As we reported in previous issues of our COVID-19 Insight report, in July and August we rapidly mobilised teams to carry out reviews in 11 different English localities, to find out how care providers have worked together in response to the pandemic. We wanted to find out how providers have collaborated to improve care for older people, who are most at risk of COVID-19.
These Provider Collaboration Reviews (PCRs) have been a very useful experience for everyone involved, collating the best of innovation across systems under pressure and sharing learning. We aim to drive system, regional and national learning and improvement, and there has been significant support for the reviews from the providers we have engaged with.
The 11 reviews focused on the interface between health and social care for people aged 65 and over. In each system we carried out a deep dive review of a local authority area and then fed this information back to the Integrated Care System (ICS) or Sustainability and Transformation Partnership (STP) leads. To get a comprehensive picture, we engaged with a wide variety of organisations locally, including primary care networks, local medical committees, adult social care providers, directors of social services, NHS trusts and independent hospitals, urgent care providers, NHS 111, community care providers, integrated care teams, urgent dental services, local Healthwatch and other organisations that represent those who use services, their families and carers.
Tackling the issues related to COVID-19 has required effective strategic planning, good relationships and practical, deliverable solutions. Some localities appear to have fared better than others, depending on the strength of previously established working relationships. Learning lessons now is especially important, so that providers can be prepared for any second peak of the virus and times of pressure on the system, such as winter.
We will publish our complete PCR findings in October, but we can already see some clear messages emerging. The reviews have brought into focus some themes and learning that can be used to inform planning for this winter and any possible resurgence of COVID-19. So far, we can see:
- Understanding local population needs, including cultural differences, was especially important.
- The quality of existing relationships between local providers played a major role in the coordination and delivery of joined-up health and social care services that meet the needs of the local population.
- There was an increased focus on shared planning and system wide governance, but pre-existing plans may not have been fit for purpose to cope with COVID-19.
- Staff across health and social care worked above and beyond their roles – we spoke to dedicated, passionate staff, committed to supporting everyone including people aged 65 and over.
- There was a range of initiatives to ensure the safety and wellbeing of staff working both on the front line and in support services.
- The move to digital working accelerated and impacted on access to services, and more generally digital solutions supported data-sharing and communication between health and social care partners and within health and social care organisations.
The individual reviews have helped to identify where provider collaboration has worked well to the benefit of local people. Sharing that learning will help drive further improvements across systems. Findings of the reviews were fed back to each ICS/STP via a high-level presentation that they could share with the providers across their system.
We will report our full findings from these first 11 PCRs in our State of Care 2019/20 report to Parliament in October 2020, considering in more detail the positive outcomes from good collaborations we have seen, and examining barriers to better collaboration. By the end of 2020/21 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, ensuring we consider how providers are collaborating to provide high-quality, safe care across a variety of pathways and population groups. We will also look at how providers are re-establishing services and pathways in local areas.
Good practice examples
Our reviews have been focused on four lines of enquiry. In advance of our full report, we want to share here some of the examples of collaborative working that we found.
People at the centre
As part of the PCR process, we wanted to see how providers had collaborated to ensure that people aged 65 and over were seen at the right place at the right time. We wanted to see how providers had worked together to understand the local population and to ensure care pathways were developed to keep people safe and how they had worked to ensure people received effective, responsive care.
During the reviews we have found examples where providers had worked collaboratively to ensure people were well supported during COVID-19.
In our Devon STP PCR, we were told about support for bereaved people through a local hospice in Plymouth. This approach meant that other providers could be assured people were getting the support they needed while dealing with other aspects of the pandemic.
Support for bereaved people: Devon STP
..In 2018, Plymouth was awarded compassionate city status by Public Health Palliative Care International – the first city in England to be named as such. This was following a conference organised in the city by St Luke’s Hospice with delegates from across many directorates and organisations. The compassionate city work evolved from that conference and has led by St Luke’s Hospice to the create of a network of over 90 individuals and organisations signed up to the charter formally adopted by Plymouth City Council. Part of being a compassionate city is recognising that care for one another at times of crisis and loss is everyone’s responsibility. The hospice has trained and established 72 end of life champions in local care homes in Plymouth.
During the COVID-19 pandemic, St Luke’s Hospice realised its compassionate friends’ cafes, which had been set up to support those who were bereaved or on that road, would not be able to continue. It therefore set up a compassionate friends’ telephone service and staffed this with trained people able to offer support for those who had been or were close to being bereaved. There was also a single point of contact telephone line for those who needed it.
People were signposted to services and networks that could support them or offered time to talk and be listened to. There were then regular calls to those who needed them to ensure the bereaved did not feel isolated. Links were made back through the support of the local public health team if other support was needed, such as access to food banks, income support and medication deliveries.
During the pandemic, the whole approach to death and the dying, and those who were left behind, has been underpinned by the multi-agency work to be a compassionate city. The local authority, adult social care, NHS trusts, the clinical commissioning group and public health all commented on the work of the St Luke’s Hospice during the pandemic and its holistic care during difficult circumstances for many families and friends.
Hospital discharge wellbeing: Sussex Health and Care Partnership ICS
Healthwatch Brighton and Hove provides the Hospital Discharge Wellbeing Project in partnership with Brighton and Hove City Council, Brighton and Sussex University Hospitals NHS Trust and the Sussex Health and Care Partnership (the integrated care system).
The project started on 7 April 2020 as part of the response to COVID-19. The service is offered to people discharged from hospital including those aged 65 and over, not just those with COVID-19 or related conditions.
By the end of May 2020, a total of 350 people had been referred and the Brighton and Hove Healthwatch team now have 60 to 80 referrals a week. People are phoned by Healthwatch trained volunteers within a few days of discharge from hospital, usually in the first week to signpost and assist people to find the help they need.
Forty-three per cent of people needed some additional support and 35% had issues or questions related to their hospital discharge. Most discharges were handled well, and in the 350 referrals, there were three discharges where significant, but avoidable, errors emerged. These were all resolved promptly and in a spirit of putting the person first.
This Healthwatch Brighton and Hove project has demonstrated that where there is a willingness, hospitals, social care and volunteers can act together quickly to help local people. This project was funded for six months as part of the COVID-19 response. The team are now extending the service to help check on people using home care services, particularly those whose home care packages have reduced over the COVID-19 period.
Understanding the local population: Frimley Health and Care ICS
Frimley Health and Care ICS covers the area of Slough. At the very beginning of the crisis, through a primary care initiative working with the local council, the mosques across Slough were closed a week earlier than rest of country.
A local GP had recognised that Friday prayers could potentially spread the risk of contracting the virus. A significant proportion of the Muslim population in the area are aged 65 or over, with the impact of this initiative meaning that potentially a significant proportion of older people in the area were not exposed to the virus.
The Frimley system also instigated female only COVID-19 testing sites as they recognised that local Muslim women would be disenfranchised about attending if male staff worked at the sites. This initiative ensured that this group of the population could access testing in a culturally sensitive way.
Local providers worked closely with the voluntary sector for food packages to be delivered to vulnerable people that were culturally sensitive .
As part of the process we looked to see how leaders and managers within providers had collaborated to ensure well planned service delivery across their system. We also looked at what providers had learnt through the pandemic and how they had shared this learning.
During the PCRs we were told about a range of new governance or command and control structures that were created in response to the pandemic. Collaboration between system leaders was facilitated by the creation of cells or groups – linked to the local resilience forum or similar governance structures – to plan and deliver services across the system for specific pathways of care or population groups, including those aged 65 and over.
Local resilience forums: Lincolnshire STP
The STP lead felt it was proven to be the right way to work, bringing health and social care together. Cells included one main provider of each type. They had cells for palliative care (set up by the council), primary care, pharmacy and prescribing, recovery, patient and discharge, volunteering and community response (to ensure there is a route for feedback and that pathways are safe). They felt these cells enabled clear escalation routes and sharing of information and ideas. Through this effective way of system working, leaders made an early decision to not discharge patients to care homes unless their COVID status was known.
Effectiveness of established relationships: Frimley Health and Care ICS
We were told that Frimley ICS was a well-established system with existing governance structures in place. System leaders met regularly at a variety of meetings before the pandemic, and these meetings were used during the emergency period, so there was no need to create new systems and processes or ways of sharing information.
We spoke with people from across the system, including the chief executives of the local authority in Slough and the acute trust, who told us that these strong pre-existing systems and relationships assisted with the response to COVID-19.
The chief executive of the local authority told us that, once they had received feedback from individual adult social care providers about difficulties on discharge of people from hospital, they spoke directly with the chief executive of the trust.
The conversation was described as helpful and productive due to the constructive feedback. It was recognised that system partners were able to be honest, open and work and pace as they all respected and trusted one another before the pandemic.
Workforce capacity and capability
We looked at how staffing across health and social care has been impacted during the pandemic – how providers had worked together across systems to ensure staffing capacity. We considered how 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. We have also looked at how providers worked together to keep staff safe.
Staff deployment and wellbeing: Bedfordshire, Luton and Milton Keynes ICS
Across the Bedfordshire, Luton and Milton Keynes (BLMK) ICS review, we were told that there was a shared strategy to ensure there was a sufficient number of staff with the right skills across health and care services.
East of England Workforce and Human Resource Cell supported workforce modelling and planning for surge during the COVID-19. They identified skills and workforce requirements and shortages at ICS level and shared these with Bedfordshire, Luton and Milton Keynes Human Resource Directors network.
System surge plans reflected deployment requirements across the system and were discussed at Bedfordshire Local Health and Social Care Cell and tactical meetings for the system. There were also weekly calls with human resource directors from across the system to discuss all things workforce related. A BLMK ICS workforce strategy was established and there were agreed workstreams around workforce modelling and supply.
We were also told how the ICS had worked with providers across the system to keep staff safe.
A mutual aid agreement had been put in place that extended across NHS and to social care, particularly to support care homes. Individual risk assessments and adjustments were made to the working environment, with those at very high risk/shielded being moved to working at home with immediate effect and/or supplied with appropriate PPE.
We were told that senior leadership communicated with staff on a regular basis though virtual meetings, individual check-in calls, communication cascades and health and wellbeing support offers – including national and local initiatives such as talking therapies, virtual sessions for mindfulness, and pilates. There were regular updates to all on infection protection and control (IPAC) measures across the health and care system and provision of IPAC training to all care homes.
Shared learning: North West London STP
To support patients in the community with the management of long-term conditions, the STP developed a COVID-19 learning forum that supported a wide range of clinicians to understand the impact on how to deliver safe and effective care remotely.
Led by primary care networks and specialists across secondary care, weekly webinars were developed on the rapidly changing disease, particularly focused on the tailored needs of primary care and the issues affecting patients in the community. There were 17 weekly sessions delivered with live questions and answers; 5,000 hours of training had been achieved, with more hours planned.
Attendees said that a range of high impact points were taken away from each session. There was effective access to specialists including those in diabetes, respiratory and musculoskeletal, which was critical and helped to change working practices for the benefit of patients who couldn’t be seen in hospital during the early part of the pandemic.
Care Home frailty pharmacist: Lancashire and South Cumbria ICS
The trust (Morecambe Bay) appointed a care home frailty pharmacist to identify patients coming into hospital from care homes and those being discharged from hospital to care homes. They implemented a post-discharge service to care homes – the frailty pharmacist followed up patients after discharge to deal with medicines queries and promote safer transfer of care. Improved communication meant that they also picked up issues, other than medicines, that helped to signpost people in the right direction to resolve them.
Digital solutions and technology
We have looked specifically at initiatives related to digital and technology in responding to COVID-19 and the impact that they have had in terms of organisations working together.
Community hub: Sussex Health and Care ICS
In Brighton and Hove, the community hub brought together the local authority, health care providers and voluntary sector organisations to ensure that people at risk, such as older people and people who were shielding, got the support they needed.
The community hub engaged with its partners to share data and matched all this up to build an app that gave a view of everyone on the list and what their needs were.
The local authority built a web-based system that updated daily with a list of people who were shielding – this could be filtered by specific needs through integrated datasets. They could filter the list to find out if the person was already known to a support organisation or statutory agency, such as housing, a voluntary sector organisation or the council foodbank, and overlay with maps of the city.
They then arranged which organisation was the best to maintain contact with the shielding or vulnerable person. They said that the “pandemic hurtled us towards developing the ‘single point of contact’ which was already in train, but this accelerated it”. They quickly developed an app because at the start of the pandemic they realised they were all contacting the same person; the app allocated a leader for each shielding contact.
The IT system generated consistent templates for letters and emails so that all correspondence from local authority and voluntary sector organisations was consistent and accounted for communication needs, British Sign Language or different languages.
Having an app and the system being web-based meant that staff across the hub could access the information they needed remotely, within agreed governance arrangements. When out and about, having map overlays to the data meant staff could access information when they were out in the community supporting people and could focus on giving people the tailored support they needed when they needed it.
The IT system supported the local authority and voluntary organisations to make referrals to each other through online forms (for help with food, medicines, financial hardship and social care). The community hub was part of the local authority cell structure that included food, vulnerable people, communication and rough sleepers and fed into silver command through the deputy director of adult social services. The work on the single point of contact, and local authority and voluntary organisations working well together before the pandemic, meant the hub could be set up quickly and information governance issues were not a barrier or delay.