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 5 March 2021
The Joint Committee on Vaccination and Immunisation (JCVI) has recommended that prioritisation for Phase II of the vaccine roll-out should continue to be based on age. Once all priority groups from Phase I have been vaccinated (see update in this section from December 30 2020), vaccines will be offered to other age-groups, starting with the oldest adults:
• all those aged 40 to 49 years,
• all those aged 30 to 39 years,
• all those aged 18 to 29 years.
The target date for offering all adults in Phase I a first dose of a COVID-19 vaccine is April 15, with the target date for offering all UK adults a first dose of a COVID-19 vaccine July 31. However, the Prime Minister also said the UK population may have to be re-vaccinated against new variants of COVID-19 in the autumn.
Update 4 March 2021
COVID-19 vaccines modified to be effective against new variants will not need brand new approval. This follows guidance developed by the UK Medicines and Healthcare products Regulatory Agency (MHRA) in collaboration ACCESS consortium partners (containing regulatory authorities from Australia, Canada, Singapore, Switzerland and UK). While vaccine manufactures will still need to ‘provide robust evidence that the modified vaccine produces an immune response’, this will not need to be based on lengthy clinical trials but can instead assess antibodies in the blood following vaccination. This process follows the approach for seasonal flu vaccines and should speed-up regulatory processes and approval.
Update 19th January, 2021
Following a sharp rise in cases, the government announced a new dosing schedule for all vaccines, confirming that booster doses for the Pfizer and Astra Zeneca vaccines would only be given after 12 weeks, rather than 21 days. The original trials did not formally test this dosing schedule, leading to considerable anguish in the medical community and the general population and Pfizer did not support the decision. Shortly after the announcement, the British Medical Association also issued an announcement, and said it was unsafe. Although this has been approved by the MHRA, in response to the rapidly changing epidemiology in the UK at the present time, and based on the existing data demonstrating between 80 and 90% efficacy (21-28 days) after the first Pfizer dose, and higher for Astra Zeneca, surveillance will be required to monitor any vaccine failures that occur during this time.
Vaccine roll out has now reached half of the over 80s group although many care homes and healthcare workers report that they have still not received the vaccine. Nonetheless, more people have now been vaccinated for Covid-19 than have been infected, which is suggestive of some progress. At the same time, GP’s report great difficulties with supplies and sometimes also with workforce challenges. Many report that they get little notice for deliveries and others say that they cannot source enough staff to vaccinate because the red tape to acquire approval is too complex. At the same time, community pharmacists have now been granted permission to vaccinate and have been offered the same legal indemnity as the NHS to enable this, Meanwhile, the Moderna Vaccine has also now received MHRA approval.
Dosing Schedule Rationale by the JCVI: https://m.box.com/shared_item/https%3A%2F%2Fapp.box.com%2Fs%2Fuwwn2dv4o2d0ena726gf4403f3p2acnu
Vaccine delivery plan: https://www.gov.uk/government/publications/uk-covid-19-vaccines-delivery-plan/uk-covid-19-vaccines-delivery-plan
Vaccine Surveillance strategy: https://www.gov.uk/government/publications/covid-19-vaccine-surveillance-strategy
Update 30th December 2020
The Joint Committee on Vaccination and Immunisation (JCVI) has advised that prioritsation for the COVID-19 vaccination programme should be age-based to most effectively prevent mortality, ensure health and social care systems are not overwhelmed and to ensure roll-out is as rapid as possible. The order of priority for each population group corresponds with data on the number of individuals who would need to be vaccinated to prevent one death. Phase I of the vaccine roll-out will target the following priority groups, starting with groups 1 and 2:
1. residents in a care home for older adults and their carers
2. all those 80 years of age and over and frontline health and social care workers
3. all those 75 years of age and over
4. all those 70 years of age and over and clinically extremely vulnerable individuals
5. all those 65 years of age and over
6. all individuals aged 16 years] to 64 years with underlying health conditions which put them at higher risk of serious disease and mortality
7. all those 60 years of age and over
8. all those 55 years of age and over
9. all those 50 years of age and over
These groups are estimated to represent around 99% of preventable mortality from COVID-19.
Update 24th December, 2020
On the 2nd December, the MHRA approved the use of the Pfizer/BioNTech vaccination, making the UK the first country to do so. The government had secured 40 million vaccine doses from Pfizer/BioNTech – enough for up to a third of the population. The JCVI prioritisation criteria have not changed and the priority has been to roll out logistics to enable vaccination of care home residents and staff, those over 80 and health workers. The vaccine has a number of supply chain challenges, including the need to be transported in dry ice to maintain a temperature of around -80 degrees Celsius. Boxes have to be used within 3.5 days of coming off dry ice and being opened, with each one containing 975 vaccines. Once the vaccine has been drawn up it must be used within hours or discarded. These constraints make it very difficult to get the vaccine into the community to people who cannot attend vaccination centres, such as care home residents, although this is slowly being addressed for those in larger care homes. Meanwhile, hospital hubs have been created nationwide to vaccinate those over 80, healthcare workers and social care workers. There were initially two anaphylactic reactions, leading the regulator to add a clause that the vaccine should be restricted to those who do not have a known history of severe anaphylaxis (as both cases did). GP’s have also now received the vaccines and an enormous effort is now underway to facilitate them to call patients in to be vaccinated, in what is probably the biggest vaccination campaign the country has ever seen. Many GP surgeries have reported that they are unable to participate in the programme because the resources imparted to them to do it are insufficient. Others are relying on healthcare volunteers as the vaccines cannot be delivered by people without training. In addition programmes have been set up to train non healthcare volunteers to enable an army of vaccinators to get through the list as soon as possible. Meanwhile, ex-Prime Minister Tony Blair has suggested that the data in the Pfizer vaccination study support the potential use of a single dose to protect more people more quickly. This has of course not been approved by the MHRA or trialled and may or may not provide lasting immunity beyond the 21 days examined in the trial. There is also not yet sufficient evidence that vaccinating lower risk groups would reduce transmission rather than just reducing serious disease, although it is expected that it will.
Meanwhile, the AstraZeneca vaccine is expected to be approved shortly by the MHRA amidst some concerns that the increased efficacy in the lower dose might require some further data to be collected and because the various subgroups in the main trial appear to have followed slightly different protocols, critically, using a different control vaccine.
Although the supply of vaccines is still uncertain, the UK has four million doses of the Astra Zeneca vaccine ready to give to the NHS and has pre-ordered 40 million doses of the Pfizer-BioNTech vaccine and has taken delivery of 800,000 so far - enough for 400,000 people. Although more than 130,000 people had been vaccinated by the 16th December, there are concerns because many hospitals and GP practices have yet to receive any vaccine doses.
Pfizer vaccine efficacy trial: https://www.nejm.org/doi/full/10.1056/NEJMoa2034577
Astra Zeneca vaccine efficacy trial: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32661-1/fulltext
Vaccine recruitment: https://www.proudtocarenorthlondon.org.uk/covid-vaccination-jobs?fbclid=IwAR1zwpLM7v0E5lqxLPO4T5-4cc0UEh_E_sU50MUethqiWRz69hUAWccK3Is
Vaccine protocols: https://www.gov.uk/government/collections/covid-19-vaccination-programme
Vaccine guidance: https://www.gov.uk/government/publications/covid-19-the-green-book-chapter-14a
Update 11th November 2020
Changes in Primary Care
A review of innovations in the NHS is being collected and has reported on initial and provisional findings. They report a rapid expansion of primary care practices to enable online consultation systems to enable digital triage. This was done through providing support on procurement and contracting, issuing guidance on digital triages, drawing together resources from NHSE/I, NHS X, NHS Digital, and others to provide implementation support for practices. The availability of online consultation tools therefore expanded from ~30% of practices in January 2020, to ~90% in June, including over 500,000 patient interactions with practices through these tools every week. Video consultation capacity was also rapidly taken up by practices, from ~30% of practices in January 2020 to ~99% in June. Suppliers made the software available at no cost for the emergency period and national funding has been allocated for the remainder of the financial year.
Feedback from patients and clinicians has been positive and evaluation work is underway to understand the impacts of these changes more systematically. The intention is that all practices should retain the ability to digitally triage using an online consultation system, and that the few remaining that don’t yet have the capability should put it in place. Video consultation capability will also be retained. Support for practices will remain in place and use of the tools is expected to climb. This work is funded through the Digital First Primary Care programme under the NHS Long Term Plan.
82.5% of all prescriptions are also now delivered digitally for dispensing, which is an increase of 12.5% since the start of the pandemic. GPs have also been supported to facilitate electronic repeat dispensing (eRD) for patients working with community pharmacists to directly support patients with their monthly repeat prescriptions over a 12 month period.
The NHS ‘111 First’ programme is working to introduce a number of initiatives to reduce the number of face-to-face contacts patients will need to experience in accessing urgent care services. The option of the NHS111 First ‘prescription’ includes a number of different interventions which are aimed at remotely triaging patients through existing NHS111 online and telephony services in order to advise and navigate patients to the service that best meets their needs. Once patients have been triaged a wider range of directly bookable services will be available to 111 callers, including Same Day Emergency Care and specialty ‘hot’ clinics. If users of the NHS 111 service do need to attend an Emergency Department a referral system will be in place so that the ED knows the patient will be coming. As a ‘heralded’ patient they will also be able to receive a specific timeslot in which to attend. As recommended by the Royal College of Emergency Medicine, the aim is to enhance patient experience by avoiding unnecessary time in A&E departments whilst managing the risk of A&E overcrowding and nosocomial infection.
The BMA GP committee England and NHSEI have agreed a DES (direct enhanced service) for general practice in England to lead the delivery of the CVP (COVID-19 vaccination programme). It will be optional for practices to sign up to the service. The service is intended to be delivered from 1 December, but the actual start date will depend on the availability of vaccines. It is expected that supply will be limited initially and that most vaccinations will take place in early 2021, giving practices more time to prepare.
Update 10th November 2020
Data from 38% of GP practices in the country shows that the Hexavalent (6 in 1) and measles mumps and rubella (MMR) childhood vaccination rates fell by 3-4% in children in week 43 of 2020 compared to 2019, which is presumed to be the consequence of social distancing measures. This is still a potential improvement as previous data suggested that MMR vaccine uptake fell by 20% during the first three weeks of the lockdown in England.
McDonald HI, Tessier E, White JM, et al. Early impact of the coronavirus disease (COVID-19) pandemic and physical distancing measures on routine childhood vaccinations in England, January to April 2020. Euro Surveill 2020;25(19):2000848. doi: 10.2807/1560-7917.ES.2020.25.19.2000848
Update 16th October 2020
The Department of Health and Social Care has announced changes to the Human Medicines Regulations 2012 that will allow the Medicines and Healthcare products Regulatory Agency (MHRA) to ‘exceptionally grant temporary authorisation, pending the granting of a licence, for new vaccines and treatments needed to tackle public health threats - provided they meet the highest safety, quality and effectiveness standards and there’s a significant public health justification for doing so’. This followed a consultation about whether vaccines should be administered without the requirement for a license, which was not eventually approved. These measures will allow the MHRA to authorise the use of a vaccine or treatment without waiting for approval from the European Medicines Agency and these will be used according to guidance, which will be published shortly by the Joint Committee for Vaccination and Immunisation (JCVI).
Update 25th September
The Joint Committee on Vaccine and Immunisation published their criteria for providing guidance on the COVID-19 vaccine when it becomes available. Interim advice has been based on early Phase I and II data on developmental COVID-19 vaccines, and mathematical modelling on the potential impact of different vaccination programmes.
Future advice will be based on information as it becomes availalbe on:
• vaccine efficacy and/or immunogenicity in different age and risk groups
• the safety of administration in different age and risk groups
• the effect of the vaccine on acquisition of infection and transmission
• the transmission dynamics of the SARS-CoV-2 virus in the UK population
• the epidemiological, microbiological, and clinical characteristics of COVID-19
At present, a provisional ranking of prioritisation for persons at-risk is set out below:
• older adults’ resident in a care home and care home workers
• all those 80 years of age and over and health and social care workers
• all those 75 years of age and over
• all those 70 years of age and over
• all those 65 years of age and over
• high-risk adults under 65 years of age
• moderate-risk adults under 65 years of age
• all those 60 years of age and over
• all those 55 years of age and over
• all those 50 years of age and over
• rest of the population (priority to be determined)
They also clearly outline the existing unanswered questions that the medicines and healthcare products Regulatory Agency (MHRA) will address
• whether a safe and effective vaccine can be developed against this disease
• when a safe and effective vaccine will become available
• the levels of population immunity when a vaccine becomes available
• what age groups a vaccine will be licensed for (it’s currently assumed that early licensure will be in adults)
• the safety of the vaccine, potential side effects and contraindications
• the dosing schedule (one, two or more doses)
• the number of doses that will initially be available, and the number of doses subsequently available
• the time period over which sufficient doses will become available
• the effectiveness of a vaccine across different age groups, especially older age groups and the effect of immunosenescence, and for different risk conditions
• the effectiveness against infection/serious disease/acquisition/transmission
• the duration of protection
Update 22nd September
In an effort to avoid a twindemic with influenza, the government has widened the criteria for influenza vaccination, which will now be offered to 30 million people, including children in Year 7, the over 50s, household contacts of those in the shielding category. Pharmacists were also permitted to vaccinate residents and staff in care homes.
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.