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Delivering core NHS and care services during the pandemic and beyond Contents

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6The NHS: Lessons learnt and building for the future

155.The pandemic has required the NHS to make fundamental changes to the way it delivers services to patients. It is crucial to assess these changes in order to build for the future and support the NHS in the long-term. As part of our inquiry, we have assessed the use of:

• a “beefed-up” 111 dial service to prevent overcrowding at accident and emergency departments;
• technology and digital alternatives (“telemedicine”) in the delivery of core medical services; and
• independent sector capacity (such as beds, facilities and staff) in supporting the delivery of core healthcare services.

Although no change comes without risk, there are lessons to be learnt from the pandemic which have the potential to substantially benefit the future of the NHS and build-upon the positive work already being undertaken by NHS Trusts, NHSE/I and the Government.

Long-term support for accident and emergency departments

156.In recent years, pressure on accident and emergency departments has been an ongoing source of concern.274 The Royal College of Emergency Medicine (RCEM) has explained that the overcrowding of A&E departments has resulted in “corridor care” becoming commonplace in hospitals with most emergency departments being “stretched beyond the capacity they were designed and resourced to manage at any one time.”275 During our session on 16 June 2020, Dr Katherine Henderson (President, Royal College of Emergency Medicine) referred to emergency departments as having “elastic walls” with teams never able to say “We are full. We are at capacity.”276

157.The RCEM told us that patients have attended A&E Departments less as a result of the pandemic and in consequence A&E Departments have “no longer been forced to pick up the pieces where community or specialist care fails to cope, especially out of hours.”277 Dr Henderson told us that the pandemic had effectively “cured” the issue of crowding in A&E departments for now.278

158.Recent data shows that admissions to emergency departments are increasing.279 Consequently, as patient presentations for emergency care begin to rise, there is a concern about how A&E departments will be able to meet patient demand while sufficiently mitigating the risk of spreading COVID-19. Chris Hopson (Chief Executive, NHS Providers) highlighted that Trusts have been “particularly concerned” about emergency departments as the winter period approaches and that “restarting the full range of emergency services is going to be complicated and difficult.”280

159.Dr Henderson explained this was a significant worry because those in need of emergency treatment are also likely to be the most vulnerable, so they tend to be at greater risk of dying from nosocomial (hospital-acquired) infections including COVID-19.281 She added that the real “risk is that [overcrowding] comes back and we do people harm.”282 Dr Henderson explained that:

The idea that you could have a vulnerable 80-year-old with a hip fracture in a corridor next to someone who might have COVID-19 is just impossible. We cannot let that happen. We need to find a way of making it possible for people to get the care they need where they need it, which does not always necessarily require going to the emergency department.283

160.The RCEM believes that there is now a “moral imperative to ensure that we never see a return to crowding or corridor care”,284 and to ensure emergency departments continue to operate with “an absolute focus on minimising nosocomial infections.”285

161.In a joint written submission, the Royal College of Surgeons of England and the Royal College of Emergency Medicine’s argue that overcrowded A&E departments are “fundamentally incompatible” with social distancing and infection control measures. This is because existing emergency departments are “too small, run down and in need of repair,” since the physical size of hospitals and departments had not increased along with demand for their services.286

A “beefed-up” 111 dial service

162.Dr Katherine Henderson suggested that the problem of overcrowded A&E departments could be resolved by ensuring further steps are taken to triage patients prior to them presenting at A&E departments. She explained that this would “make sure that the right patients come to the emergency department and that there are other routes of access to care for urgent patients who do not need emergency care”.287

163.The Royal College of Surgeons of England and the Royal College of Emergency Medicine have said that evidence shows that patients with less acute needs are already willing to use telephone services rather than attend emergency departments:

Calls to NHS 111 in March reached nearly 3 million, over twice the number recorded the previous March. While this figure fell substantially in subsequent months, the 1.62m calls offered in May 2020 was 11% higher than May 2019, indicating that NHS 111 is being more widely used.288

164.Dr Henderson consequently endorsed a “call first” approach whereby a “beefed-up” 111 dial service could be used to ensure that patients are able to use the most appropriate pathway to meet their needs, rather than patients presenting at Emergency Departments by default.289 Dr Henderson told us:

We have not focused on getting 111 as robust as it needs to be, and appreciating the need for clinical input—having clinicians available to give advice to the people who are answering the phones, so that you get a robust disposal decision, as it is called. That is a realisation that COVID-19 has given us. There are huge advantages in there being people who can give good, sensible advice to somebody who understandably is worried about risk and has defaulted to the safest option, which is to go to A&E.290

165.Dr Henderson further explained how the 111 dial service would work:

There is going to be no change in the provision of 999 access to emergency departments, nor would there be a scenario that we could envisage whereby we would be turning away people who are in desperate need of care. Some people do not have access to smartphones. They are not going to be able to ring 111. They are homeless; they are in domestic violence; or they are very vulnerable.291

166.Nigel Edwards (Chief Executive, The Nuffield Trust) agreed that A&E Departments could be supported by “bolstering the 111 service”.292 Mr Edwards explained:

[…] we should probably consider the type of approach that is used in Norway, Denmark and the Netherlands where you do not go to the ED unless you have had a referral from the equivalent of a 111 service or a GP, or the ambulance service has decided to take you. There are ways of dealing with the homeless and people who do not have telephones.293

Dr Charlotte Augst (Chief Executive, National Voices) also agreed that “whether we call 111 before we go to A&E will determine whether we weather the storm.”294

167.On 30 June 2020, Sir Simon Stevens told us that “The evidence you heard from Dr Katherine Henderson, President of the Royal College of Emergency Medicine, makes a lot of sense to us”.295 Professor Steve Powis (National Medical Director, NHSE/I) also told us that an important long-term aim for NHSE/I, prior to the pandemic, was to ensure that the 111 dial service was used “to signpost people and to help people […] get their treatment in the most appropriate place”.296 Professor Powis explained that:

We [NHSE/I] want to move increasingly to a 111 first model […] We are piloting various forms of Call First in London, Portsmouth and other areas, because we want to make sure that we get the exact model right and that we get the data back that will tell us what the right model is.297

168.Amanda Pritchard (Chief Operating Office, NHSE/I) further explained:

One of the things that we are trying to do in the pilot is to use 111 as a way of directing people to the appropriate next-step service. Getting the range of bookable services as wide as possible is part of the pilot. Portsmouth is particularly focusing on that as a critical part of testing the model.298

169.Historically, accident and emergency departments have been over-stretched, over-burdened and running over capacity. We have heard that the initial decline in patient attendances at A&E departments during the pandemic to some extent “cured” the problem of “corridor care”.299 However, as presentations at A&E begin to increase, the Government and NHSE/I need to ensure emergency departments do not become overwhelmed by patient demand and remain able to provide high-quality and safe treatment for all patients.

170.We welcome the news that the Government and NHSE/I are piloting a ‘111 dial first’ scheme to support the triaging of patients before they attend A&E departments.300 The introduction of an expectation that a patient will call first before walking into an A&E department is a sensible change to support A&E departments during the pandemic, and has much to commend it as a long-term reform. 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.

Technology and digital alternatives (“telemedicine”)

171.Technology and digital alternatives have been rolled out across a range of core healthcare services to ensure treatments and appointments can continue and that updated information can be provided to patients. Such “telemedicine” has largely been welcomed as a positive innovation in circumstances where many medical services would otherwise be unable to meet the needs of patients. The pandemic has also encouraged greater innovation and the wider deployment of technology to support the productivity of healthcare services. The Secretary of State, along with other NHS leaders, has shown significant leadership on technological innovation across the NHS which we have heard has provided a much-needed boost to the delivery of core healthcare services during the pandemic.

172.During our session on 1 May 2020, Claire Murdoch (National Mental Health Director, NHSE/I) told us that NHS Trusts across the country have been organising online groups. These groups provide support to people “recovering from addiction, older people or people with serious mental illness.”301 She noted that this has been achieved in a series of “days and weeks” despite these online groups originally being planned to be rolled out over a three to four year period.302

173.During the same session, Gill Walton (Chief Executive, Royal College of Midwives) told us about how important technology has been to the delivery of maternity services during the pandemic. She explained:

One of the positives from the pandemic is the use of technology; there has been more virtual contact and follow-up with women through midwives and maternity services than before. That is important, and we need to keep stepping it up. While some face-to-face contacts have been reduced, virtual contact and telephone contact have been increased. That is a good thing and something to hold on to for the future.303

174.Throughout our inquiry, we have heard about the wide-reaching and beneficial use of technology - particularly telephone and digital consultations - across a range of settings during the pandemic. Examples include:

• Professor Martin Marshall (Chair of Council, Royal College of General Practitioners) told us that only 23% of consultations in general practice are currently being conducted face to face, compared to 70% prior to the pandemic304 and that the “use of remote technologies, particularly online technologies, and even the basic telephone, will improve access [to healthcare services] for young people.”305
• Nigel Edwards (Chief Executive, The Nuffield Trust) noted that “We have seen an upswing in the use of digital for communication between GPs and consultants. That offers some very major opportunities to build on.”306
• Claire Murdoch (National Mental Health Director, NHSE/I) said that, in order to combat the reduction in referrals to mental health services, NHSE/I have brought forward an “all-age, 24/7 crisis services”307 and consequently patient “access [to mental health services] has happened a lot more quickly because we are able to see more people through digital routes.”308
• Roche Diabetes Care has said that the use of apps in supporting diabetic individuals has been “effective” and “needs to continue beyond the pandemic, to empower each individual living with diabetes to manage their condition”.309
• Asthma UK and the British Lung Foundation have welcomed the use of technology “with 71% of routine consultations being delivered remotely during this crisis compared to just 25% the same time last year.” They have said that “We now have a golden opportunity to build on all this innovation” and to “make improvements” for the long-term.310

175.However, although much of the evidence we have received has praised the greater use of telemedicine in the healthcare system, we have also heard that the use of remote consultations and other forms of technology has not been appropriate in all circumstances. This is because, in some cases, there are inequalities that result from differing levels of digital access and literacy amongst patients which can prevent some of the most vulnerable patients from accessing the medical services they require. Concerns have also been raised as to whether the use of telemedicine is an effective means of treatment even for those who are not digitally excluded. Sir Robert Francis (Chair, Healthwatch England) broadly described the benefits and risks of the continued use of telemedicine:

Clearly, an enormous amount could be done by way of digital appointments, and we should bottle that and keep it. There has been a notorious reluctance—not necessarily willing reluctance but institutional reluctance by the NHS—to do what everyone else is doing and to communicate in a way that most of the rest of society has been doing for a long time. You can reach people in a digital way as you could not possibly do otherwise. By the way, we are only at the threshold of exploiting the benefits of that.311

[…] But, as I mentioned, there are people who are socially isolated or elderly people who may be living on their own. There are people who still do not have internet access. There are people in communities where access is difficult, even if they have a computer in their house, because there are privacy issues and the like. We have to cater for them.312

Digital communications are great because a lot of people—maybe the majority—can benefit from them, but they cannot be the only solution. We have to remember the other people whose needs cannot be met that way.313

176.During the same session, Daloni Carlisle, an NHS patient, told us about her own experiences of using telemedicine. Daloni explained:

It was much easier for me not to have to go out to a waiting-room and sit in a waiting-room at a point when I had shingles and was feeling very unwell. It was great to be able to make that diagnosis on the telephone. I felt quite safe in that diagnosis, but ideally a doctor should have had a look at that. As a way of dealing with things in a crisis, it was totally acceptable and had advantages, but I am not sure that it would be good long term. It also depended on me having the internet.314

[…] A successful telephone consultation requires quite a lot of confidence from the patient’s side. You have to be quite confident in your ability to talk about what you are experiencing and your symptoms. […] I do not think patients are pushing for telephone consultations. I am not convinced that doctors are either.315

177.We have heard that the increased use of technology and digital alternatives to deliver medical services has negatively impacted already marginalised groups. Consequently, there has been a clear message, as the Royal College of Psychiatrists has stated, that “Those with lack of digital literacy, lacking in confidence using technology or with little or no access to digital platforms must not be disadvantaged.”316

178.Rethink Mental Illness has claimed that clinical appointments and community services which are now taking place online have become less helpful to patients. This is because individuals are finding such digital services “impossible to engage with” and it has left them “feeling abandoned”.317 Mind has highlighted that not all patients will have access to the necessary technology or have the right skills to enable them to receive support via digital channels. Mind has drawn attention to those with mental health problems and those with disabilities as being disproportionately excluded by telemedicine.318 Mind has also suggested that individuals may not feel comfortable talking about their mental health online or may not be in an environment where they are safe to talk about their mental health.319

179.Blood Cancer Alliance has suggested individuals whose first language is not English have found it harder to follow online guidance and videos.320 Meanwhile, Healthwatch England has said that “People affected by homelessness and those on low incomes are two groups that may be particularly affected” by the use of telemedicine.321 Age UK has also outlined the potential challenges that the increased use of telemedicine will have on older patients. For example, Age UK has claimed that 36% of people aged 65 and over are “not online” but should still be able to access health and care in the way that suits them best.322 Dr Jennifer Dixon (Chief Executive, The Health Foundation) also told us about the risks telemedicine posed to “patients, particularly those with chronic disease and those in socioeconomic groups who may not be so used to using technology.323

Assessing the future of telemedicine

180.Dr Jennifer Dixon (Chief Executive, The Health Foundation) highlighted the need “to think very carefully about the [need for] longer-term assessments of the impact of technology”.324 Similarly Richard Murray (Chief Executive, The King’s Fund) called for the “evaluation” of the use of technology to be conducted in order “to make sure that it has worked exactly and as well as we think it has done.”325 Richard Murray explained that the rapid, and potentially longer-term, switch to virtual consultations could have several negative consequences and many of which have not yet been fully explored. This includes exacerbating potential inequalities and issues relating digital exclusion, in addition to potential unintended patient safety consequences.326 Mr Murray told us:

There is some evidence that GPs doing telephone and video consultations become more risk averse, order more tests and are more likely to prescribe antibiotics. They may well make mistakes.327 […] We also need to make sure that [telemedicine] has not altered inequalities.328

181.Dr Charlotte Augst (Chief Executive, National Voices) also emphasised the need to assess the use of telemedicine and ensure that technology is effectively deployed to meet patient need. Dr Augst suggested that:

We need to move from a perspective that, “This works for a lot of people. Let’s hope it doesn’t exclude people,” to “Because there is a real risk that we will exclude people, we will tailor our technology responses and our face-to-face responses to pick up people with the biggest need and who find it the hardest to access services anyway.” We must focus on meeting the needs of people who have the most complexities going on and might find it the hardest to get solutions.329

182.Concerns relating to patients being digitally excluded or constrained from accessing core health services has been further assessed by Healthwatch England, National Voices and Traverse in their joint report The Dr Will Zoom You Now (July 2020). The report noted that:

The reality is that for many, remote and virtual consultations are the only options at the moment so it is important we continue to hear from people about whether it is actually working for them or not and what support is needed to ensure people feel confident to receive healthcare in this way.330

183.On 30 June 2020, Amanda Pritchard (Chief Operating Office, NHSE/I) told us that the use of technology and digital alternatives in the long-term is important. Amanda Pritchard claimed that NHSE/I is considering: “How do we use technology most effectively to find different ways of accessing services? How do we make sure that the people who need face-to-face care can access it safely? At the moment, all the effort is going into really trying to push that restoration journey but recognising that it is not straightforward.”331

184.We welcome the support of the Secretary of State and the Chief Executive of NHSE/I for technological innovation in the NHS. The use of technology and digital alternatives (“telemedicine”), although it has had a mixed response from some patients and medical practitioners, shows that the NHS is innovating. We also welcome the wider deployment of technology which has helped to improve productivity across the healthcare system. Although the use of technology has been much-needed and largely worked in supporting the delivery of health and care services, there is nevertheless a risk that many individuals in need of medical advice or treatment will be digitally excluded. Therefore, in order to ensure telemedicine benefits all patients equally, a clearer and more comprehensive assessment is required to ensure that technology does not replace key elements of health services (such as face-to-face consultations) or disadvantage other groups, and to also ensure the benefits of telemedicine can be maintained and built-upon. Parts of the NHS have also explored new options for the delivery of care, trialling new pathways for treatment. These hold real promise for future NHS productivity. It is vital that successful examples of innovation in models of service delivery during the pandemic are brought forward, alongside technological and digital innovation.

185.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.

The independent sector

186.The independent sector’s provision of additional bed capacity has played a significant role in supporting the NHS in responding to the pandemic. The Government’s and NHSE/I’s agreements with the independent sector, in this respect, has provided a much-needed boost to facilities, staff and capacity available for the delivery of core healthcare services. Consequently, we have received calls for longer-term agreements to be made with the independent sector in relation to bed capacity and other facilities.

187.Throughout our inquiry we have heard that, due to social distancing and infection control measures, there is currently not enough capacity in the healthcare system to meet the growing patient demand. On 16 June 2020, Dr Layla McCay (Director, NHS Confederation) emphasised to us that there is “anxiety” about how much capacity will be required in the coming months, and that “capacity will be needed not just in the acute sector but in primary care, in community services and in social care”.332 This was also echoed by NHS Providers in its written submission:

Extra staff, equipment and beds have been made available following a blanket contract agreed between the NHS and the independent hospital sector. We believe there is a strong argument to contract this capacity for a further period and Trusts recognise their responsibility to ensure this capacity, if it is contracted for a further period, is used to best effect.333

188.Concerns about capacity have been further reflected in a survey conducted at the end of June 2020 by NHS Providers of its member Trusts. The survey showed that only 7% of respondents said that their Trust will be able to return to “meeting the needs of all patients and services users that require services immediately”. Trusts told NHS Providers that, although overall the provider sector would open more capacity over the coming months, currently capacity is nearly half (53%) of what it was before COVID-19.334 Commenting on the survey during our session on 30 June 2020, Chris Hopson (Chief Executive, NHS Providers) told us of the importance of retaining capacity from the independent sector. Mr Hopson explained:

We have demand up there and we have dropped capacity down there; and the key thing we need the Government to do is to help us get capacity back up. The Government has promised that the NHS will have everything that it needs, but […] they need to ensure that we carry on using independent sector capacity.335

189.Similarly, on 16 June 2020, Professor Derek Alderson (President, the Royal College of Surgeons of England) was clear in his testimony to us that “the Government needs to commit to maintaining [access to the independent sector’s] facilities”.336 Professor Alderson told us that “for the foreseeable future, the capacity within our NHS resource alone is insufficient for us to be able to get surgery started again and maintain a sustainable and resilient service as we move into the winter” and consequently retaining access to the independent sector will be “essential”.337

190.On 30 June 2020, Amanda Pritchard (Chief Operating Office, NHSE/I) reiterated what we have heard throughout our inquiry: «The independent sector has been critical» to supporting the NHS.338 She explained that “What that means in the short term is that we [NHSE/I] are very keen to continue the partnership arrangements with the independent sector because that provides some much-needed additional capacity on top of normal NHS facilities.”339

191.During the same session, we questioned Sir Simon Stevens about what long-term arrangements should be made with the independent sector in order to sufficiently support NHS services. He told us that:

Going into July [2020], we hope that we will, on the back of some decisions that we want to be able to take around access to independent sector hospital capacity and other capacity that we will need, set a clear trajectory for the rest of the year. At that point, when hospitals know what resources and beds they have available, they will be able to provide the kind of guidance that you mention340

192.We have sought to clarify the position of the Department of Health & Social Care and NHSE/I on securing capacity from the independent sector in the longer term. On 21 August 2020, Sir Simon wrote to us and explained that “The government has confirmed funding for the remainder of this year to cover some continuing use of independent hospitals, nightingale reserve capacity and community health discharge services”.341 On 6 August 2020, Rt Hon Matt Hancock also wrote us and explained:

Looking ahead to winter, the Prime Minister has announced £3bn of extra NHS funding to ensure the retention of the Nightingale hospital surge capacity and continued access to independent hospitals capacity to help meet patient demand.

[…] Continued access to independent sector capacity will be in place to further support the recovery and restoration of elective services.342

193.We commend the efforts of the Government, NHSE/I and the independent sector for stepping up and securing independent sector capacity (i.e. beds, staff and facilities) which has been crucial to supporting the NHS during the pandemic. It is clear that such independent sector capacity will be needed over the coming months as the restoration of core healthcare services is prioritised, particularly over the winter period.

194.We recommend, in addition to our recommendations in Chapter 2, that the Government and NHSE/I clarify what plans there are to continue to use independent bed capacity and other independent resources as the winter period approaches. We further recommend that the Government and NHSE/I set out i) what the current level of capacity is across all NHS services, ii) what assessment it has made of what additional capacity will be required, in the medium and long term, to ensure the restoration of non-COVID NHS services and iii) what level of capacity it is expecting and planning to retain from the independent sector in the medium and long term. We expect this information by the end of October 2020.

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