Update 15th August 2020
On the 15th August, two weeks before schools opened, the Health Secretary announced in a paywalled news article his intention to disband Public Health England (PHE), the country’s national organisation for public health. The media article was inaccessible to most PHE staff, causing considerable anxiety amongst the Public Health community (https://www.telegraph.co.uk/politics/2020/08/15/hancock-axes-failing-public-health-england/ and (https://www.bmj.com/content/370/bmj.m3257). The following day, he gave a speech at a think tank, outlining his intentions to merge the newly created Joint Biosecurity Centre, the NHS Test and Trace service as well as the Health Protection, chemicals and radiation, emergency response and other functions from within PHE by April 2021. The new organisation will be called the National Institute of Health Protection (NIHP) and is to be led by Baroness Dido Harding as the interim Chief Executive Officer and will operate under the direction of the Department of Health and Social Care as PHE did. It is as yet unclear how the rest of the leadership for the NIHP will be determined or how relevant public health expertise will inform appointments. There has been little support for this decision from the public health community so far who have raised concerns about the historic funding cuts to PHE, merging in the middle of a pandemic, the absence of a formal inquiry to outline what problems this merger is intended to fix and about the risks of creating siloes between health protection and health inequalities and health improvement work (https://www.health.org.uk/news-and-comment/news/dismantling-phe-in-the-midst-of-a-pandemic-carries-serious-risks and
The government has committed to a consultation before next year to establish what role other PHE functions should assume, including health improvement, health inequalities, healthcare public health and global health and who should be responsible for them. There are some suggestions that some of these functions may return to the NHS, while others believe that they will be delivered local authorities, although with current funding constraints this would be extremely challenging (https://www.hsj.co.uk/news/exclusive-many-public-health-responsibilities-to-return-to-the-nhs/7028265.article).
Update 4th August 2020
A letter issued to NHS Trusts on 31st July confirmed that COVID-19 inpatient numbers have now fallen nationally from a peak of 19,000 a day, to around 900 today. Following stakeholder engagement they announced a third phase including an accelerated return to normal services in the short window before winter. This would be coupled with preparation for a surge in winter demand, including for COVID-19, explicitly tackling staff wellbeing and inequalities. At the same time, the NHS people plan was published to support workforce wellbeing (https://www.england.nhs.uk/ournhspeople/).
The accelerate return of services includes return to full operation of all cancer services to be overseen by a national cancer delivery taskforce, involving major patient charities and other key stakeholders. Delivery plans are expected to be commissioned by September 2020 to March 2021 to reduce inequalities, increase diagnostic capacity, including for endoscopy and diagnostics in the community, restarting cancer screening.
Recovering elective surgery activity before winter will also include using contracted private hospitals. Elective cases ad overnight or day cases are expected to return to 80% of capacity by September 2020 and to 90% by October 2020. Frist outpatient attendances are expected to return to 100% of last year’s levels by September, face to face or virtually. The current system of block payments, that was introduced during the peak of activity will flex with delivery until further notice.
For scheduled care, self-isolation guidelines are in place to enable hospitals to remain COVID-19 secure. Collaboration has been advised between primary and secondary care to avoid unnecessary outpatient appointments where a clinically-appropriate and accessible alternative exists. Where appointments are necessary, the national benchmark is that at least 25% could be conducted by telephone or video including 60% of all follow-up appointments.
General practice, optometry and community services are expected to resume normal services and to reach out to vulnerable patients. In particular, GP services are expected to catch up with the backlog in screening and immunisations, as part of the new primary care network contracts. GPs are also expected to undertake structured medication reviews in care homes and must ensure that they can offer face to face consultations as well as remote ones. Self-referral will now be facilitated to relieve clinical time.
Hospital discharges will now be facilitated by a discharge to assess model to the community, including an assessment of funding eligibility and additional support to rehabilitate patients at home for up to 6 weeks. This will initiative will also receive half a billion pounds of government funding. (https://www.gov.uk/government/news/more-than-half-a-billion-pounds-to-help-people-return-home-from-hospital). Continuing Healthcare Assessments, which determine eligibility for NHS (rather than local authority) funding to social care will also now be reinstated.
Mental health investments are also now to be increased and expanded, including 24/7 crisis helplines, decommissioning mental health dormitories and ensuring better physical health checks and treatment reviews for people with learning difficulties.
The NHS has earmarked £3 billion to support winter preparedness and this will include ongoing independent sector capacity, the Nightingale hospitals, and the support to accelerate discharges as described above until March 2021. If NHS test and trace are able to secure 500,000 tests per day and background infection rates also increase, regular asymptomatic staff testing may also be instituted.
Universal staff uptake of the flu vaccine will also be facilitated and promoted and delivery of any potential COVID-19 vaccine will also need to be promoted.
Health inequalities are a major source of concern and the NHS has designated a national advisory group who have recommended the following:
• Analysis and community engagement of the most vulnerable groups with improved engagement of those who require additional support
• Digitally enabled care pathways to facilitate inclusion from Black and Asian communities
• Preventative programmes that will be promoted include flu vaccinations, management of long term conditions, obesity reduction and health checks.
• By September, every NHS organisation must have a named executive Board member responsible for tackling inequalities and a commitment to demonstrate how senior staffing levels will match those of the overall workforce.
• All NHS organisations must ensure that all ethnicity and inequality data is complete.
Primary care has now mostly moved to a system of telephone and video triage with patients only being seen in person for the most serious concerns.
Emergency procedures should still continue, such as treatment of acute heart attacks and management of trauma post road accidents, although attendances to hospital for these have fallen dramatically (https://www.gov.uk/government/publications/emergency-department-weekly-bulletins-for-2020). It is intended that some services will be provided in privately commissioned hospitals.
There is an awareness of the need to support vulnerable people with long-term care needs and to discharge to social care but there is very little support to them in place, despite emerging mutual aid groups developed by the NHS and local authorities. It is expected that safeguarding practices will also continue as far as possible to protect vulnerable children and adults.
A telephone triage system has been introduced to facilitate new cancer referrals and avoid unnecessary hospital attendance (https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/cancer-alliance-information-on-managing-cancer-referrals-19-march-2020.pdf). However, urgent cancer treatment services are to be maintained as far as is possible (https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0119-_Maintaining-cancer-services-_-letter-to-trusts.pdf)
Home usage of medically managed abortion medications were approved in England on 30th March 2020 for a temporary period, with the measure later adopted in Scotland and Wales (https://www.gov.uk/government/publications/temporary-approval-of-home-use-for-both-stages-of-early-medical-abortion--2).
The main change of note to the operation of social care services is the easing of the Care Act (2014) in the Coronavirus Act 2020 (http://www.legislation.gov.uk/ukpga/2020/7/contents/enacted/data.htm). Intended to enable local authorities to focus resources on the most urgent needs, these changes remove the requirement for councils to meet various duties in the Act such as undertaking detailed needs, eligibility and financial assessments. The intention is to allow councils to provide enhanced support to those who are ill or self-isolating and to reduce other care provision and is intended as a last resort for councils with a requirement to report to the Department of Health. So far, seven councils are known to be taking advantage of these easements (https://www.cqc.org.uk/guidance-providers/adult-social-care/care-act-easements-it). Stakeholders have expressed concerns that councils are cutting care existing packages in order to shift resource to short-term care and that these packages may not be restored following the crisis (https://www.carersuk.org/news-and-campaigns/press-releases/carers-uk-responds-to-new-guidelines-on-care-act-easements).
The health and social care systems in England are separate and there are well-known issues in the coordination of care between the two. Access to state-supported social care is means-tested, organised via local councils and paid for via mix of private and public money and delivered via around 24,000 different providers of different types and sizes (https://www.nuffieldtrust.org.uk/news-item/offer-and-eligibility-who-can-access-state-funded-adult-care-and-what-are-people-entitled-to). The plan to discharge patients from hospitals to free up 15,000 beds has nevertheless demonstrated how the two sectors can work together effectively, with the help of dedicated funding and abandonment of usual administrative requirements. However, the longer term implications for the social care sector are unclear. The social care system in England is widely acknowledged to be in a state of crisis and entered the pandemic in a fragile state with significant workforce challenges, high levels of unmet need and a volatile provider market (https://www.nuffieldtrust.org.uk/research/social-care-the-action-we-need). There was nevertheless hope that a wholesale reform of the system was on the horizon (https://www.politicshome.com/news/article/matt-hancock-kicks-off-crossparty-talks-on-social-care-crisis-in-letter-to-mps).