more substantive action will need to be taken to support the wellbeing of staff, particularly before the busy winter period. We note that the People Plan states further announcements will be made once the Government has confirmed funding arrangements for the NHS.

We recommend that NHSE/I set out in detail what further specific steps it would like to take over the coming years to support the mental and physical wellbeing of all staff and a plan to deal with the specific issue of sustained workplace pressure due to the current pandemic and backlog associated with the coronavirus. This information should be made available to us in advance of any forthcoming Government spending announcements or by the end of October 2020 (whichever is earlier) in order for 66 Delivering core NHS and care services during the pandemic and beyond us to clarify what NHSE/I’s priorities for NHS staff are, and to judge how far the Government’s eventual spending commitments enable their implementation.

We further recommend that NHSE/I should develop a full and comprehensive definition of “workforce burnout”, and set out how the wellbeing of all NHS staff is being monitored and assessed. This information should be made available to us by the middle of October 2020, to enable us to scrutinise it in the course of our inquiry into Workforce Burnout and Resilience in the NHS and social care.

We note, meanwhile, that there is no equivalent of the NHS People Plan for the social care workforce. We will have more to say about support for those working in social care in our forthcoming report on Social care: workforce and funding. (Paragraph 141) Support for BAME NHS staff members

The NHS is founded on the principle of equality and is one of the most diverse and inclusive organisations in the UK. It hugely benefits from the diversity of its staff as in turn so does the nation. In recent months, there has been a much-needed focus on supporting NHS staff from a Black, Asian and Minority Ethnic background (BAME). COVID-19 has, regrettably, disproportionately harmed and resulted in excess BAME deaths. We welcome the introduction of risk assessments and other initiatives, as set out by Professor Steve Powis, which are being implemented to protect BAME NHS staff from the risk of catching coronavirus.

We have also heard that some BAME NHS staff face discrimination and racism in the NHS and that, across the NHS, the levels of diversity must be improved. We accept Sir Simon Stevens’ comments that “there are systemic features to discrimination and racism, and the NHS is both part of the problem and part of the solution”. Nonetheless, it is unacceptable that any BAME NHS employee should face discrimination, harassment or racism when working for the NHS. It is clear that more must be done to ensure that all NHS staff—regardless of their race, ethnicity or cultural heritage—feel safe, confident and proud to work for the NHS.

The NHS must increase its efforts to eradicate all forms of discrimination and racism from in its organisation. We therefore recommend that NHSE/I provide a full and comprehensive definition of the “racism and discrimination” that it seeks to eradicate from the NHS. We invite NHSE/I and the Department for Health & Social Care to set out in detail its strategy to tackle racism and discrimination and to promote diversity in the NHS, including information on targets and deadlines by the end of

Historically, accident and emergency departments have been over-stretched, over- burdened and running over capacity. We have heard that the initial decline in patient attendances at A&E departments during the pandemic to some extent “cured” the problem of “corridor care”. However, as presentations at A&E begin to increase, the Government and NHSE/I need to ensure emergency departments do not become overwhelmed by patient demand and remain able to provide high-quality and safe treatment for all patients.

We welcome the news that the Government and NHSE/I are piloting a ‘111 dial first’ scheme to support the triaging of patients before they attend A&E departments. The introduction of an expectation that a patient will call first before walking into an A&E department is a sensible change to support A&E departments during the pandemic, and has much to commend it as a long-term reform. We recommend that the Department and NHSE/I provide us with an update by the end of November 2020 on the progress of these pilots and other steps that are being taken, in both the short and long-term, to support A&E departments. (Paragraph 170) Technology and digital alternatives (“telemedicine”)

We welcome the support of the Secretary of State and the Chief Executive of NHSE/I for technological innovation in the NHS. The use of technology and digital alternatives (“telemedicine”), although it has had a mixed response from some patients and medical practitioners, shows that the NHS is innovating. We also welcome the wider deployment of technology which has helped to improve productivity across the healthcare system. Although the use of technology has been much-needed and largely worked in supporting the delivery of health and care services, there is nevertheless a risk that many individuals in need of medical advice or treatment will be digitally excluded. Therefore, in order to ensure telemedicine benefits all patients equally, a clearer and more comprehensive assessment is required to ensure that technology does not replace key elements of health services (such as face-to- face consultations) or disadvantage other groups, and to also ensure the benefits of telemedicine can be maintained and built-upon. Parts of the NHS have also explored new options for the delivery of care, trialling new pathways for treatment. These hold real promise for future NHS productivity. It is vital that successful examples of innovation in models of service delivery during the pandemic are brought forward, alongside technological and digital innovation.

We recommend that NHSE/I and the Department for Health & Social Care set out their assessment of how effective the use of technology and digital alternatives (“telemedicine”) has been across all health and care services. As part of this assessment, we ask that both NHSE/I and the Department to clearly set out how they plan to ensure patients’ wellbeing is not jeopardised by the risk of being digitally excluded from accessing medical treatment and advice. We also ask that NHSE/I and the Department set out what aspects of telemedicine have worked well, including which new models of service delivery have worked particularly well, and what plans there are 68 Delivering core NHS and care services during the pandemic and beyond (if any) to invest in and support the further use of such technology and new pathways in the health and care system. We request an update on these matters by the end of

We commend the efforts of the Government, NHSE/I and the independent sector for stepping up and securing independent sector capacity (i.e. beds, staff and facilities) which has been crucial to supporting the NHS during the pandemic. It is clear that such independent sector capacity will be needed over the coming months as the restoration of core healthcare services is prioritised, particularly over the winter period.

We recommend, in addition to our recommendations in Chapter 2, that the Government and NHSE/I clarify what plans there are to continue to use independent bed capacity and other independent resources as the winter period approaches. We further recommend that the Government and NHSE/I set out i) what the current level of capacity is across all NHS services, ii) what assessment it has made of what additional capacity will be required, in the medium and long term, to ensure the restoration of non-COVID NHS services and iii) what level of capacity it is expecting and planning to retain from the independent sector in the medium and long term. We expect this information by the end of October 2020. (Paragraph 194) Delivering core NHS and care services during the pandemic and beyond 69