Recommendations & Conclusions
14 items
2
Recommendation
Fifty-Third Report - Covid 19: supporti…
Accepted
DHSC and NHS Digital took too long to identify all clinically extremely vulnerable people. Individuals were not formally eligible for the central support of food boxes and medicines delivery offered through the shielding programme until they were on the Shielded Patients List. NHS Digital used national hospital and GP data …
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DHSC and NHS Digital took too long to identify all clinically extremely vulnerable people. Individuals were not formally eligible for the central support of food boxes and medicines delivery offered through the shielding programme until they were on the Shielded Patients List. NHS Digital used national hospital and GP data to identify clinically vulnerable people. However, it took over six weeks for the number of people on the Shielded Patients List to stabilise at 2.2 million people, with 900,000 people added between 18 April and 7 May. The time taken to add people was because of the need to work with GP IT system providers to design, build and gather GP data, which were on different systems to the readily available national data, and then to complete the next necessary step of GPs and hospitals using their clinical judgement to add and remove people from the list. NHS Digital believes that faster access to data in GP records would help. It also suggests that government invest in the digitisation of hospital records, noting that primary care data has been digitised, and is now a richer source of information than hospital data. Recommendation: Within six months, DHSC and NHS Digital should set out a detailed plan on how they will improve access to and join-up NHS data systems to ensure quick and secure access to all patient records.
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Government response AI summary
The government commits to learning lessons from identifying CEV people and improving national data use. Work is underway on a national GP dataset and digitising the health service with shared care records, which will be detailed in a forthcoming draft data strategy for health and …
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HM Treasury
3
Recommendation
Fifty-Third Report - Covid 19: supporti…
Accepted
Huge local variation strongly suggests that GPs were inconsistent when judging who was clinically extremely vulnerable and should therefore be advised to shield and be eligible for support. As well as NHS Digital using national data to identify clinically vulnerable people, GPs and hospital doctors were quite sensibly asked to …
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Huge local variation strongly suggests that GPs were inconsistent when judging who was clinically extremely vulnerable and should therefore be advised to shield and be eligible for support. As well as NHS Digital using national data to identify clinically vulnerable people, GPs and hospital doctors were quite sensibly asked to review those listed, and, using their clinical judgement, add or remove people. The 6 Covid 19: supporting the vulnerable during lockdown list grew from 1.3 million to 2.2 million largely as a result of GPs adding people. However, the extent to which it grew varied hugely in different areas, with increases in those being added between 12 April and 15 May ranging from 15% to 352% by local authority. DHSC acknowledges that clinicians took different approaches to adding people. DHSC and NHS Digital believe they did everything possible to ensure consistency, where they identified possible over-inclusion or over-exclusion, they have worked with NHS England’s clinical directors to challenge some of the differences. DHSC tells us that NHSE&I and NHS Digital consider that ultimately additions were a decision for local clinicians. DHSC has also provided us with details of NHS Digital’s analysis of the variation as of 11 February 2021. Based on this analysis, DHSC concludes that the level of variation in how local clinicians added people to the list is acceptable. However, and despite the best intentions of all involved, it is not credible to assert that the same criteria and judgements were applied consistently in all parts of the country when the extent of local variation in numbers added was so vast. Recommendation: Within six months, DHSC and NHS Digital should provide to the Committee a detailed explanation for the local variation in growth for the shielded patient list between April and May 2020 including the extent it was due to appropriate clinical judgements and identify lessons for how to support a consistent clinical approach in future.
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Government response AI summary
The government agrees there was huge local variation and commits to conducting further analysis to understand the drivers and identify lessons for the future, with findings to be provided to the Committee by October 2021.
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HM Treasury
4
Recommendation
Fifty-Third Report - Covid 19: supporti…
Accepted
Government chose a centrally-directed system to support clinically vulnerable people as it did not have confidence all local authorities and supermarkets could meet people’s needs, particularly for food. MHCLG spoke with some local authorities and supermarkets early on to assess their capacity, but could not do a full assessment of …
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Government chose a centrally-directed system to support clinically vulnerable people as it did not have confidence all local authorities and supermarkets could meet people’s needs, particularly for food. MHCLG spoke with some local authorities and supermarkets early on to assess their capacity, but could not do a full assessment of local authority capacity to support the most vulnerable because of the urgency of the task. Instead, it used the information it had available to have a centrally-directed supply of food boxes which cost £200 million, as this was likely to guarantee a supply of food to every part of England, particularly given its concerns about shortages in supermarkets. However, some local authorities had queried why government chose a centrally-directed rather than a local system of support, particularly for food, and felt that they would have provided better quality support. Starting in April, as confidence grew in the supply chain and as it developed its understanding of local authority capacity, MHCLG moved to a locally-led model which was in place by summer 2020. This model focused on access to supermarket deliveries and having local authorities offer food to suit the needs of the local population where needed. MHCLG calculates that it has provided local authorities some £4.6 billion in un-ring-fenced funding in 2020–21 to help with COVID costs. Recommendation: MHCLG should ensure that local authorities will continue to have the capacity and resilience to support the needs of clinically extremely vulnerable people, particularly given the significant increase of people advised to shield in February 2021 – from 2.2 million to 3.9 million people.
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Government response AI summary
The government disagreed that a centrally-directed system was chosen due to lack of confidence in local authorities, highlighting councils as crucial partners. They stated that councils received funding, demonstrated good performance, and MHCLG continues to work closely with them and keep funding under review to …
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HM Treasury
8
Conclusion
Fifty-Third Report - Covid 19: supporti…
Accepted
DHSC told us it recognised that advising people to stay inside and away from society does have risks as well as benefits. Of those surveyed, some 36% reported worsening mental health and wellbeing while shielding.14 Charities also told us of the impact of lockdown on people not categorised as clinically …
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DHSC told us it recognised that advising people to stay inside and away from society does have risks as well as benefits. Of those surveyed, some 36% reported worsening mental health and wellbeing while shielding.14 Charities also told us of the impact of lockdown on people not categorised as clinically extremely vulnerable people. They reported how the over 70s and the blind and partially sighted, who were not advised to shield, and therefore not eligible for support through the Programme, struggled to access food. The Royal National Institute for the Blind wrote that the government’s ‘one size fits all’ approach left many blind and partially sighted people behind.15 Identifying all clinically extremely vulnerable people
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Government response AI summary
The government acknowledges the difficulties faced by non-clinically vulnerable groups and highlights existing support services such as priority supermarket referrals and NHS Volunteer Responders, committing to consider future preparedness measures for such groups.
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HM Treasury
9
Conclusion
Fifty-Third Report - Covid 19: supporti…
Accepted
The list of medical conditions that the chief medical officers developed to define clinically extremely vulnerable people was shared with NHS Digital on 18 March 2020. DHSC tasked NHS Digital to use patient data to identify those affected and create a list of people to be advised to shield (the …
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The list of medical conditions that the chief medical officers developed to define clinically extremely vulnerable people was shared with NHS Digital on 18 March 2020. DHSC tasked NHS Digital to use patient data to identify those affected and create a list of people to be advised to shield (the shielded patient list – or the list).16 NHS Digital held or had easy access to some patient data but GP data were held within GP IT systems, which were not immediately accessible to NHS Digital.17
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Government response AI summary
The government disagrees with the conclusion that identification took too long but states it is committed to learning lessons and that work is already underway to develop a strategic national GP dataset, digitize the health service, and publish a data strategy.
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HM Treasury
12
Conclusion
Fifty-Third Report - Covid 19: supporti…
Accepted
DHSC acknowledged that there are advantages with NHS data systems—such as having large amounts of data—and disadvantages, for example challenges in connecting and using legacy systems.24 We asked NHS Digital what would help to identify patients earlier. NHS Digital told us this would require a technical solution, faster access to …
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DHSC acknowledged that there are advantages with NHS data systems—such as having large amounts of data—and disadvantages, for example challenges in connecting and using legacy systems.24 We asked NHS Digital what would help to identify patients earlier. NHS Digital told us this would require a technical solution, faster access to GP data would help, while ensuring that the general practice which collects the data is comfortable with how it will be used. NHS Digital also suggested that government invest in the digitisation of hospital records, noting that primary care data has been digitised, and is now a richer source of information than hospital data.25 Local variation in the extent to which people were added to the Shielded Patient List
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Government response AI summary
The government stated that work is already underway, with NHS Digital developing a national GP dataset for faster access to information and working on digitising health records and shared care. These developments will be outlined in a forthcoming data strategy for health and social care.
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HM Treasury
13
Conclusion
Fifty-Third Report - Covid 19: supporti…
Accepted
NHSE&I asked GPs and hospital doctors to add or remove people from the list, based on their clinical judgement, and as their patients’ conditions or treatments changed over time.26 However, the extent to which the list grew between 12 April and 15 May 2020 varied hugely in different areas, with …
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NHSE&I asked GPs and hospital doctors to add or remove people from the list, based on their clinical judgement, and as their patients’ conditions or treatments changed over time.26 However, the extent to which the list grew between 12 April and 15 May 2020 varied hugely in different areas, with increases in the list ranging from 15% in Carlisle to 352% in Hounslow, with an average increase across local authorities of 73%. This was not a small number of authorities with variance from the average 73%: 33 authorities saw their list sizes more than double between these dates, whereas 17 saw their list sizes increase by less than a third over the same period.27
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Government response AI summary
The government agrees to provide a detailed explanation for the local variation in the shielded patient list growth and identify lessons for a consistent clinical approach, committing to send these findings to the Committee by October 2021.
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HM Treasury
14
Conclusion
Fifty-Third Report - Covid 19: supporti…
Accepted
NHSE&I was not responsible for managing any local variations and did not challenge local clinical decisions.28 DHSC has told us that NHSE&I and NHS Digital considered that ultimately additions were a decision for local clinicians. It noted that the approach to local additions was endorsed by the UK Chief Medical …
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NHSE&I was not responsible for managing any local variations and did not challenge local clinical decisions.28 DHSC has told us that NHSE&I and NHS Digital considered that ultimately additions were a decision for local clinicians. It noted that the approach to local additions was endorsed by the UK Chief Medical Officer who provided guidance on 18 Q 21; C&AG’s Report, paras 12, 2.5 19 Qq 21–22 20 Q 21; C&AG’s Report, para 2.6 21 C&AG’s Report paras 2.5, 2.10 22 SVL0002 - Written Evidence submitted by Asthma UK and the British Lung Foundation p.3 23 C&AG’s Report, para 2.6 24 Qq 23–24 25 Qq 21–22, 97–98 26 Qq 21, 23, 25; C&AG’s Report, para 2.6 27 C&AG’s Report, Figure 8, analysis of underlying data 28 C&AG’s Report, para 2.9, Figure 8 Covid 19: supporting the vulnerable during lockdown 11 the shielded patient list. DHSC also explained to us how NHSE&I and NHS Digital took steps to try to ensure this process was consistently applied across England. For example, it told us how on 12 April NHS Digital noticed that additions by GPs showed wider than expected variation and identified that GPs were adding patients in bulk using computer searches rather than assessing individual patients. In response, NHSE&I told GPs that there should be no automated process used to compliment or supplement individual clinical identification.29
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Government response AI summary
The government agrees to provide a detailed explanation for the local variation in the shielded patient list growth and identify lessons for a consistent clinical approach, committing to send these findings to the Committee by October 2021.
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HM Treasury
15
Conclusion
Fifty-Third Report - Covid 19: supporti…
Accepted
NHS Digital told us that for the people whom it had identified and added centrally to the list, in line with the clinical criteria set by the chief medical officers, there is very little variation by area.30 DHSC acknowledged that it has seen variation in regions, and in local areas …
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NHS Digital told us that for the people whom it had identified and added centrally to the list, in line with the clinical criteria set by the chief medical officers, there is very little variation by area.30 DHSC acknowledged that it has seen variation in regions, and in local areas clinicians would have adjusted their approaches when adding people. DHSC explained that in a few cases it tried to understand whether variation reflected a genuine underlying illness, or different thresholds for adding people to the list.31
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Government response AI summary
The government agrees to provide a detailed explanation for the local variation in the shielded patient list growth and identify lessons for a consistent clinical approach, committing to send these findings to the Committee by October 2021.
Read full response →
HM Treasury
16
Conclusion
Fifty-Third Report - Covid 19: supporti…
Accepted
We asked DHSC if it had created a postcode lottery of support, and if people with certain conditions in some areas, would have different support to people in other areas with the same conditions.32 DHSC told us that it did everything possible to ensure that it had consistent application of …
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We asked DHSC if it had created a postcode lottery of support, and if people with certain conditions in some areas, would have different support to people in other areas with the same conditions.32 DHSC told us that it did everything possible to ensure that it had consistent application of the policy. NHS Digital and DHSC explained that where they saw areas that had high or low numbers of people being added, they had worked with NHS clinical directors to challenge these areas and followed some up directly.33 As a result of such work, DHSC was confident that it had not identified any systematic differences in approach, and that were there was variation, there was no indication that guidance had not been consistently applied. DHSC told us that it also worked with the Royal College of General Practitioners, who had training modules to try and ensure that there was a consistent understanding and approach in adding people to the list.34 DHSC also provided us details of NHS Digital’s analysis of the variation of 11 February 2021 which DHSC considered showed few local areas outside the normal expected range. Based on this analysis, DHSC concluded the level of variation in how local clinicians added people to the list to be acceptable. It contended that local variation in the number of people identified and added to the list could be explained by demographic variations in the English population and the “inevitable difference” in decision making arising from local clinical judgement.35 A centrally-directed system to support clinically extremely vulnerable people
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Government response AI summary
The government disagreed that there was huge local variation, stating that most areas fell within expected distributions, while acknowledging six areas added more people than expected. They committed to conducting further analysis to understand this variation and identify lessons, with findings to be reported to …
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HM Treasury
17
Recommendation
Fifty-Third Report - Covid 19: supporti…
Accepted
Government quickly needed to ensure that those shielding had reliable access to food, medicines and care. It chose a national system of support run by central government.36 MHCLG considered that a centralised offer was more likely to guarantee delivery of food boxes in every part of England at the start …
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Government quickly needed to ensure that those shielding had reliable access to food, medicines and care. It chose a national system of support run by central government.36 MHCLG considered that a centralised offer was more likely to guarantee delivery of food boxes in every part of England at the start of the pandemic, when there was real concern about food shortages in supermarkets.37 MHCLG consulted with a small number of local 29 Letter from DHSC to the Committee 10 March 2021 30 Qq 27, 32, 46 31 Qq 25–26, 28, 47 32 Qq 29–30 33 Qq 25, 28 34 Qq 30, 31 35 Letter from DHSC to the Committee 10 March 2021 36 C&AG’s Report, para 1.5 37 Q 73 12 Covid 19: supporting the vulnerable during lockdown authorities as to the best way to support people shielding, but acknowledged that it had not done a full assessment of local authority capacity in the way it would for a business-as- usual programme, and had made a judgment based on the evidence available at the time.38 MHCLG told us that it engaged with local authorities, and some reported they would not have been able to provide the food delivery service in the early months of the pandemic.39 However, the NAO reported that some local authorities queried why government had chosen a centrally directed rather than a local system of support, particularly for food, and some authorities felt that they would have provided better quality support.40 MHCLG was confident that it had made the right decision to have a national system to provide food boxes, rather than a local one.41
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Government response AI summary
The government accepts the recommendation and states it has tested future delivery confidence with councils, finding them confident to rapidly stand up shielding support, and continues to work closely with them while keeping funding under review.
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HM Treasury
20
Conclusion
Fifty-Third Report - Covid 19: supporti…
Accepted
This locally-led model focused on providing eligible people with priority access to book supermarket deliveries, rather than Government providing standard food parcels.48 Defra told us that almost everybody that signed up for food box support was matched and prioritised by a supermarket, and that these half a million people have …
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This locally-led model focused on providing eligible people with priority access to book supermarket deliveries, rather than Government providing standard food parcels.48 Defra told us that almost everybody that signed up for food box support was matched and prioritised by a supermarket, and that these half a million people have continued to be prioritised by the supermarkets over the last months and for the foreseeable future. MHCLG observed that as the pandemic has progressed, fewer people have needed support through this programme, and felt confident that a locally led model, reinforced with the new registration system built over the summer, has proven an effective way of delivering the programme. MHCLG also reported that it now has good information about what 38 Q 74 39 Q 80 40 C&AG’s Report, para 3.22 41 Q 80 42 Q 78; C&AG’s Report, para 1.7 43 Q 74; C&AG’s Report, para 3.7 44 C&AG’s Report, paras 19, 21, 27, Figure 1 45 Q 80 46 C&AG’s Report, para 4.10 47 Q 75 48 Qq 74, 75; C&AG’s Report, Figure 14 Covid 19: supporting the vulnerable during lockdown 13 local authority activity is on the ground, in terms of the delivery of the programme.49 MHCLG calculates that is has provided local authorities some £4.6 billion in un-ring- fenced funding in 2020–21 to help with COVID costs.50 49 Qq 74–76 50 Q 83 14 Covid 19: supporting the vulnerable during lockdown 2 Communicating with vulnerable people Difficulties in gaining assurance that people’s needs were met
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Government response AI summary
The government states it agrees with the recommendation (likely an implicit one regarding local authority capacity) and considers it implemented. MHCLG has tested future delivery confidence with councils and continues to work closely with them to ensure support for CEV individuals.
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HM Treasury
24
Conclusion
Fifty-Third Report - Covid 19: supporti…
Accepted
The DWP contact centre relied on telephone numbers in NHS patient records to call clinically vulnerable people who had not yet registered their needs. In some 375,000 cases out of the 800,000 people that the contact centre could not get hold of, or over 20% of the 1.8 million people …
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The DWP contact centre relied on telephone numbers in NHS patient records to call clinically vulnerable people who had not yet registered their needs. In some 375,000 cases out of the 800,000 people that the contact centre could not get hold of, or over 20% of the 1.8 million people the centre attempted to contact, it was because of missing or inaccurate phone numbers. While government knew that a proportion of telephone numbers in NHS records were missing or inaccurate, the Programme agreed to use telephone numbers from NHS records to follow-up hard-copy letters.57 51 Qq 60–64 52 C&AG’s Report, paras 2.10, 3.2 53 Q 65; C&AG’s Report, paras 17, 3.4–3.5 54 Qq 64–65 55 Q 68; C&AG’s Report, para 17 56 Qq 66–69 57 C&AG’s report, para 2.8, 3.6, 3.24 Covid 19: supporting the vulnerable during lockdown 15
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Government response AI summary
The government acknowledges the issue of inaccurate contact details and states NHSX is leading a program to improve patient contact details and ensure the NHS Number is the primary identifier. DHSC and NHS Digital will report back with details of ongoing work and plans.
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HM Treasury
26
Conclusion
Fifty-Third Report - Covid 19: supporti…
Accepted
DHSC told us it is trying to improve contact information by asking clinically extremely vulnerable people to ensure their GP records are up to date and will continue to update the records as patients improve their record keeping with their doctor. DHSC also noted that increasing numbers of patients are …
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DHSC told us it is trying to improve contact information by asking clinically extremely vulnerable people to ensure their GP records are up to date and will continue to update the records as patients improve their record keeping with their doctor. DHSC also noted that increasing numbers of patients are adding their email addresses to their GP records.62 58 Q 65 59 Qq 56, 60–62, 64 60 Qq 56, 61 61 C&AG’s report, para 3.24. 62 Q 60 16 Covid 19: supporting the vulnerable during lockdown
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Government response AI summary
The government stated that during the shielding program, DHSC used letters to encourage CEV people to update their GP contact details to facilitate communication, aligning with the committee's observation.
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HM Treasury