Ninth report - Clearing the backlog caused by the pandemic

Our key new recommendation is that, by April 2022, the Department of Health and Social Care works with NHS England to produce a broader national health and care recovery plan that goes beyond the elective backlog to emergency care, mental health, primary care, community care and social care. It should be sensitive to the needs of local populations, incorporate the plans already announced in the ten-year plan, and explain how they will be delivered by the new Integrated Care Boards (ICBs). That plan must also set out a clear vision for what ‘success’ in tackling the backlog will look like to patients. In setting those metrics for success, the plan must take account of the risk that a reliance on numerical targets alone will deprioritise key services and risk patient safety. Instead, it must embrace a range of indicators to demonstrate that hidden backlogs are also being tackled and compassionate cultures encouraged.

It is not appropriate to set a numerical target for the proportion of appointments carried out remotely in general practice. Instead practices should respond to the needs of their local populations and work together with patients to establish the most fitting medium for their consultations based on clinical outcomes. Remote care is not for everyone, and it is essential to avoid unintended clinical consequences that may occur.

NHS England has already commissioned an evaluation of the role of digital tools in primary care. We recommend that it publishes that evaluation at the earliest opportunity and uses it as a basis to produce clear and consistent guidance on best practice in • Reducing bureaucracy and day-to-day IT administration tasks, including those associated with referrals, routine blood tests, and follow-up appointments. • The use of remote consultations in general practice. This should include guidance on how to approach conversations with patients about remote care, considering that while patients may not necessarily always be able to have a face-to-face appointment, they should have input into the decision and the rationale for any refusal should be transparent and consistent.

We further recommend that NHS England looks beyond primary care in its assessment of the use of digital tools and considers the impact of an increased usage of such tools not only on patients, but also on other parts of the health and care system, especially at the primary care and secondary care interface

Managed well, we see enormous potential for a beefed-up version of 111 to regulate the demands on emergency departments and ensure that patients get the right care, in the right place, at the right time. However, we acknowledge concerns that without sufficient clinical validation these objectives cannot be met. Without robust evidence from the evaluation of the pilot so far, we cannot judge its success Clearing the backlog caused by the pandemic 35 or suggest improvements. We are already part of the way through a challenging winter—if findings are not available soon, NHS England risks missing opportunities to improve services at this crucial time.

We therefore recommend that NHS England completes and publishes evaluations of NHS 111 call first services as soon as is practicable, including learning from those evaluations and the implications for any future iterations of the service.

The response to long covid shows both the kind of integrated, patient-centred care the NHS can provide when systems work effectively, and the frustration and detriment experienced by patients who have to “fight” to access to the right care when systems do not work effectively. We heard that long covid provided an opportunity to develop truly integrated services, and that care—although variable—was excellent in the best centres. We welcome NHS England’s commitment to provide effective long covid services. However, during our inquiry we heard heart-rending testimony from people who had struggled to access the care they needed, and who did not feel believed or cared for. This is simply not acceptable. We note that NHS England’s current plan for long covid extends to 2022. With covid-19 set to become endemic, NHS England must ensure that its plans to tackle long covid continue. We understand that knowledge of covid-19 and long covid is constantly evolving, and that plans will therefore need to adapt over time, but we are likely to see increasing numbers of people living with this condition. We cannot afford to let them down.

We therefore recommend that NHS England publishes, before the end of this financial year, a long covid plan covering the period until 2023. The plan must be developed in consultation with a wide range of stakeholders, including patient groups. NHS England should integrate this into its wider health and care recovery plan, as long covid is likely to have implications for demand and workforce across a range of services.

It is not acceptable for patients awaiting planned treatment or feeling the debilitating effects of long covid to feel “abandoned” by the NHS. We appreciate the uncertainty about the length of future waiting lists, but this is no excuse for lack of communication—whether this be confirmation of a patient’s next round of treatment or simply a conversation to assure them that they have not been forgotten. We heard that waiting lists are not static, that conditions can worsen, and that active management is recommended. A commitment to keeping in touch would not just benefit individual patients, but also help local systems actively to manage their lists and inform decisions about prioritisation.

The national health and care recovery plan must set out a clear vision for what ‘success’ in tackling the backlog will look like, and what patients can expect their care to look like in their local area in the coming years. The plan must include minimum expectations for ICBs in managing waiting lists actively and communicating with patients awaiting planned care. The Department of Health and Social Care, NHS England and local ICBs must share responsibility for communicating the ‘offer’ to the wider public, considering the “social backlog” facing many members of the public. We request the Department of Health and Social Care to report back to us on how this will be delivered. (Paragraph 66) 36 Clearing the backlog caused by the pandemic

Lastly, we heard that patient involvement in services was important to tackle long covid. It should also be taking place in other areas. We have previously called for the Care Quality Commission’s assessments of Integrated Care Systems (ICSs) to include consultation with patient groups and patient outcomes, and we continue to believe in the importance of this.

We again recommend that the Care Quality Commission includes consultation with patient groups and details of patient outcomes in its assessment of ICSs. (Paragraph 68) Funding and policies to tackle the backlog

The pandemic has had a negative impact on health inequalities and highlighted the crucial importance of effective public health services in supporting local populations. Public health services are therefore vital allies in tackling the backlog, and we are surprised at the decision merely to maintain current public health grant funding levels.

As part of its national health and care recovery plan, we recommend that the Government sets out the contribution that public health services will make, and ensures that this contribution is backed with a level of funding that acknowledges their crucial role.

We note that the Government decided to resist an amendment to the Health and Care Bill that would have required it to publish independently verified assessment of health, social care and public health workforce numbers at least once every two years, leaving a gap between its rhetoric about supporting frontline staff and the biggest single long-term measure that would relieve that pressure. Without an independent forecast of future workforce needs, it remains impossible for anyone to know whether enough doctors, nurses or care staff are being trained. We still believe that giving an assurance to NHS staff that the appropriate number of new staff will be trained in the future is the biggest single long-term measure the Government can take to gain the confidence of frontline staff that it has a grip of this problem. Unless it can do that, the risk is that generous taxpayer-funded settlements for services or capital are wasted.

We repeat our recommendation that HEE must be required (whether in its own right or as part of NHS England) to publish objective, transparent and independently-audited annual reports on workforce projections that cover the next five, ten and twenty years, including an assessment of whether sufficient numbers of staff are being trained. These projections must cover social care as well as the NHS given the close links between the two systems. We urge NHS England to ensure that workforce planning is included in any future iterations of the elective recovery plan.

We recommend that the Government undertake an urgent review of short-term recruitment and retention issues within the health and care workforce, including productivity improvements, sharing of best practice through data, removal of professional demarcation, use of technology, additional training places and additional immigration measures. This should be published before the arrival of the funding due in early 2022. (Paragraph 94) Clearing the backlog caused by the pandemic 37

Investing resource in our health and care workforce will ultimately save money— for example through reduced locum and agency fees over time—and help build a better, safer health service. It will also give hope to staff—who are feeling increasing desperate and who face yet more challenges on top of those posed by the early phases of the pandemic.

We call on NHS England to demonstrate its ongoing commitment to staff wellbeing by publishing a refreshed People Plan to cover the financial year 2022/23 as soon as is practicable.

An NHS running too ‘hot’ for patients to move from crowded emergency departments into wards cannot provide safe, efficient or effective care in the long- term. Furthermore, the advent of ICSs offers an opportunity to provide patients with more integrated care so that they can leave hospital promptly once medically fit.

As part of its broader health and care recovery plan, the Government must produce an independently-verified analysis of how many, and what type, of extra beds the NHS needs in order to provide safe and effective everyday care for patients, whilst also responding to need directly created by the pandemic. This plan must be accompanied by sustainable, long-term plans to tackle delayed discharges.

We welcome the £2.3bn pledged in the Spending Review to create around 100 new community diagnostic hubs, but we are yet to see detailed plans for their implementation.

Ahead of the arrival of the new funding from the Spending Review in Spring 2022, we recommend that Government provides more details on the 100 new community diagnostic hubs, including where they will be placed, who will staff them and how they will contribute to service improvement within and beyond the covid-19 landscape.

Access to care should not be dependent on where you live in the country. Regional and national co-ordination will be necessary to ensure that strategies aimed at tackling the backlog do not have the unintended consequence of increasing health inequalities.

We recommend that NHS England, together with ICBs and the new Office for Health Improvement and Disparities (OHID), work together to deliver regional and national coordination as the system tackles the backlog in elective care. If the independent sector is to prove an effective partner in tackling that backlog, the Government must ensure that plans take into account people living in those areas with less access to independent care. The goal must be equity of access to care on waiting lists regardless of geographic location.

We have heard much about how a robust social care system that can support hospital discharges and free up capacity is essential to clear the backlog. We welcome the inclusion of the social care workforce in the refreshed Framework 15. Social care, however, did not receive an adequate settlement in the spending review, with the £5.4 billion over three years falling well short of the £7 billion annual increase we have previously recommended. Even after the spending review period, there 38 Clearing the backlog caused by the pandemic is no guarantee of additional funding from the Health and Social Care Levy, so we remain very concerned that social care will remain the poor relation. Without the right support for social care, a recovery plan for the NHS is doomed to failure.

In light of the Government’s commitment to reform social care, we again recommend that it publishes a ten-year plan for social care, setting out how it in detail how it will tackle the structural and financial problems the sector faces in the short-term, and operationalise its longer-term ambitions. The Government must also acknowledge the needs and wellbeing of staff working in the social care sector by publishing a People Plan for social care, aligned to the ambitions set out in the NHS People Plan.

To encourage better integration and mutual understanding across health and social care, we again recommend that a duty is placed on ICSs so that where a decision by an ICS affects carers and the social care sector, the ICS must undertake a formal consultation with the groups and sectors affected.

There is enormous potential for technology to support a transformation in NHS care that will bring benefits for patients and staff alike. However, this potential will not be realised while many providers still struggle with basic IT infrastructure. The Wade-Gery report calls for a roadmap for the delivery of its recommendations.

NHS England must produce its roadmap in response to the Wade-Gery report on Putting data, digital and tech at the heart of transforming the NHS at the earliest opportunity so that we and others are able to scrutinise it ahead of implementation.

The upcoming national introduction of ICBs provides the opportunity for local integration and innovation. This opportunity must not be wasted, particularly in the context of the backlog. There must be clear incentives for ICBs to deliver integrated and innovative care, with ICSs held accountable for the care they deliver.

We have previously recommended that Care Quality Commission ratings include an assessment of the progress ICBs make on the integration of information technology between primary care, secondary care, and the social care sector. We repeat this recommendation here. Although the CQC is an independent body, we believe that including the delivery of integrated care and the effective use of technology within the domains it inspects would encourage further progress on integration.

We recommend the Government creates a platform to share examples of good practice and innovation at ICB level so that lessons can be learnt, and practices adapted in ways that reflect the health needs of local areas. Without this, the risk of regional inequalities in waiting lists and postcode lotteries will continue.

We again recommend that a duty be placed on ICBs for them to have regard to mental health and public health. (Paragraph 128) Clearing the backlog caused by the pandemic 39