This is the 2020/21 edition of State of Care
The pandemic has magnified issues already faced by local health and care systems. They have tried to maintain or adapt services where possible to support their local populations in different ways. The response to COVID-19 has acted as a catalyst for good care in some places, through an advancement in collaboration.
During a series of provider collaboration reviews (PCRs) in the past year, we have looked at how the different services in local systems worked together to understand and meet the needs of their local populations in the face of the pandemic.
Navigating disruption to services
Closure or disruption to services during the pandemic has meant that some people have not received care they needed. Access has varied by sector and locality. We heard how access to urgent mental health care, primary care or dental care became more difficult, sometimes increasing demand in other parts of the urgent care pathway, such as hospital emergency departments.
Systems tried to ensure access in different ways. For example:
- A general practice worked with the voluntary sector and their local authority to support homeless people. They were provided with hotel accommodation and received better access to care because providers knew where they were. Some were provided with the technology required for remote consultations.
- North West Ambulance Service employed pharmacists in their NHS 111 call centres to support prescription requests – this helped people avoid going to A&E. Similarly, specific medication was made available to ambulance crews to support patients at the end of their life.
- Leicester, Leicestershire and Rutland Clinical Commissioning Group expanded the provision of chemotherapy at home, ensuring patients continued their treatment plans and in a safer environment.
- When we reviewed cancer services in several regions, they all used mutual aid and/or staff redeployment based on capacity needs to ensure sufficient levels of staff with the right skills – this included movement of staff between providers, as well as movement of staff within a single provider.
- Efforts were made by some systems to respond to reductions in cancer referral rates at the beginning of the pandemic, by identifying areas where screening uptake was poor and promoting access to cancer screening services for early referral and diagnosis. Cancer screening messages were also targeted to people living in deprived areas or in areas where certain cancers are more prevalent.
- One collaborative multi-agency approach we heard about involved health, education, social care services and parents – this met the needs of a young person with a learning disability during a period of crisis, by securing rapid access to specialist intervention, an appropriate education setting and a bespoke curriculum.
Communicating the status of services to people who needed to access care was often challenging. Some local systems and providers used social media, local radio and television to reach out to communities. Some used their multilingual workforces to create videos in different languages.
We reported in last year’s State of Care about the high volume of guidance from central authorities for providers and how it frequently changed. In trying to keep people up to speed, we heard how providers sometimes struggled with the pace of change – they described ‘information overload’ and sometimes conflicting guidance during the peaks of the pandemic.
Many appointments changed to a remote or digital method of delivery, including for example counselling sessions for people with cancer and some day care activities for people with a learning disability.
These helped to improve access for many people, but remote or digital consultations were not right for everyone or for some population groups. The flexibility of digital care was identified across local systems as something to maintain for some patients, while it was acknowledged that they were not ideal in all circumstances.
The pandemic has led to significant changes in how NHS services are delivered and used. The NHS is keen to build on some of these changes, as seen through its priorities for 2021/22, which include transforming community and urgent and emergency care to prevent inappropriate attendance at emergency departments and reduce length of stay.
Through our PCRs, we have seen how the flow of people through the health and care system has been supported by the redesign of heath and care pathways or models of delivery in many places, in direct response to the need to keep people safe and reduce the pressure on services treating patients with COVID-19.
In the PCR looking at urgent and emergency care during autumn 2020, we heard about changes to pathways to reduce the pressure and demand on emergency department attendance and hospital admission. For example, some health and care systems established 24-hour mental health crisis lines to support people with urgent mental health needs away from a hospital setting if this was clinically appropriate. Also, some primary and community care services made the decision to provide urgent care in people’s own homes rather than asking them to attend an urgent care service, as they considered this a safer option.
The NHS 2021/22 priorities document set out the request to every local system to set out their plans to accelerate the rollout of the two-hour crisis community health response at home (8am-8pm, seven days a week) by April 2022. Systems have also been asked to progress work already underway to promote the use of NHS 111 as a primary route into all urgent care services.
Keeping older and frail people safe
We saw during our provider collaboration review of urgent and emergency care how the community assessment and treatment centres (CATUs) in Cornwall brought together multi-disciplinary teams that were closer to people’s homes. With a focus on frailty, geriatricians were moved from acute sites into the CATUs to support keeping older and frail people out of hospital during the pandemic. This approach was developed before the pandemic, but then accelerated, as a long-term way of caring for older and frail people. It was welcomed by system partners and the model is being explored by neighbouring systems.
Collaboration makes a difference
Health and social care providers have been operating in different conditions during the pandemic. At the start, NHS England took on extensive powers normally held by clinical commissioning groups (CCGs) – this enabled the purchase of services from the private sector and powers to exercise CCG functions to support the provision of services across the NHS.
Representative organisations, think tanks and other bodies – for example The King’s Fund and NHS England – have pointed to the way collaborative approaches have allowed commissioners to share ownership of challenges and responsibility for service improvement, with a focus on cooperation and collective leadership, as well as joint ownership of risk and accountability among commissioners and providers.
Integrated care systems, bringing together commissioners and providers of health and social care services with local authorities and other partners, intend to offer a more strategic outcomes-based approach to care. The pandemic has sped up some of this collaboration, strengthened relationships between system partners, and provided the opportunity for peer support and the sharing of resources.
We saw in some systems that where collaborative relationships already existed,they remained strong in the pandemic. Some systems had established efficient system-working before the pandemic – this then helped them in their timely response as they were able to build on existing structures and relationships. Similarly, the Local Government Association reported that a shared purpose has resulted in stronger relationships both within and across organisations in local places during the pandemic.
Cross-sector working was helped by good communication, information sharing and shared values – it was acknowledged that this enabled better outcomes for people.
Among the systems we reviewed in our report on cancer services, a priority was maintaining personalised care for people. There were multidisciplinary team meetings and system-wide calls to plan and deliver cancer services collaboratively.
System partners worked together, includinghospices, adult social care providers, mental health providers, the voluntary sector, local authorities and NHS trusts.For example, we heard about a hospice that worked in collaboration with the local authority to enable cancer care inthe community. They also worked with GPs and district nurses to develop training and provided medicines administration training to families and carers.
In one local system, expectant mothers with a learning disability were supported through aplanned multi-agency approach. They were given an enhanced package of care including hospital passports – andthey had pre-birth tracking meetings attended by public health, midwifery and a learning disability team.
However, collaborative working was varied among the systems we reviewed. Where we found less collaboration among services, we heard concerns about the effect this had on providers’ ability to plan for care that might be needed in local populations.
There was a lack of integration of adult social care providers into system-level planning and decision-making. Smaller providers and home care services in particular did not feel represented at system-level. Similarly, when we reviewed services for people with a learning disability, there was a lack of involvement in wider system planning. A key finding from our cancer review was that the lack of adult social care integration would be a barrier to wider system recovery plans.
When we looked at urgent and emergency care, some adult social care providers said they did not feel supported or included by GP practices and NHS trusts – this was particularly around the coordination of discharge of people from hospitals to care homes or into people’s own homes. We also found limited evidence about the involvement of voluntary and community services in planning.
Among cancer services, we found in our collaboration review that most systems reported gaps in recording people’s demographic data. This may affect how well providers can monitor people moving through cancer pathways, their understanding of health inequalities and the effects on people’s experiences.
Do not resuscitate decisions – the challenges different sectors face in working together
In October 2020, the Department for Health and Social Care commissioned CQC to conduct a special review into ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions. The review was commissioned following concerns raised early in the pandemic that DNACPR decisions, also known as DNRs and DNARs, were being made without involving people, their families and/or carers if so wished, and were being applied to groups of people.
Applying a DNACPR decision to groups of people of any description (known as ‘blanket’ DNACPR decisions) is potentially discriminatory and unlawful under the Equality Act 2010. People’s rights may also be at risk where individuals are not properly informed or involved in conversations about putting a DNACPR decision in place, or where decisions are not reviewed in a timely way.
Through our review, we found that people and those close to them had mixed experiences of how well they were involved, and supported to be involved, in conversations about their care. When people were involved in conversations, the huge number of acronyms and use of inaccessible language could be confusing and prevent people from being fully engaged.
We heard that conversations around whether people would want to receive cardiopulmonary resuscitation (CPR) often came out of the blue and that, due to increased pressure on staff time during the pandemic, happened at a faster pace in busier settings. People told us that they felt that they were not given the time or information to fully understand what was happening or even what a DNACPR was. In some cases, people were not always aware that a DNACPR decision was in place. This could be hugely distressing for people and their families and/or carers.
We also heard that there was a general lack of awareness and confidence among people, families and care workers about what a DNACPR decision meant, and how to challenge this.
Every area we looked at had taken steps to make sure that services were aware of the importance of taking a person-centred approach to DNACPR decisions and advance care planning. However, we found that providers had to cope with a huge amount of guidance about all aspects of the pandemic that lacked clarity and changed rapidly, leading to confusion.
While there was a wide range of training available for staff, we were concerned that not all clinicians, professionals and workers had access to this due to a lack of funding and difficulties freeing up time to attend training sessions. Where staff had training, there were concerns about whether it gave them the necessary knowledge and skills to engage with people in a meaningful way, and ensure that their needs were met and their rights protected.
At a system level, we found that advance care planning, end of life care and DNACPR decisions were often not sufficiently high on the agenda, and leaders lacked oversight of DNACPR decisions. For example, we found evidence of poor record keeping, a lack of learning being shared across systems, and underdeveloped strategies for advance care planning and end of life care.
While collaboration generally increased during the pandemic, it also tested how well commissioners, health and social care providers and patient representative bodies were able to work in partnership to make decisions and provide guidance around advance care planning and DNACPR decisions. Areas that already had infrastructure and governance processes in place were better able to work together to manage the overall challenges created by the pandemic.