As we reported in the September COVID-19 Insight, and our State of Care report in October, we are embarked on a programme of provider collaboration reviews. These reviews aim to show the best of innovation across systems under pressure, and to drive system, regional and national learning and improvement. There has been significant support for the reviews from the providers we have engaged with.
Our latest review has looked at urgent and emergency care in eight areas in October and November. Urgent and emergency care (UEC) covers a wide range of services that people turn to when they need immediate help, including NHS 111, GP out-of-hours services, urgent treatment centres, accident and emergency, ambulance services and pharmacies.
Even before COVID-19, the UEC system in England faced many challenges. These are not simply issues within hospital emergency departments or a result of seasonal variation – issues are present year-round and across the entire care system.
During our review, we looked at new models of collaborative provision across systems, including access to care and the flow of people through the system and ensuring people using urgent and emergency services receive high-quality, safe care. We interviewed other providers about their interaction with urgent and emergency care services, including care homes and home care agencies, as well as engaging with local Healthwatch.
We also set out to capture what was understood about inequalities, particularly any disparity in access to care. In addition, we looked at what collaboration took place to help care for children and young people.
The reviews have brought into focus some themes and learning that can be used to inform planning for this winter and any further impact from the pandemic. Tackling COVID-19 has required effective strategic planning, good relationships and practical, deliverable solutions. Some urgent and emergency care systems appear to have fared better than others, sometimes benefitting from the strength of previously established working relationships.
We will publish the full findings from our review in January 2021, but some key points are emerging from our evidence. So far, we can see:
- The pandemic was a catalyst for innovation and change, requiring providers to respond at pace, work together and deliver care in new ways – it was an enabler for system working at UEC level.
- The quality of existing relationships between local providers played a major role in the coordination and delivery of joined-up UEC services to meet the needs of the local population.
- Providers expressed their concern for the mental health and resilience of their staff as they approached winter. Some NHS trusts said the pandemic’s impact on staff resilience was the biggest risk. There were examples of good collaboration to ensure staffing levels, but we saw little evidence of widespread shared strategies – at a whole-system level – for managing the anticipated increase in demand for UEC services.
- Some people told us they were very positive about the care they received – a theme was associating good care outcomes with organisational efficiency. But some complained about disjointed care where they experienced a lack of communication between services on their care pathway. Providers told us that communicating well with the public about what service to access and when was challenging.
- For different reasons, some people or groups may have missed out on the care they needed. There was a lack of capacity in some places and closures in mental health, dental and primary care affected some UEC services that remained open, especially NHS 111.
- Inequality was found in some places – for people who needed care as well as for staff at different care providers. There was varied understanding of inequalities in people’s access to UEC locally, while individual services tried to protect more vulnerable employees, including people from Black and minority ethnic groups.
- Digital technology was used more widely and more often to enable people’s access to services. Some systems have worked to address negative impacts, trying to ensure patient choice and tackle any digital exclusion.
By spring 2021, we will have looked at provider collaboration in all ICS and STP areas in England. Our full programme of reviews will focus on different topics, considering how providers are collaborating to provide high-quality, safe care across a variety of patient care pathways and population groups.
Good practice examples
Our reviews have demonstrated some examples of strong collaborative working among services.
People at the centre of their care
We wanted to see how UEC providers collaborated to ensure that people were seen in the right place and at the right time – and how providers worked together to ensure care pathways were developed to keep people safe, and how they had worked to ensure people received effective, responsive urgent and emergency care.
In Cornwall, community assessment and treatment centres (CATUs) were created to bring multi-disciplinary teams together, closer to people’s homes. With a focus on frailty, geriatricians were moved from acute sites into the CATUs to help keep older and frail people out of hospital. This approach was welcomed by system partners and the model was explored by neighbouring STP/ICS systems.
In Newham, East London, a multidisciplinary discharge hub was created early in the pandemic. It included hospital and social care staff, a clinical commissioning group (CCG) infection and prevention control nurse, Age UK, and an equipment service provided by the local authority. The hub was considered successful in making hospital discharges safer. This has encouraged providers to assess ways of continuing the service in future.
UEC services had to rapidly formulate their communication strategies during a time of confusion and uncertainty about capacity and demand. They had to strike a balance between encouraging people to seek help if needed and staying away from emergency departments.
A good example of proactive messaging happened on the Isle of Wight, where NHS communications worked with the CCG and local authority communications to get messages to the local population. A regular slot on local radio was used to share important messages with the public.
In Cheshire and Merseyside, we saw that a focus on health inequalities was a priority. Recognising the need to better understand and to measure the needs of the people in the system who are most at risk, a population health laboratory was developed. They used a set of pooled data from all providers to design and deliver the most appropriate service for certain communities. Daily updates were provided to the system – the infection rates and patient groups affected showed where gaps in provision could be.
There was limited information on ways in which providers identified and responded to the needs of people from a Black and minority ethnic background when they accessed UEC services. But some services tried to identify risk, including a system in Herefordshire & Worcestershire where patients’ vulnerabilities were flagged on the electronic patient record with West Midlands Ambulance Service, and made known to emergency departments in advance.
The public health team at the local authority in Northamptonshire had established an equality impact framework, looking at groups that may have been disadvantaged. It was published on the council website so that different providers and commissioners could make use of it in decision making.
Different ways communicating advice and guidance were used, in particular social media and local radio. In some systems, people in local communities helped to deliver key messages to help improve the spread of important information. In East London they used community leaders and influential people on TV and on Bengali radio channels.
Workforce capacity and capability
We looked at how staffing across UEC was affected during the pandemic – how providers worked together across systems to ensure staffing capacity. We also considered how UEC providers had tried to make sure there were enough employees with the right skills to cope with new and increased demands resulting from the pandemic. And we considered how providers worked together to keep their employees safe. Examples included:
- In West Yorkshire and Harrogate, children’s safeguarding training at level 3 was turned into an online version and included topics that were emerging during lockdown, such as the risks in online medical consultations.
- In Hampshire and the Isle of Wight, the widely known ‘Think Family’ model was strengthened through staff training. Ambulance crews were taught to ‘think family’ to strengthen their assessment of potential safeguarding issues for children. This was important because there were very few professionals who were seeing children in their home environments during the pandemic.
- A shared strategy for workforce planning in Northamptonshire looked ahead to the winter months, considering national and local staffing as well as staff skills, to see where it could be beneficial to move staff around – and where upskilling would be useful.
- The evidence we gathered around protecting Black and minority ethnic employees was found almost exclusively within individual providers. However in Northamptonshire we heard how the local authority had set up a ‘scientific advisory cell’ for the system, which included information about the increased risk from COVID-19 to people from Black and minority ethnic groups.
- Liverpool City Council commissioned a workforce capacity dashboard across health and social care in Cheshire/Merseyside. They also held a workshop with providers to review winter pressures. Joint commissioning of winter plans had started early and was an example of open dialogue.
- In the Suffolk and North East Essex ICS a gap in dental nurse provision was identified by the 111 service that supported people calling with non-urgent dental enquiries. The local system subsequently recruited dental nurses, who are generally self-employed, via a social media campaign.
Digital solutions and technology
We looked for digital and technological initiatives used in response to COVID-19 and at the impact that they had for UEC providers working together across health and social care.
The purchase of electronic tablets for care homes by one of the NHS providers in Cornwall and the Isles of Scilly was widely celebrated. This technology enabled virtual ward rounds and primary care assessments, ensuring residents had continued support in their homes.
Healthwatch Essex carried out an evaluation of digital literacy for their ICS. During our review, the second phase of this project was ongoing, also involving Healthwatch Suffolk. The ICS was keen to maintain patient choice and reduce the digital exclusion gap.