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

2Resuming services and preparing for the future

Public trust

15.The Department stressed that it had to respond quickly to the COVID-19 pandemic often with “imperfect knowledge”, which was why its approach had altered over time.43 But Care England told us that PPE guidance had changed no fewer than 40 times, causing confusion and anxiety to service providers and staff.44 When we asked why the PPE guidance had constantly changed, the Department said that when updating its guidance it was trying to match clinical advice, as understanding of the virus changed, to available supply. We challenged it on why it would in effect toughen guidance when it knew there was already insufficient supply. For example, guidance which said care homes needed new PPE for each patient had caused considerable anxiety. The Department told us it could not “simply be driven by supply in this case”.45

16.By comparison, because testing capacity was limited during the earlier stages of the pandemic, the Department said it had sought clinical advice on where that capacity was best deployed. Eligibility for tests changed as capacity increased and the Department noted that testing was the area which had evolved the most over time.46

17.Concerns about the transparency of Government’s reporting about the measures it has taken, particularly around PPE and testing, have been widely publicised.47 We heard from stakeholders in the health and social care sector who highlighted issues with inadequate and unreliable PPE supply.48 For example, despite the fanfare around a large consignment of PPE being secured from Turkey, it did not contain the volume expected nor meet required standards.49

18.Testing for COVID-19 is fundamental to controlling the virus, and to informing and reassuring the public.50 Yet, while Government’s announcement of its 100,000 daily test target by the end of April had a galvanising effect to start with, NHS Providers reported that it had ended up being a distraction from developing the right kind of capacity and testing approaches in all areas of the country.51 The UK Statistics Authority publicly criticised the Government for the way it counted tests and has urged greater clarity about how testing targets are defined, measured and reported.52 Similarly to PPE, we heard how unkept promises on tests had led to a loss in confidence among some providing NHS services.53

19.We were keen to know how the Department would ensure sufficient stockpiles of PPE and testing capacity as it rolls out its ambitious ‘track and trace’ programme and the NHS resumes routine services while continuing to deal with COVID-19 this autumn and winter.54 It reiterated that testing capacity had now expanded significantly.55 Public Health England also explained that it was “ramping up” the size of its local health protection teams from 360 staff to 1,100 by the end of July, in light of the test and trace part of the programme.56 Given its failure to boost the PPE stockpile during January and February despite recommendations from the New and Emerging Respiratory Virus Threats Advisory Group, we asked how the Department was going to ensure lessons were learned so there would be adequate PPE this winter. The Department claimed it had been in the process of responding to this advice when COVID-19 hit. It said it was aiming in future to have PPE supply for 90 days ahead by signing longer-term contracts to guarantee overseas supply; increasing the proportion of PPE made domestically; and better understanding demand.57

Managing staff well-being

20.NHSE&I explained that the NHS was carrying 100,000 staff vacancies going into the pandemic.58 It said the workforce had been boosted by around 20,000 students; retired NHS staff; and a further 600,000 volunteers (working across a range of public services, including the NHS) who stepped forward to work on the frontline during the crisis.59 Given the potential reliance on the student workforce in the event of a second wave, we asked about the operational impact of the NHS’s June decision to cut short its student nurse programme, which was providing paid placements. NHSE&I told us that this had always been the intention as final year students who qualified would move into substantial placements at more senior grades while second year students would need to return to the academic part of their courses.60

21.There have been numerous media reports of PPE shortages for health and social care staff and stakeholders have told us how the failure to provide adequate and timely PPE has impacted staff morale, trust and confidence.61 In the period from 6 April to 19 May, more than 80% of local resilience forums reported that PPE was having a high or significant disruptive impact in their area across health and social care services, putting staff and others at risk.62

22.Testing for NHS workers (with symptoms) only began from 27 March, with eligibility extended to social care workers (with symptoms) from 15 April, after the pandemic had passed its first peak. In the period up to 15th April up to a maximum of five symptomatic residents in each care home would be tested, and from the 28th April all symptomatic care home residents were offered testing but this was capped at 30,000 tests per day between residents and staff. From 28 April, all social care workers were eligible for tests, but the Department capped the daily amount of care home tests at 30,000 (to be shared between staff and residents).63 Stakeholders told us that failures in testing had also led to increased anxiety and frustration as well as increased absence due to unnecessary isolation. For example, the NHS Confederation told us that the NHS had had an unprecedented level of absence during the first weeks of April.64 When asked about testing staff, the Department said it had made this available in care homes as capacity increased and there were now around 70,000 tests a day available to all care home staff as well as residents. NHSE&I told us it had now started testing asymptomatic staff and referenced Public Health England’s large-scale study testing staff to see if they had COVID-19 now, or had previously had it, which would provide more information on how and when it was best to test.65

23.We were concerned about the NHS needing to call on the same staff who have already worked exceptionally long hours during the first peak in order to deal with the backlogs of treatment, while also standing ready for a potential second peak.66 NHSE&I explained that it was “encouraging people to take leave, so that they are refreshed going into the autumn and winter, as well as encouraging people who have returned to stay with us and those who have volunteered to continue to offer their support”.67 We asked how the NHS was looking after its workforce given the emotional trauma of treating patients with COVID-19 and the fact that the NHS interim people plan had not referred to treating the mental health of its staff. In response, NHSE&I sought to assure us that staff health and wellbeing was a “primary focus nationally, regionally and locally”. It recognised the need for targeted psychological and mental health support for staff across the health service and pointed to plans to roll out more widely an existing mental health programme for doctors as well as helplines and other support for particular staff groups.68

Securing additional capacity

24.Under its reasonable worst-case scenario, the Government expected over 4% of the population might require hospital admission for COVID-19 and 30% of those would require critical care. NHSE&I told us that the number of COVID-19 patients admitted to hospital had risen from a few hundred in mid-March to 18,000 two weeks later.69 As NHS Providers stated, the healthcare sector responded at pace to ensure that the NHS had enough capacity for the expected large number of COVID-19 patients.70 The additional capacity secured by NHSE&I included new Nightingale hospitals as well as contracts with independent providers for an additional 8,000 beds, 18,700 staff and 1,200 ventilators. The contracts were to run until 28 June but could be extended. Use of the Nightingale hospitals so far has been limited.71

25.Between mid-March and mid-April, the NHS and armed forces are to be commended for increasing the number of beds available for Covid-19 patients from 12,600 to 53,700 in a very short space of time. The additional capacity inside existing NHS hospitals helped to ensure that at no point during the pandemic did the number of patients exceed the number of available beds.72 Independent and Nightingale capacity created a ‘buffer’ on top of that, and NHS Providers also welcomed the private sector support which had been offered to date.73 We recognise the need to have moved at speed to set up these arrangements. However, we were also concerned about the trade-offs with securing value for money and an apparent lack of transparency. We asked NHSE&I about the use and cost of the capacity secured through independent hospitals. NHSE&I told us that “several hundred thousand patient treatments”, such as chemotherapy and diagnostic tests, had been delivered as well as equipment. Despite the open book accounting arrangements in the contract, NHSE&I would not provide even a rough estimate of costs until these had been audited and said it might be “several weeks” before it could share the data with us.74 The use and cost of the Nightingale facilities are also not yet known. We also noted with concern some evidence from stakeholders that contracts awarded during the period have lacked transparency.75 When asked about stories of bonuses to directors in independent hospitals being charged to the taxpayer, NHSE&I told us the contract explicitly prohibits compensation for bonus payments beyond what would have been acceptable in the NHS.76

26.Access to NHS services has reduced significantly during the COVID crisis, potentially creating huge pent-up demand, which will add to the substantial waiting lists that existed before the pandemic.77 NHSE&I told us that access to emergency and critical services, such as cancer, has been maintained throughout the crisis although use of these services had been lower than usual. It also told us that it was now encouraging the NHS to resume more routine services.78 Stakeholders from the NHS and independent provider sectors have expressed concerns that resuming services, while the pandemic is still ongoing and with the potential for a second peak, will be challenging and will require full use of capacity across both sectors.79 We asked NHSE&I what plans it had to address these concerns in the near future. NHSE&I told us that the arrangements with the private sector were likely to continue for the rest of the year in order to provide a continuing ‘buffer’ for routine surgery, cancer care and other conditions but it noted that the basis on which it contracted with independent hospitals was likely to change and it was likely to follow a competitive procurement. As discussions are still ongoing, NHSE&I could not provide details on how independent hospital capacity would be allocated but assured us that it would be available for networks of hospitals and GPs in a given area to draw on. It also said that the Nightingale hospitals would be on standby in case of a second pandemic peak.80

43 Q 32

44 RSC0001 Care England submission

45 Qq 90–91

46 Qq 20, 25

47 For example, BBC news on its Panorama programme on PPE and BBC statement on Panorama, Monday 27 April: Has The Government Failed the NHS?

48 RSC0001 Care England submission; RSC0002 Local Government Association submission; RSC0004 NHS Providers submission; RSC0005 Association of Anaesthetists submission; RSC0010 NHS Confederation submission

50 Qq 24–26

51 RSC0004 NHS Providers

53 RSC0010 NHS Confederation submission

54 Qq 51–52, 56–57, 78–79

55 Qq 25, 27

56 Qq 49–50; Public Health England letter from Professor Paul Johnstone to PAC Chair, 2 July 2020

57 Qq 76, 78, 79

58 Q 109

59 Qq 5, 94

60 Qq 96–97

61 Qq 21,23, 26–27; Committee of Public Accounts, NHS capital expenditure and financial management, Eighth Report of Session 2019–21, HC 344, 8 July 2020; RSC0010 NHS Confederation submission; RSC0001 Care England submission; RSC0002 Local Government Association submission; RSC0004 NHS Providers submission

62 C&AG’s Report, para 4.28

63 C&AG’s Report, para 3.16

64 RSC0012 National Institute for Health Research (NIHR) Health Protection Research Unit in Merging and Zoonotic Infections; University of Liverpool, Institute of Infection and Global Health, and University of Oxford, Nuffield Department of Primary Care Health Sciences submission; RSC0010 NHS Confederation submission; RSC0004 NHS Providers submission; RSC0005 Association of Anaesthetics submission

65 Qq 98–101

66 Qq 102–105, 108–111; C&AG’s Report, para 4.30; RSC0010 NHS Confederation submission; RSC0004 NHS Providers submission

67 Q 57

68 Qq 102, 105, 111

69 Qq 14,109, 116

70 RSC0004 NHS Providers submission

71 C&AG’s Report, paras 10, 2.6, 2.7, 4.4; Ev Independent Healthcare Providers Network submission

72 Q 56; C&AG’s Report, para 10; RSC0007 Independent Healthcare Providers Network submission; RSC0010 NHS Confederation submission

73 Q 63; RSC0004 NHS Providers submission; RSC0007 Independent Healthcare Providers Network submission; RSC0006 Spire Healthcare submission

74 Qq 64–74

75 C&AG’s Report, para 2.7; RSC0011 Future Care Capital submission

76 Q 65

77 Q 59; C&AG’s Report, para 12; Committee of Public Accounts, NHS waiting times for elective and cancer treatment, One Hundredth Report of Session 2017–19, HC 1750, 12 June 2019; and NHS capital expenditure and financial management, Eighth Report of Session 2019–21, HC 344, 8 July 2020; C&AG’s Report, NHS financial management and sustainability, para 4; RSC0007 Independent Healthcare Providers Network submission; RSC0006 Spire Healthcare submission; RSC0005 Association of Anaesthetics submission

78 Qq 56, 59; C&AG’s Report, para 2.21

79 RSC0010 NHS Confederation submission; RSC0007 Independent Healthcare Providers Network submission; RSC0005 Association of Anaesthetics submission

80 Qq 56–59, 63

Published: 29 July 2020