3. Providing health services effectively
The section on PROVIDING HEALTH SERVICES EFFECTIVELY describes approaches for service delivery planning and patient pathways for suspected COVID-19 cases. It also considers efforts by countries to maintain other essential services during periods of excessive demand for health services.
3.1 Planning services
Update 28th July, 2020
The Royal College of Physicians has published six priorities to plan for future COVID-19 waves, which include: Estates and buildings, flu vaccines, workforce, PPE, partnership working and testing. In a briefing about the future of the NHS, they found that almost half of physician specialities, including cardiology, gastroenterology and rheumatology, expected to be working at less than previous pre-COVID activity levels for at least 12 months or more. They make recommendations to transform urgent and emergency care pathways, with an emphasis on workforce, integrated care, service redesign and quality improvement, education, improved conditions for overseas workers and harnessing the use of digital health, among other things. The NHS Confederation has also launched a campaign, called NHS Reset to contribute to the public debate on what the health and care system should look like post-COVID-19 (see: https://www.rcplondon.ac.uk/guidelines-policy/rebuilding-nhs-rcp-priorities-resetting-services and
It has been reported that the government will announce £3bn in additional funding to the NHS to support the Nightingale hospitals and to sustain testing at 500,000 tests per day ahead of the second wave and there are also report that the 4 hour waiting time in A&E may also be adapted to ease pressures in the winter (https://www.theguardian.com/world/2020/jul/16/boris-johnson-to-give-nhs-extra-3bn-to-prepare-for-winter-coronavirus and https://www.hsj.co.uk/quality-and-performance/new-aande-targets-to-be-rolled-out-before-winter/7028139.article). An extended flu vaccination programme has also been announced for those between the ages of 50-64 and all school year groups up to year 7 in addition to the usual groups. The implementation plans to enable such an expansion have not been made public, with many GP’s fearing that they often struggle to procure sufficient vaccines until midway through the flu season in normal years, and manufacturers voicing concern that they may not be able to deliver such a volume (http://www.pulsetoday.co.uk/news/gps-look-set-to-face-unprecedented-flu-vaccine-shortages/20041058.article).
Update 12th June, 2020
NHS hospitals are planning to restart elective work and dentists were advised that they could return from June 8th. This process is being managed trust by trust, with great variations in local procedures and the role for repeated testing. It was originally presumed that dentists would not return until July 4th, and many have said that they have not had enough warning to put in place sufficient safety processes to enable them to reopen (https://www.bbc.co.uk/news/health-52913826).
Update 7th May, 2020
On 29th April, the NHS Chief Executive, Simon Stevens wrote to Chief Executives of all NHS Trusts, highlighting the need to release and redeploy capacity in the NHS to consider initiating non-emergency clinical work over the next 10 days (https://www.hsj.co.uk/download?ac=3045627). These measures are to be considered with great caution, retaining considerable additional capacity in order to be prepared for an acute surge in emergency admissions. The NHS has said it would also supply additional ventilators to trusts so that operating theatres can be repurposed again for usual care. These decisions are to be made locally and to be determined by the availability of PPE, laboratory capacity and medicines.
In particular, the letter outlines the need to expand the 111 (telephone first point of contact) telephone line so that it can enable rapid emergency treatment via ambulances as well as frailty services and hot specialty clinics that bypass the emergency department.
A second intention is outlined to stand up capacity for cancer services to enable cancer treatments and surgery to continue in cancer hubs. Although emergency cancer treatments and surgery had continued through the lockdown period, much of the non-urgent procedures had not, for example breast reconstruction surgery mastectomy surgery.
These measures will involve the use of testing at the point of hospital admission as well as pre-admission testing and testing prior to discharge to a care home as well as testing for staff, with fast enough turnaround times to facilitate decision making. As described in section 1.5, there is also a pilot underway to guide the testing of asymptomatic staff.
On 14th May, the NHS published an operating framework for NHS leaders to start to think about resuming urgent and planned services in hospitals. The plan advocates for using testing for planned admissions followed by a period of 14 days isolation prior to coming to hospital (https://www.england.nhs.uk/coronavirus/publication/operating-framework-for-urgent-and-planned-services-within-hospitals/).
Before the lockdown period:
On the 30th January, the NHS declared a Level 4 National Incident. To maximise healthcare provision, NHS England declared that they would:
• Free up 30,000 English NHS beds and 100,000 general and acute beds
• Discharge all medically fit patients from hospitals, with responsibilities set out for community providers to accept them
• Block-buy private bed capacity in independent hospitals within 2 weeks
• Increase distribution of oxygen supplies
• Continue to distribute the national stockpile of PPE, which was stockpiled for Pandemic Influenza
• Provide remote consultations for vulnerable groups who have been advised against attending outpatient hospital appointments
Despite these commitments, it is unclear how many of these plans were systematically fulfilled across the country.
COVID-19 was initially classified as a ‘High Consequence Infectious Disease’ (HCID). This meant that care was delivered in five specialised hospitals nationwide that were considered to be equipped to deal with the infection risk and high dependency. Special hazardous area response teams were also designated to transport confirmed cases to designated hospitals. As the number of cases has increased, this status was withdrawn and patients are now triaged to any hospital, rather than only those specially designated for high consequence infectious diseases. There are designated wards and intensive care departments allocated to deal specifically with COVID-19 patients and operating theatres have been transformed into critical care units to increase capacity.
Measures to reconfigure service delivery to increase treatment capacity are being implemented as additional recovery wards are being procured in hotels, GP services are moving to video conferencing, elective procedures will be ceased by 15 April 2020 for three months and both beds and ventilators are being procured in the private sector.
To facilitate the rapid provision of needs across sectors, data protection practices have been relaxed during the pandemic until September 30th.
Local Authorities have also mobilised teams to support vulnerable patients in the community through the development of mutual aid cells and legislation has been passed to facilitate the provision of medications for vulnerable patients without the need for repeat prescriptions.
Care homes have been advised to work with the NHS and local authorities to establish local support networks and identify local capacity to accommodate NHS patients.
In response to numerous companies marketing unauthorised COVID-19 products, the Medicines and Healthcare Products Regulation Agency has also disabled 9 domain names and social media accounts.
Guidance has been published to reduce the risks around handling dead bodies following COVID-19 deaths. Pandemic Multi-Agency Response Teams have also been set up to facilitate handling of corpses at the time of death. Additional temporary mortuary capacity has also been developed by Local Authorities.
To account for increased care needs in people being stepped down from critical care beds, some local health commissioners commissioned rehabilitation beds in the community.
During the lockdown period:
A number of measures have been undertaken to enable the effective provision of services.
In Primary Care, most General Practice (GP) consultations are now undertaken remotely and employ the use of different types of telephone and video conferencing software and text messaging. The Royal College of General Practice has offered free e-learning training on the use of video conferencing in General Practice, as well as end of life care and other specialist services. GP’s have been instructed to proactively reach out to patients who are shielding to offer enhanced remote care where possible (https://elearning.rcgp.org.uk/course/view.php?id=373). Practice varies considerably between practices, but mostly, patients are triaged to minimize unnecessary face to face consultations. Many practices also run hot and cold services in which individuals with symptoms suggestive of COVID-19 are seen in a separate building or floor of an existing practice and most GPs now wear PPE for all consultations. Many GP’s are also piloting bluetooth devices such as stethoscopes and ECP monitors, which are either used in car parks or in some care homes.
While most vaccination services were not actively cancelled, there are fears that many childhood and maternal vaccinations have not been completed when they should have been, raising concerns of potential future outbreaks.
Screening services have for the most part been delayed and follow-ups for individuals with abnormal screens have also being delayed and people who have been screened and subsequently develop alarming symptoms have been encouraged to seek help early.
In Secondary Care, there are a number of initiatives, which vary by specialty. For example, cardiothoracic surgery has all been cancelled in London and the South East, apart from very urgent cases. A network of cardiothoracic teams have created a ‘cold’ centre where bypass surgery can be undertaken, on the basis of a patient having 2 negative swabs, being symptom-free and having a clear CT chest. This is perceived to be a potential model for restarting major surgery going forwards.
In gastroenterology, telephone consultations are used for routine clinics but as this specialty depends heavily on endoscopies for diagnosis of new patients, many patients have had their care delayed. Emergency surgery for example for emergency biliary obstruction, gastrointestinal bleeds and feeding tubes continue, but cancer service diagnostics are still on hold. For cancer services, there are now multidisciplinary team meetings, which continue using MS Teams.
Stroke services have adopted a different kind of model, using telemedicine but continue to run Transient Ischaemic Attack clinics using ambulatory tests such as imaging and blood tests as well as telephone consultations. Some have also implemented ‘cold’ stroke services in day hospitals to streamline pathways for patients with a suspected stroke. Hospitals are sharing imaging data regionally using the UK based PACS imaging system and mobilizing digital health records in A & E and acute admissions in order to enable remote assessment and reduce the risk of harm.
NHS England, Public Health England and HMPPS are working in partnership to ensure consistency of healthcare service delivery in prisons in England throughout the pandemic, and to provide appropriate population management strategies to minimise the effects of COVID-19. Public Health England has published guidance on COVID-19 for secure settings (see: https://www.gov.uk/government/publications/covid-19-prisons-and-other-prescribed-places-of-detention-guidance/covid-19-prisons-and-other-prescribed-places-of-detention-guidance) and has worked with HMPPS to design and publish a compartmentalisation strategy (https://www.gov.uk/government/publications/covid-19-population-management-strategy-for-prisons) for population management within prisons during the pandemic. NHS England is investing in the rapid rollout of telemedicine technologies across the prison estate supported by the digital teams at HMPPS, with this service to remain in place to improve healthcare delivery post pandemic.
For Gypsy Roma Travellers, the government outlined a series of measures, including that councils should use their additional funding to provide housing where necessary, but to allow them to continue to live in caravan parks where possible. These communities have historically been marginalised and are known to be in poor health and many have historically already struggled to access health services, particularly for vaccinations. It is unclear what efforts have been made to ensure these populations access vaccination programmes during the lockdown (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/882564/COVID-19_-_mitigating_impacts_on_gypsy___traveller_communities.pdf).
On March 27th , the the Ministry of Housing, Communities and Local Government also wrote to local councils asking them to ensure that homeless people, particularly rough sleepers received support and were offered somewhere to isolate safely within 48 hours. However, it was unclear how this could be achieved given lack of funding and acute housing shortages in many areas
Councils in many areas used hotels to offer somewhere for these roughs sleepers to stay, and services were set up in local areas to facilitate their access to testing, although this was by no means widespread and most were just told to isolate if they developed symptoms and to go to hospital if they were unwell (https://www.theguardian.com/society/2020/may/05/covid-19-hotel-homeless-people-uk, https://www.medrxiv.org/content/10.1101/2020.05.04.20079301v1). As the lockdown is easing, there are proposals that these homeless populations will be asked to leave these hotels and there are no known alternatives as yet, other than returning to the streets.
Undocumented migrants who were previously housed in detention centres have also been a source of concern, Detention Action have also pressured the government into 350 releases, system-wide case reviews and a bar on many new detentions but many people who are not deemed as ‘vulnerable’ still remain in detention centres, where little is known about their real access to hygiene facilities and healthcare. https://detentionaction.org.uk/stories/covid-19-immigration-detention-releases-where-we-stand/). The Home Office has also announced that asylum seekers will not be evicted from government accommodation for a period of three months, starting March 28th 2020.
Protection for people vulnerable to domestic violence has been noted, and the government published guidance with links to helplines on April 14th (https://www.gov.uk/government/publications/coronavirus-covid-19-and-domestic-abuse/coronavirus-covid-19-support-for-victims-of-domestic-abuse) stating that perpetrators should be asked to leave and victims should dial 999 if they felt they were at risk. No specific national frameworks have yet been put forward but these plans are being managed by local authorities.