This is the 2020/21 edition of State of Care
We have talked to a broad range of organisations that represent health and social care service providers, as well as many that work on behalf people who use services, about the challenges for the recovery of services after the effects of the pandemic.
Meeting people’s needs and maintaining their wellbeing
There was widespread recognition from public and provider stakeholders that the key to successful recovery is ensuring services meet people’s needs and providing appropriate access. Provider stakeholders highlighted the challenges they face in meeting public expectations about the care and support they want.
There was a strong view from provider stakeholders in secondary care that a national focus is needed to support people while they are on a waiting list, and to support people to manage aspects of their own health care. Public stakeholders said that the management of waiting lists will be key and, for those experiencing delayed care, interim support needs to be provided. One comment from provider stakeholders was that there needs to be a cultural change away from thinking about NHS services as individual transactional interactions, toward whole pathways that are person-centred.
Overall, provider and public stakeholders were united in the view that people’s wellbeing should be a focus of recovery. People who use care services have often become isolated during the pandemic. Health and social care staff across all sectors are feeling exhausted, demoralised, stressed and dealing with trauma from the pandemic.
System working and innovation
Overall, there was a view that the pandemic prompted improved system working, and that this shouldn’t be lost during recovery; instead it should be strengthened and embedded. We heard how general practice has worked closely with adult social care providers, and the independent sector with the NHS, to deliver care. The successful delivery of the vaccination programme is a good example of the kind of effective system working providers would like to see more of.
Allied to this was a strong view from provider stakeholders that the pandemic had enabled and accelerated significant innovation in use of technology and service models, and that a ‘good’ recovery should maintain this innovation where it has been successful. They stressed that to enable this, there needs to be good evaluation on where innovation has worked well, including the impact on people using services and the impact on the wider system.
However, public stakeholders highlighted that delivery of remote or digital health and social care needs to take on a more sophisticated and personalised model. They warned that the system needs to be careful about making assumptions about who might be happy with digital care delivery and who won’t be.
The importance of monitoring the impact of remote appointments post-COVID was highlighted. Public stakeholders raised concerns they have around the use of online appointments for people with severe mental illness, people with sensory/cognitive impairments and those who need interpreters.
More broadly, there were concerns about new models of care, that have emerged during the pandemic, that are inaccessible or exclude some population groups. This link between access and inequality is highlighted, for example, where digital primary care excludes people who do not have access to digital infrastructure. Provider stakeholders had a clear view that recovery should focus on addressing health inequalities, in particular those that were amplified by the pandemic.
Importance of data
There was a strong view from adult social care representatives that the pandemic has accelerated the need for better and consolidated data collection. We heard how data collection during the pandemic was disjointed and created barriers to effective service delivery – so a strong central plan to remove duplication and improve how adult social care data is collected from the sector would be key to understanding how to effectively support recovery.
There was general agreement that a key part of successful recovery will be a better use of data to design and deliver care. This includes recognising and fixing where current data is poor, either in particular parts of the system or for specific population groups. This should also include ensuring that the system improves its ability to provide relevant and accurate information that the public can use.
System response and commissioning
There was a strong view from provider stakeholders that they need government and system partners to support ‘good’ recovery by focusing much more on outcomes for people using services – and by a change in culture that provides funding, and supports commissioning and oversight that is focused on this rather than other measures.
Allied to this was a need for clear roadmap and plan for system recovery, accompanied by high-quality and easy to understand guidance from the Department of Health and Social Care and government. Public stakeholders agreed that greater direction is needed on how the system will get back up and running.
All provider stakeholders agreed that to support effective recovery and long-term service delivery, commissioning needs to improve – in terms of commissioning being more flexible and focused on people’s needs but also that commissioning needs to be more integrated across health and social care.
There was a shared view that current workforce challenges are a key barrier to successful recovery, in particular the ability to recruit and retain staff in key areas. We heard a number of suggestions on how this should be addressed, including updated national workforce strategies that cover all sectors, raising the status of the adult social care workforce to achieve parity with health care, ensuring that career progression, pay and rewards are suitable to recruit and retain people across all sectors. We also heard how adult social care staff are now expected to perform a wider range of tasks than before the pandemic, many of which would have been performed by health professionals. The ability of staff to continue to do this well will need investment in workforce development and formal changes in service specifications.
One impact of COVID-19 was the restriction or cancellation of different services. In many places, resources were redirected. Furthermore, the pandemic caused some people to not come forward for care and treatment they needed. These factors have caused a backlog and increased current demand for all kinds of care that people need, ranging from non-urgent surgery in hospital to vital cancer or cardiology care.
Equal access to care is critical as local systems and providers try to grapple with longer waiting lists. To tackle inequality, systems must first do more to understand the needs of local populations – better use of data could help design and deliver care. In our provider collaboration reviews this year, we found that not all systems were aware of local population needs, particularly some minority groups that were known to be more vulnerable to COVID.
While every local area is different, we have seen strategic planning in some local systems that is focused on the longer term and making sure care is happening in the best place – plans need to involve all the organisations in a local area, include adult social care providers more prominently in decision-making, and value the contribution of carers and the voluntary sector in maintaining people’s wellbeing.
To help drive recovery nationally, providers highlighted to us the need to examine how health and social care services have changed, and to evaluate the impact of these changes. This includes building on the digital transformation and using it innovatively to create new approaches to care but also taking the time to understand how it can be used fairly and accessibly for all those who need care and support.
We have heard how shared electronic records during the pandemic has enabled care to be tailored specifically to meet individual needs when accessing services.
Better use of information will be important as services recover. Among the learning we have seen during the pandemic, local systems were innovative when under extra pressure to protect vulnerable people. In our review of collaboration among providers during a peak of COVID-19, we reported on the way some urgent and emergency services adapted.
It was important that care professionals knew about people’s vulnerabilities so that care could be adapted. The electronic patient record (EPR) helped, as well as access to any ‘flags’ – notes on GPs’ patient records highlighting important medical information about a patient.
In one system the EPR was used to record known patient vulnerabilities and it was available to emergency departments (EDs) before a patient arrived at hospital. Shielding letters that had been sent to patients were also shared with EDs and added to patient records so this would flag if the patient attended an ED. At a care home, people’s vulnerabilities were included on residents’ care plans – these were shared with ambulance crews, as well as with visiting clinicians and hospital staff.
Hospitals’ plans for recovery
In May and June 2021, we asked 73 NHS trusts about their approaches to longer waiting lists and how they are considering people’s care in a fair and equal way.
Trusts have told us their focus in tackling the backlog is people with the greatest need according to clinicians’ priority codes, and those who have waited longest. The scale of the task varies from place to place – some trusts say they are back to pre-COVID lengths of lists, others say their lists are “hugely challenging”.
We have heard about trusts’ focus on communicating with patients about their delayed treatment and efforts to make sure people are ‘waiting well’, as well as patient monitoring to assess risks.
Trusts are tackling waiting lists in a variety of ways, including use of the private sector, patient-initiated follow-up (PIFU), accelerator sites and virtual outpatients. We have also heard how collaboration is already key in service recovery. Primary care services are taking advice and guidance from NHS trusts about diverting patients to more appropriate routes for their care – this was helping to slow the growth of waiting lists. However, we are also aware that this places extra pressures on primary care.
Technology and digital solutions are a significant part of trusts’ plans for helping people who need care while tackling their waiting lists. For example, we heard about an interactive digital outpatient platform in orthopaedics, enabling patients to track their post-operative recovery, check in on any changes in condition, and request follow-up or advice and guidance rather than following traditional face-to-face review methods. However, the trusts said that much of the innovation was in its early stages and had yet to be evaluated for its impact and outcomes for people who use services.
Increasing capacity will be important is tackling backlogs. In many hospitals, this starts with the de-escalation of intensive care unit capacity and reclaiming operating theatres, to create elective bed capacity, and bringing staff back to their substantive roles.
There are challenges for trusts: some hospitals are still experiencing high levels of COVID-19 patients, with intensive care unit beds and operating theatres used for these people; social distancing and infection prevention and control arrangements reduce the capacity of hospitals, especially for those with older estates or reduced space; and trusts report vacancies in key areas that they are struggling to fill.
We have heard how tackling inequalities is a focus in many recovery plans. However, much of this was in the planning – there were few examples of established initiatives or outcomes. We heard that people from areas of higher deprivation were more likely to experience longer waits or get admitted to hospital via ambulance, or not attend outpatient appointments.
Better NHS trust patient records and linkage with primary care datasets will be important for addressing inequality as local systems recover. Some trusts have acknowledged they need to improve the completeness of their records – this could help to identify barriers to care and help ensure that people’s characteristics are recorded on initial registration, or fill gaps during subsequent patient interactions.