Readying the NHS and social care for the COVID-19 peak Contents

1Lessons from the NHS and adult social care response to the COVID-19 pandemic

1.On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health & Social Care (the Department), NHS England & NHS Improvement (NHSE&I), the Ministry of Housing, Communities & Local Government (the Ministry) and Public Health England on Readying the NHS and adult social care in England for COVID-19.2

2.In England, the Department has overall responsibility for health and social care policy while NHSE&I leads the NHS, providing oversight and support for NHS trusts and foundation trusts. Local NHS trusts provide hospital, community and mental health services, alongside GPs, while local authorities assess care needs and commission social care and public health services. The Ministry of Housing, Communities and Local Government (MHCLG) has responsibility for the local government finance and accountability systems. Public Health England, working with local authorities and NHS partners, provides health protection services and public health advice, analysis and support to government and the public.3 This includes monitoring, preparing for and responding to public health emergencies such as COVID-19. Public Health England (PHE) is an executive agency of the Department.4 At the start of the outbreak, the only central stock pile—held by PHE was designed for a flu Pandemic. We welcome Lord Deighton’s appointment to lead on PPE supply.

3.COVID-19 is an infectious respiratory disease caused by a newly discovered coronavirus, first identified in China in December 2019. On 31 January 2020, England’s Chief Medical Officer confirmed the first cases of COVID-19 in England. Over the following months, the UK government mobilised a wide-ranging response to COVID-19, covering health, social care and other public services, and support to individuals and businesses affected by the pandemic. By the end of April, the government had allocated an additional £6.6 billion to support the health and social care response to COVID-19 and £3.2 billion to local government to respond to COVID-19 pressures across local services, including adult social care.5

Accountability arrangements for the COVID-19 response

4.The scale and nature of the COVID-19 pandemic are without precedent in recent history and the NHS and the adult social care sector have had to reorganise their services at great speed.6 Before the pandemic, NHSE&I commissioned most NHS services through NHS local commissioners (clinical commissioning groups).7 In March this year, the Department gave NHSE&I temporary emergency powers to lead and organise all NHS services directly as it responded to COVID-19.8

5.NHSE&I told us that it declared a level 4 incident, the highest level of emergency response the NHS can provide from 30 January. This was followed by a series of actions to prepare the NHS for the expected surge in COVID-19 patients, including weekly briefings for NHS leaders from early February, and, in a 17 March letter to NHS service providers and commissioners, outlining detailed preparations to free up beds and redirect staff and other resources.9 But it was not until the 15th April that the Government published an Action Plan for Adult Social Care.10 Actions taken by the NHS, alongside the Government’s social distancing policies, ensured that there were sufficient beds and ventilators to provide treatment for COVID-patients when required.11

6.When challenged on the lack of similarly clear leadership in the social care response, the Department acknowledged that statutory responsibilities for social care are spread between national government, local government and individual providers. The Department is responsible for overall policy across health and social care but it recognised the “considerable ambiguity in how social care is managed” and that the fragmented system had made it “considerably more difficult” for Government to take action.12

7.There have been serious and widespread concerns about the lack of timely testing for both staff and the public and inadequate PPE provision particularly in social care.13 When we queried the arrangements for ensuring access to testing, we were told that several bodies were involved, including the Department, Public Health England and NHSE&I. For example, NHS laboratories tested patients and some NHS staff, while other parts of the testing programme were run elsewhere.14 NHSE&I told us it had followed Public Health England’s strategy on whom to test.15 Public Health England clarified that its testing policy in March was based on the limited testing capacity at the time as agreed with the NHS and the Chief Medical Officer.

8.Similarly, procuring and distributing PPE involved a range of bodies, including the Department, Public Health England, local NHS providers and care homes, yet until the appointment of Lord Deighton in mid-April no one took the lead in making sure there was sufficient PPE.16 Public Health England told us that it was responsible for holding and adjusting the PPE stockpile on behalf of the Department, but did not make policy decisions on its contents, management or use.17 When challenged on its part in ensuring sufficient PPE supply, the Department explained that it had worked with NHSE&I, alongside the Foreign Office and others, to source international supply, but it stressed the difficulties it faced given worldwide demand. We noted the significant increases in PPE supplies since Lord Deighton’s appointment.18

Discharging people from hospitals to care homes

9.On 17 March the NHS told trusts to discharge urgently all medically fit hospital patients with COVID-19 to maximise inpatient and critical care capacity. On 2 April, the Department told care homes that they needed to make their full capacity available and could admit patients with COVID-19 by isolating suspected or confirmed cases. Some Local Authorities were pressurising Care Homes to take patients discharged from hospitals.19 Yet until 15 April there was no policy to test patients for COVID-19 before discharging them to care homes. By this point 25,000 people had been discharged from hospitals to care homes and the Department does not know how many had COVID-19.20

10.Some organisations such as Care England highlighted to us the flawed nature of this policy and reported that, given the absence of testing and inadequate PPE, social care felt abandoned.21 When we challenged the Department and the NHS on such a reckless and negligent policy, the Department told us that when the NHS issued its guidance in March COVID-19 was not widespread.22 NHSE&I said it has always been the case that they want to discharge people who are clinically fit and staying in hospital could be harmful for the elderly.23 When asked why those discharged had not been tested, it told us it was following testing advice provided by Public Health England.24 Public Health England clarified that, at the start of the outbreak, testing was limited to 3,500 tests a day nationally and so it had agreed with the NHS and the Chief Medical Officer priority groups for testing: those in intensive treatment units; those with respiratory infections; and limited testing in care homes to diagnose outbreaks. Public Health England also told us that “what was becoming clear in the back-end of March and certainly from the beginning of April was that there was an asymptomatic phase, which means that people can transfer the virus without ever having symptoms, or a significant pre-symptomatic phase, which is where the virus could be shared”.25 It is clear that the availability of test and testing should have been ramped up much more quickly after the NHS had declared Level 4 National Incident (its most severe incident level) on the 30th January 2020.

11.We remained concerned that the Department had continued its policy of discharging people untested into care homes even once it was clear there was an emerging problem.26 The number of first-time outbreaks in individual care homes peaked at 1,009 in early April. Between 9 March and 17 May, around 5,900 care homes, equivalent to 38% of care homes across England, reported at least one outbreak of the disease.27 The Department defended the decisions it took as rational based on the information it had at the time and stated its belief that the clearest correlations between social care outbreaks and other issues related to staff with the disease rather than patients discharged from hospital. However, it also acknowledged “that is not the same as saying that we would do the same again”.28

Delays to reforming adult social care

12.This Committee has warned before that the Department lacked an effective overall strategy or plan to integrate health and care and that poor outcomes could arise as a result.29 As Care England told us, for too long “adult social care has been kicked into the long grass by governments of all stripes.”30 Despite numerous white papers, green papers, consultations, and independent reviews over the past 20 years, meaningful integration of health and social care was yet to occur going into the pandemic.31 The Department noted that the experience with COVID-19 had heightened the need for reform.32

13.We heard how frequently social care had taken second place to the NHS’s needs, particularly in accessing test kits and results, and securing reliable PPE supply for care homes, which had been neither timely nor coordinated.33 When questioned, the Department denied that social care had been forgotten, citing the work it had done in the sector and that it had “taken a more national and more interventionist role in social care than ever before” when issuing guidance and additional funding, for example. It said that testing capacity had been limited but as it increased was opened up to all care staff.34 On the subject of PPE supply, the Department asserted, “at no point has there been an instruction for the NHS to be prioritised over the care sector”.35 When we pressed the Department on why it did not publish its action plan for adult social care until 15 April, over four weeks after the initial NHS letter on plans to respond to the outbreak, it told us the plan brought together and enhanced previous guidance given.36 Government Policy prior to the action plan was that the social care sector procure their own PPE. This was against a background of the NHS’s huge purchasing power and tightening domestic and worldwide demands for PPE. It did acknowledge, however, that the thousands of independent providers and the funding model for social care made for a very challenging and tough context in which to respond to COVID-19. This was apparent in the imperfect data it had to work with. The Department told us that data was much better and more timely in the NHS than for social care, due to the structural differences between the two.37

14.This Committee has also challenged the Department before over not delivering on its overarching responsibilities towards the care market, and having no credible plans to ensure the sector was sustainably funded.38 We note it was not until June 2020 that the Department appointed a director general for adult social care to lead on its social care policies, four years after the previous director general left the post.39 The Ministry of Housing, Communities & Local Government told us that it had provided £3.2 billion additional funding to local government with instructions to prioritise social care and, of the £1.25 billion spent so far, £500 million had gone on social care.40 On 15 May 2020 the government also announced a £600 million Infection Control Fund for local government, to tackle the spread of COVID-19 in care homes in England, which was in addition to the £3.2 billion.41 Given reports of increased risk of provider failure and calls from the Local Government Association and NHS Providers to secure a sustainable future for social care, we pressed the Department on whether it would have to rescue any failing providers in the weeks ahead. It told us it was focusing on ensuring the continued provision of services to individuals but was looking closely at the evidence base to understand the different challenges faced by different providers, including increased costs and in some, but not all, cases, reduced demand.42

2 C&AG’s Report, Readying the NHS and adult social care for COVID-19, Session 2019–2021, HC367, 12 June 2020

3 C&AG’s Report, para 4

5 C&AG’s Report, paras 4, 9

6 Department of Health and Social Care, The Exercise of Commissioning Functions by the NHS Commissioning Board (Coronavirus) Directions 2020, 23 March 2020

7 C&AG’s Report, NHS financial management and sustainability, Session 2019–21, HC 44, 5 February 2020

8 C&AG’s Report, para 1.17

9 Q 10; C&AG’s Report, para 1.3, 1.13

10 C&AG’s Report, para 1.3

11 Qq 58, 63, 118–119; C&AG’s Report, paras 10–13,18

12 Qq 11, 120

13 Committee of Public Accounts, NHS capital expenditure and financial management, Eighth Report of Session 2019–21, HC 344, 8 July 2020, para 22; C&AG’s Report, paras 19, 20; RSC0010 NHS Confederation submission; RSC0004 NHS Providers submission; RSC0001 Care England submission

14 Qq 18–20, 23–26, 34, 98

15 Qq 17–19

16 Qq 62, 75, 79, 87–88

17 Qq 75

18 Qq 62, 87–88

19 Q13

20 C&AG’s Report, paras 3.19–3.20

21 RSC0001 Care England submission

22 Qq 21–22

23 Q 16

24 Qq 14, 16–18

25 Qq 20, 84

26 Qq 19, 21–23

27 C&AG’s Report, para 3.15

28 Qq 23, 43

29 Committee of Public Accounts, Interface between health and adult social care, Sixty-Third Report of Session 2017–19, HC 1376, 19 October 2018

30 RSC0001 Care England submission

31 C&AG’s Report, foreword

32 Q 121

33 RSC0002 Local Government Association submission; RSC0005 Association of Anaesthetists submission

34 Qq 11–12, 27, 38

35 Q 42

36 Qq 11–12

37 Qq 31–38, 40; C&AG’s Report, para 13

38 Committee of Public Accounts, The adult social care workforce in England, Thirty-Eighth Report of Session 2017–19, HC 690, 9 May 2018

40 Qq 28–29

41 C&AG’s Report, Overview of the UK government’s response to the COVID-19 pandemic, Session 2019–21, HC 366, 21 May 2020, Figure 4

42 Qq 30, 92–93; C&AG’s Report, para 14; RSC0004 NHS Providers submission; RSC0002 Local Government Association submission

Published: 29 July 2020