The Committee published its Second Report of Session 2019–21, Delivering core NHS and care services during the pandemic and beyond (HC 320), on 1 October 2020. The Government response was received on 24 December 2020 and is appended to this report.
For elective care, the official statistics show that waiting times have been impacted by the pandemic, from a combination of enhanced IPC measures, and patients choosing to defer their care. The pace of recovery of elective care since the first wave of Covid-19 inpatients means that the total number of people waiting over 18 weeks has fallen month on month since July. Total cancer treatments are now back at or above the levels seen in 2019. However, the number of people waiting over 52 weeks has been rising, which is why additional funding for elective catchup will focus in part on these waits.
The waiting list in October 2020 was 4.5m, slightly lower than the same time last year.Through the ‘phase 3’ guidance issued at the end of July 2020, focus has been on increasing elective activity by accelerating the return of non-Covid health services to as near-normal levels as possible whilst also preparing for winter demand pressures. Hospitals are now carrying out more than a million routine appointments and operations per week, with around three times the levels of elective patients admitted to hospital than in April.
The NHS has been working with Royal Colleges to ensure clinical processes to prioritise the waiting list according to clinical need and length of waiting time. Patients should be part of a shared decision-making discussion around their care.
In responding to the pandemic, trusts have been working collaboratively to sustain access for patients, and this has been supported by the development of more “hub” working models to support elective recovery.
This ‘‘Adopt & Adapt’’ approach uses the following key components:
The £1bn allocated through the Spending Review for the 2021/22 financial year will support the NHS in tackling the elective backlog and support hospitals to cut long waits for treatment by carrying up to one million extra checks, scans and additional operations or procedures.
Through its COVID-19 recovery and existing planning processes, DHSC and NHSE/I are currently working (with NHS organisations) to agree how this funding will be spent in order to achieve maximum value and ensure the clinical needs of patients are best met.
Monthly appointment numbers continue to rise since April and overtook pre-Covid-19 peak in September and October. An estimated 282.5 million appointments were booked across all GP practices in England in the twelve months up to October 2020.
The Department and NHSE/I continue to work with general practices to help them meet demand safely and reassure patients that they should seek care when they need it. Steps being taken include:
We recognise that on top of the usual winter pressures and the commitment to recover routine activity, general practice is also delivering an expanded flu programme and playing an integral part in the delivery of Covid vaccination. We will continue to monitor the delivery of GP services throughout winter and support practices to ensure that patients receive the care they need.
In relation to mental health services, we recognise this is a very difficult time for people, and the immense strain that the pandemic is placing on everyone’s lives.
While mental health referrals dropped during the first wave, these are nearly back to pre- pandemic levels and we would urge anyone who needs help to reach out for it. Mental health trusts have responded rapidly to support people through the pandemic and will continue to do so through winter—mental health services have remained ‘open for business’ throughout the pandemic, with care often delivered remotely via telephone or video as well as face to face where appropriate.
All mental health trusts have established 24/7 urgent mental health helplines where people experiencing a mental health crisis can access urgent support and advice (ahead of the schedule in the NHS Long Term Plan), and have continued to meet waiting time targets e.g. Improving Access to Psychological Treatment services and early intervention in psychosis waiting times. This is why we have, since March, provided £10.2 million of additional funding to mental health charities to support adults and children, including £6million to the Coronavirus Mental Health Response Fund, led by Mind and the Mental Health Consortia, and £4.2million to mental health charities through the Government’s £750million Coronavirus Charities Fund.
We also recognise the pressures the pandemic is having on children and young people. We have invested £8million in our Wellbeing for Education Return programme, which is providing schools and colleges all over England with the knowledge and access to resources they need to support children and young people, teachers and parents. We also remain committed to implementing the core proposals set out in our response to the Green Paper consultation on improving children and young people’s mental health provision.
Moving into winter we adapted the national restrictions to support people’s wellbeing – we have kept schools, further education colleges and universities open as we know how important this is for children and young people’s wellbeing and we have extended the furlough scheme to provide financial security during this time.
To further support people’s mental health in the context of a second wave of COVID-19, and the winter months, in November we brought forward our Wellbeing and Mental Health Support Plan setting out the steps we have taken to strengthen the support available for people who are struggling, our commitments to ensure services are there to support those who need it, and the provision in place to keep our frontline workers well. The plan also includes a commitment, backed by £50million, to boost capacity and support good quality discharge for mental health service users from inpatient settings.
In addition, as part of the Spending Review, we announced that the NHS will receive around an additional £500 million next year to address waiting times for mental health services, give more people the mental health support they need, and invest in the NHS workforce.
It remains this government’s priority to support people’s mental healt—that is why we are investing an additional £2.3billion a year by 23/24 to deliver the most ambitious major expansion and transformation of mental health services ever across England. This growing investment in mental health services will see 345,000 more children and young people and a further 380,000 more adults accessing specialist NHS treatment a year by 2023/24, if they need it.
The backlog in dental appointments is a function of the precautions needed to avoid infection through COVID-19. DHSC acknowledges the impact that the coronavirus pandemic has had on the provision of NHS dentistry across the country and is working with the profession to increase the level of service as fast as possible, acknowledging the ongoing social distancing and infection prevention and control requirements.
Guidance has now been published by Public Health England that updates infection prevention control procedures. This includes reduced time to rest a room between patients. Whilst this should allow dentists to see a greater number of patients, dentists will still be seeing significantly fewer patients per day than pre COVID-19.
The Department is in the early stages of exploring how dentistry may be able to use Point of Care testing to increase patient throughput in future, however this is heavily dependent on a number of factors, such as the availability of testing technologies and a full assessment of the impact on risk for patients and staff.
Immediate changes to services due to the overriding need to limit transmission of COVID-19 at the end of March included:
On 28 May 2020 we wrote to NHS dental practices setting out the arrangements to restart face to face dental services from 8 June. Since then we have seen practices re opening for face-to-face care. In doing so practices have managed challenges presented by the need for infection prevention control and social distancing in order to minimise infections and the risk presented to staff.
Practices have restructured patient flows, adopted use of extensive PPE, incorporated fallow time to follow aerosol generating procedures in line with IPC guidance, and increased use of remote triage and consultation. These constraints impact on the tempo of clinical care, practice capacity and overall throughput and will remain in place for the foreseeable future.
We are focused on a combination of activities to support practices to maximise throughput and capacity within the current system, protect the staff who work in those practices, and prioritise activity to minimise deterioration in oral health.
We continue to engage with the profession and stakeholders to produce regular guidance supporting providers and commissioners to deliver these aims in the form of regular letters and Standard Operating Procedures.
We have seen a rise in dental activity month by month between July and September which is likely to reflect practices refining new procedures to operate more efficiently within current constraints. However, we anticipate this will plateau over time.
We will seek a longer-term contractual position with the BDA which reflects the need to maximise use of current capacity for highest priority patient care whilst recognising the constraints of operating safely in line with current guidance.
Staff in dental practices need access to high grade PPE to maintain the safety of staff and patients. DHSC has provided access for dental practices to funded PPE via an online portal and we are working to encourage practices to sign up.
We have asked that all dental practices undertake a staff risk assessment and continue to maintain and act on these assessments over time, taking mitigating actions where they are indicated.
Our focus remains on addressing oral health needs that may have increased, developed or gone unmet during the initial phase of the pandemic. Practices should continue to restore activity and prioritise care in line with letters and Standard Operating Procedures (SOPs) currently in force. Practices are expected to:
The application of this prioritisation approach will be made possible by practices continuing to undertake remote triage in advance of face to face care.
The limited system capacity, and significant backlog of routine work, means that we can expect urgent dental care to make up higher proportion of total activity over coming months than we would have seen pre-pandemic. We will continue to have in place arrangements as required for urgent dental care through UDCs or practices.
Prerana Issar’s letter of 03 December 2020 set out a number of positive developments on the NHS workforce in recent years, but we understand that you are seeking in addition aclearer understanding of our supply and demand assumptions and scenarios over a longer strategic timeframe. We will write to the Committee again in the New Year to provide a fuller picture on the ranges of projections for key workforce groups that are informing policy.
4. We recommend that Sara Hurley (Chief Dental Officer for England) sets out her assessment of the challenges facing dentistry services in England, and clarifies what steps will be taken to ensure dentistry services are able to continue to be restored to meet patient demand in the safest possible way whilst also remaining financially sustainable. (Paragraph 68)
The Chief Dental Officer for England’s remit extends to clinical policy and does not cover operational delivery or contracting, which sits with the Department of Health & Social Care and the NHS.
This assessment has focussed on the restoration of primary dental care services, this is not to diminish or dismiss the range of issues relating to specialist dental care or access to secondary care. This would be subject to a separate analysis.
The COVID-19 pandemic has undoubtedly challenged the delivery of safe dental care as much as it has proved a challenging time for the dental sector. We asked the dental profession to temporarily cease face-to-face dental care in the interests of public safety. In accepting this significant ask and then tackling the complexities of resuming face to face dental care in the new COVID-19 landscape the dental profession has remained steadfast to the principles of patient care and compassion. In stepping up to the challenges and stepping into new roles and new responsibilities I continue to be extremely proud of our profession’s response to the crisis.
The postponement of elective dental care, at the outset of the pandemic, prompted over 18,000 dental professional volunteers to register to support surge capacity whilst others re-orientated their practices and teams to support patients via remote dental consultations. The NHS delivered a national urgent dental care system of remote consultation and has staffed over 600 NHS urgent dental care (UDC) hubs. This collective endeavour has ensured timely access to advice and treatment. The majority of these UDC hubs were set up and run by general dental practitioners and their dental teams. These committed teams of dental professionals have continued to provide contingency access to urgent dental care throughout the Summer and Autumn of 2020.
The vast majority of dental practices are now open for face to face care and they have remained open throughout the re-imposition of national restrictions (04 November – 02 December 2020).
Our clinical focus remains:
Between June and November, we saw improvements in access with an expanding range of treatments being offered. Approximately 45% of NHS face-to-face dental care is for urgent dental care. Work continues with the British Dental Association (BDA) on future contract mechanisms with the intention of introducing a link to delivery of activity and outcomes.
The plan for the resumption of dental services in England was published in the Transition to Recovery SOP (4 June 2020). A graduated approach to the resumption of the full complement of dental care provision has been shaped by the necessary compliance with national Infection Prevention and Control (IPC) requirements and a full appreciation of the impacts of the range of patient and workforce protection procedural changes required in every dental practice. The plan acknowledges the demand for care, the need for clinical risk management and the application of a range of evidence-based alternative treatment pathways as well as the necessary agility to respond to a resurgence of COVID-19.
Based on this plan, dental practices have successfully resumed face-to-face dental care, but it is not business as usual. The challenges associated with restoration of dental services are significant and will endure into 2021/22 and beyond. Practices are subject to maintaining social distancing, providing remote consultations ahead of any face to face appointment, implementing necessary IPC guidance and prioritising urgent dental care cases. The quantity and complexity of urgent care presentations and resumption of suspended dental treatment plans is placing demands on clinical time and resources. All these factors will continue to constrain the level of “routine” activity that practices are able to deliver safely, particularly where “fallow-time” is required after aerosol generating procedures.
In assessing future capacity, confidence in process and procedures together with an emerging range of measures offer potential for a reduction in time associated with IPC and delivery of a concomitant increase in practice tempo. The number of patients that can be safely seen in a clinical day will continue to increase.
5. We request an update from the Department of Health & Social Care by the end of November 2020 on what steps are being taken to ensure that there is a consistent and reliable supply of appropriately fitting PPE to all NHS staff in advance of the onset of winter and a potential second wave. (Paragraph 87)
The government is confident that there will be a consistent supply of PPE this winter. Since the initial PPE Plan in April, the UK PPE supply chain has stabilised; there are around 32 billion PPE items on order and there is a strategic stockpile of approximately 4 months’ stock of each product category stored in warehouses.
The government is firmly committed to addressing the reported practical difficulties of some PPE to ensure there is appropriately fitting PPE on the frontline. We are committed to understanding user needs and taking appropriate action to incorporate user feedback in PPE provision. Feedback has largely focused on the fit of face masks where an appropriate fit is critical for effective protection.
DHSC have also developed enhanced supplier relationships partnerships with selected mask manufacturers and suppliers to secure a wider range of FFP3 masks to:
In September, as part of the strategy to diversify the portfolio of FFP3 masks, DHSC’s Face Mask Category Team published a catalogue of 16 different FFP3 masks from 10 manufacturers/ suppliers that are available from the DHSC PPE Programme. Eight models of FFP3 masks are available to the NHS now, with over 30 million units available for distribution. A further eight types will be available in the next two months as part of the UK make strategy. The increased range and diversity of FFP3 masks will make it easier for NHS staff to find a mask that successfully fits and these FFP3 are different shapes and sizes, including a specific model available in small, medium and large sizes.
The masks in the catalogue have been selected because they have resilient high-volume supply chains and meet the highest technical and clinical standards. These supply chains have been established and are managed by DHSC and its partners from Factory to NHS users. The manufacturers are long-established in the PPE industry, have a global scale and have been minimally disrupted by the pandemic.
Additionally, four out of the 10 manufacturers featured in the catalogue are UK-based. This enables us to have a closer relationship with manufacturers and offers more opportunities for the industry to hear directly from the user and involve them in the design and development of products. Some UK manufacturers are already actively ensuring that frontline user experience and preferences are being incorporated into the design and development of products.
DHSC are also ensuring that NHS trusts are receiving their choice of masks, minimising the need for new fit-testing and ensuring staff on the frontline can access masks they have successfully fit-tested to. This system enables each NHS trust to select the percentage of each mask that they’d like to receive, based on which masks best suit their staff. They also have the option to order some specifically for the purpose of fit testing.
Alongside building and managing the resilient supply of high quality FFP3 masks, the government is improving the availability and quality of fit testing in trusts to ensure appropriate PPE is available to NHS staff members. The government has established a Fit Testing Programme for England. This has been set up to support NHS trusts in their fit testing of staff to the new supplies of UK Made FFP3 masks as they become available, and that these fit testers are trained to Health and Safety Executive standards.
The government is also committed to maximising user comfort and minimising any harm caused by wearing PPE, particularly for those individuals wearing PPE for prolonged periods. Southampton University are undertaking research on PPE use and skin damage including critical thresholds for PPE use, the frequency of breaks required to relieve the skin and the specific regions of the face affected by different FFP3 mask designs.
We are also considering the needs of patients who may be impacted by the PPE worn by staff, for instance those who rely on lip-reading and facial expressions to communicate. DHSC piloted the use of clear face masks and delivered 250,000 masks to NHS and social care providers across the UK as part of the first phase. We are now in the second phase of this pilot; we are gathering further feedback to understand the scale and distribution of demand to inform future procurement.
6. We accept the advice we have received from many eminent scientists that there is a significant risk that not testing NHS staff routinely could lead to higher levels of nosocomial infections in any second spike. We therefore urge the Government to set out clearly why it is yet to implement weekly testing of all NHS staff. (Paragraph 121)
7. We ask that Professor Whitty sets out to what extent testing capacity has impacted the advice he and his colleagues have provided to the Government on routine testing of NHS staff. We further ask Professor Whitty to clarify whether he has advised the Government to introduce routine testing of all NHS staff in the current virus hotspots and if not why. (Paragraph 123)
8. We recommend that, by the end of October 2020, the Government and NHSE/I set out: i) what current capacity there is for testing all NHS staff, ii) what further capacity (if any) will be required and iii) how long it is likely to take to secure sufficient capacity to offer routine tests to all NHS staff. (Paragraph 125)
Professor Whitty provided a response to recommendation 7 through a separate letter dated 03 November 2020. This letter is attached at Annex A.
As set out in the letter from Professor Stephen Powis on 9th November 2020, following further scientific validation of the lateral flow testing modality, and confirmation from Test and Trace that they can now supply the NHS with sufficient test kits, asymptomatic testing of all patient-facing NHS staff is now possible. Full roll is under way, as kits are delivered from Test and Trace.
12. We recommend that the Department and NHSE/I provide us with an update by the end of November 2020 on the progress of these pilots and other steps that are being taken, in both the short and long-term, to support A&E departments.
The aim of NHS 111 first is to support the triaging of patients before they attend A&E departments and help them access the most appropriate service. All systems have now been nationally assured against a 111 First minimum specification and implementation has continued through December. The minimum specification requires:
As part of 111 service improvements, additional 111 capacity has been put in place. We have increased communications to patients to further expand awareness of using NHS 111. A national communications ‘Think 111 first’ campaign was launched on 1 December with a roll out designed to mitigate sharp increase in activity through a graduated increase in intensity over the first three weeks of the campaign.
There has also been additional capital investment provided to support urgent and emergency care:
This includes trust schemes to expand waiting areas and increase the number of treatment cubicles, which will support patient flow and infection control measures this winter.
13. We recommend that NHSE/I and the Department for Health & Social Care set out their assessment of how effective the use of technology and digital alternatives (“telemedicine”) has been across all health and care services. As part of this assessment, we ask that both NHSE/I and the Department to clearly set out how they plan to ensure patients’ wellbeing is not jeopardised by the risk of being digitally excluded from accessing medical treatment and advice. We also ask that NHSE/I and the Department set out what aspects of telemedicine have worked well, including which new models of service delivery have worked particularly well, and what plans there are (if any) to invest in and support the further use of such technology and new pathways in the health and care system. We request an update on these matters by the end of 2020. We will investigate the use of technology and new pathways in the health and care system more extensively as part of our work in the new year.
In responding to the COVID-19 pandemic, NHSX has been able to support health and social care services in accelerating the uptake of pioneering technologies, to what will be a long- term, transformational effect. We have significant evidence of how widely digital technology has been embraced during the pandemic.
Remote consultations have become embedded within the NHS, through the availability of digital communication tools and the hardware to support them, protecting patients, and clinical capacity. Before COVID-19, survey data suggested only 3% of GP practices had video capability for remote consultations in place; this is now thought to be almost 99%.
This capability is supported by the increased capacity for calls, texts and data for frontline staff on mobiles, broadband to support clinicians working from home, and the electronic sharing of patient records. The NHS has accelerated the use of many digital services at great pace. As a response to the pandemic, NHSX have enabled the use of GP-Connect across the whole primary care estate, easing facilitation for authorised professionals in multiple care settings to directly access GP records, which are held elsewhere, in a safe and secure manner. They have also enabled wider access by authorised professionals to an enriched Summary Care Record with Additional Information which allows a health and care professional to see a patient’s medical history and further helps support older patients and those with complex comorbidities.
The public have benefited from the use of the NHS App—we have seen a significant increase in its usage during the pandemic. This demonstrates the appetite amongst the public for using digital to access health information, prescriptions and services.
Public and clinical confidence in digital depends on the security of information. In March NHSX published Information Governance guidance to support health and care staff during the COVID-19 period. This gave the system greater confidence to appropriately use information and tools. In October 2020 NHSX launched an Information Governance Portal, as the home of IG guidance for the health and care system. This for IG professionals, front line staff and the public and is supported by the National Data Guardian and the Information Commissioner’s Office.
Artificial Intelligence (AI) has demonstrated its potential to enhance the monitoring and diagnosis of patients’ conditions. The first round of NHS AI Awards, run by the NHS Accelerated Access Collaborative, in partnership with the NHS AI Lab and the NIHR was announced in September. The awards support technologies from their initial feasibility to deployment, evaluation and potential scalability within the health and care system. The first awards include examples of remote monitoring of patients including Brainomix Ltd e-Stroke Suite which uses AI to interpret stroke brain scans and share information between hospitals in real-time, and Rhythm Technologies Ltd’s Zio Service, an ambulatory ECG monitoring service, utilising AI-led processing and analysis for cardiac monitoring.
AI has been further used in the National COVID-19 Chest Imaging Database, a UK database containing X-Ray, CT and MRI images from patients across the country. This is to support a better understanding of the COVID-19 virus and develop AI technology which will enable the best care for patients.
As we shift into a more digitally transformed age, we acknowledge that technological solutions may be less accessible to some groups. Individuals may lack access to a device or may not have the digital skills needed to use them effectively. A direct benefit of using digital platforms is that it frees up the time of healthcare professionals to spend with patients that require face-to-face care, across all health and care settings.
We are supporting service developers to ensure that all services are inclusive. This includes the commissioning of ; helping healthcare providers and service designers to ensure that digital services are as inclusive as possible, and meet the needs of all sections of their populations. The guidance and templates in the , help service developers build digital services that put people first and are; consistent, usable, and accessible. We recently published the . This forms a baseline assessment of the suitability of apps and digital services for use by the NHS, social care or directly by citizens. There are five core assessment areas which digital technologies must adhere to; one of those which developers are assessed on is the accessibility and usability of their product.
NHSX is also working with NHS regions to pilot a digital health champions scheme, with specific communities, to be complemented with an online learning platform providing up-to- date knowledge about core NHS digital products and services.
The NHS Long Term Plan and the DHSC Technology Vision set out a clear expectation that services are digitised to a core level of maturity and are connected through initiatives such as shared care records. These are then used as a springboard for pathway transformations which improve outcomes, experience and value of care. NHSX will support the health and care system to do this.
In summary, the COVID-19 response has greatly accelerated the use of digital technology, has mainstreamed remote consultations and we are beginning to see a similar effect for remote monitoring. Overall, we are creating greater flexibility and resilience in the workforce, and providing more flexibility in the delivery of services. We have also seen improved decision making and access to information through the better use of data and simplified information governance guidance. We want to embed and extend these changes to support the health and care system’s recovery from the pandemic and ongoing resilience.