The Welsh NHS Confederation response to the Health, Social Care and Sport Committee’s inquiry into the COVID-19 outbreak, and its management, on health and social care in Wales.

Contact:

Nesta Lloyd-Jones, Assistant Director, Welsh NHS Confederation.

Date:

13 May 2020

 

Introduction

1.    The Welsh NHS Confederation welcomes the opportunity to respond to the Health, Social Care and Sport Committee’s inquiry into the COVID-19 outbreak, and its management, on health and social care in Wales. The Welsh NHS Confederation represents the seven Local Health Boards, three NHS Trusts and Health Education and Improvement Wales (HEIW). We also host NHS Wales Employers.

 

2.    Since the beginning of March our priority has been supporting and representing our members to respond to COVID-19. Our engagement with our members has focused on the active support of Executive Director Peer Groups’ response to COVID-19, with over 150 meetings in the past two months, including significant support to Assistant Medical Directors Peer Group meetings and the Workforce and Organisational Development (W&OD) Directors Peer Group, facilitated by NHS Wales Employers. NHS Wales Employers have worked with colleagues across Welsh Government and with trade union partners to provide ongoing clarity to ensure that the advice, guidance and support to NHS staff is joined up. To date, NHS Wales Employers have published three updated versions of their Frequently Asked Questions for NHS Managers and Employers.

 

3.    In addition to supporting members, we have been working closely with our partners in other parts of the health and care system to ensure we can provide a ‘whole system’ perspective. Throughout this time, we have continued to work with our stakeholders, including Royal Colleges, third sector and social care organisations, to respond to the pandemic so that we can highlight any issues and offer potential solutions to the Welsh Government. We have held bi-weekly meetings with members of our Policy Forum, made up of over 60 health and care organisations, to keep them informed of the most up to date developments and share information and intelligence so that the sector is aware of the key issues and priorities.

 

 

Summary

4.    The challenges posed by COVID-19 are considerable and over the last two months we have been experiencing unprecedented demand on all our health and care services. NHS organisations have shown flexibility and innovation throughout this period by delivering a remarkable response to COVID-19. Since receiving the first coronavirus patient in early March, NHS Wales has developed and enabled sufficient critical capacity in the system to deal with the anticipated surge in demand. It is a huge credit to our health and care services in Wales, and to the response by the public to the measures put in place, that we have not exceeded NHS capacity throughout the COVID-19 pandemic so far. The measures put in place by Health Boards and Trusts, working with partners, has been one of the outstanding success stories as we all continue to fight this virus.

 

5.    The response to COVID-19 could not have happened without the excellent partnership working across Wales with local government, the voluntary sector and the private sector. Our briefing, Partnership working across Wales to support the response to COVID-19, highlights just some of the partnership working, from providing increased services digitally to support people to stay at home, to working with local government and the private sector to increase bed capacity across the system, and the donations of personal protective equipment (PPE). In particular throughout the pandemic there has been close partnership working and co-operation between the NHS and social care to ensure critical connections are in place to support patient pathways. From the beginning, there has been a focus on service users receiving support from social care, including in care home settings, and the NHS has been working with social care partners to understand the risks and mitigate them.

 

6.    Throughout this time testing has been key and will continue to be a priority in the future. We welcome the Test, Trace and Protect strategy published recently by the Welsh Government, which will help us move to the next stage of the response to the virus. The Plan outlines three major activities for concerted public health action at scale. These are; Increasing testing of critical workers to enable them to return to work; a new system of home testing for the public if they have coronavirus symptoms; and a new app to track symptoms in the general population and contact others who have symptoms or have tested positive.

 

7.    We must recognise and acknowledge the dedication and commitment of our staff, who have gone about dealing with this pandemic with professionalism and courage in the face of extremely difficult circumstances. They continue to demonstrate they are our most important asset. The call for additional staff was significant, whether from health professionals returning to service or health professional students wanting to be part of the NHS response.

 

8.    Finally, we would like to acknowledge the significant support from the public and patients in complying with the lock down measures. This support has saved lives and has protected the NHS now and in the future. The community response to COVID-19 is highlighted through our recent publication, Community spirit and resilience in response to COVID-19. We are grateful to everyone in Wales who are following the measures.

 

 

Key areas

The NHS response and increasing capacity

9.    In just a matter of weeks, national and local NHS and social care leaders have worked together effectively to bring about the necessary changes to successfully manage and meet the expected demand on NHS services. NHS organisations have created a significant amount of additional surge capacity when preparing for the anticipated peak in COVID-19 cases, including physical space and the necessary workforce.

 

10. The initial NHS planning and preparation for COVID-19 included the suspension of significant activity in order to free up capacity and staff to prepare. These actions have been critical in ensuring the NHS was able to respond effectively to the needs of COVID-19 patients in Wales. The NHS discharged hospitalised patients with non-COVID-19 issues swiftly, allowing sufficient ICU bed capacity to be made available.  More than 7,000 extra beds have been created with new field hospitals across Wales opening to ensure the NHS could deliver the best possible care to those who need it most. This, and other new ways of working, have been delivered at pace and scale and will help transform the way services are delivered to patients beyond the pandemic.

 

11. While the modelling of predicted numbers of COVID-19 patients led to the building of increased capacity through the introduction of field hospitals, fortunately the public response to the measures put in place to minimise the peak has meant that the NHS, to date, has not needed to utilise the surge capacity at the scale originally predicted.  So far the NHS has been able to manage the demand, however, the field hospitals have not been constructed in vain and have delivered a valuable resource, as they may be needed in the future to provide step down care to support patients to be discharged from hospital or be needed to treat COVID-19 patients  should there be a second peak.

 

12. Wales, like the rest of the world, is still learning about COVID-19 and progress of the virus is difficult to determine. While, based on the monitoring of a range of data over the last fortnight, it appears that the first peak has passed in Wales, like all other nations, we do not have certainty about the future profile of COVID-19 demand. This means it remains vital to retain the ability to respond effectively to an increase in COVID-19 patients and to ensure any future peaks do not overwhelm NHS services.

 

 

Health and care workforce

13. The commitment of NHS staff, who have shown tremendous courage and bravery in the face of the COVID-19 pandemic, is to be acknowledged and respected. The NHS has had significant success in expanding the workforce to cope with the increase in demand in response to COVID-19, through returning professionals, students and new recruits. Guidance regarding progression, redeployment, rotations, appraisals, education programme updates and more can be found on HEIW website. We must also acknowledge the logistical achievements health leaders have delivered in redeploying staff to expand critical care capacity and the speed at which new field hospitals have been constructed. Tribute must be given to members of our NHS family who have tragically died in the line of duty.

 

14. In planning our services for the months ahead, there is a clear focus on the wellbeing of the NHS workforce, and in particular those frontline and support staff who have been under significant pressure in responding to COVID-19. All staff can now access wellbeing resources, developed by HEIW in partnership with staff health and wellbeing leads across NHS Wales and Trade Union partners, to look after their own health during this time and we have been encouraging staff who feel they need it to utilise this service.

 

15. NHS Wales Employers has been at the forefront of co-ordinating the W&OD response to the outbreak at an all Wales level. NHS Wales Employers have been supporting, facilitating and chairing the virtual W&OD peer group meetings, which initially met three times per week (recently reduced to twice weekly), and developing a series of Frequently Asked Questions to guide managers and staff in their approach to the outbreak (including any variations to terms and conditions of service). This has involved facilitating partnership working at an all Wales level, including the development of a Joint Statement on industrial relations and facilities during the pandemic, and representing the service at the weekly Welsh Partnership Forum Business Committees and Workforce Redeployment and Wellbeing Groups (which forms part of the overall Welsh Government response to the outbreak). NHS Wales Employers have led on the development of a number of other products which support the service, including homeworking guidance and a set of principles to underpin the movement of staff within and between organisations as required due to the changing demands on the service.

 

16. NHS Wales Employers have also kept in close contact with colleagues in England, Scotland and Northern Ireland to ensure a consistent approach to the workforce response across the 4 countries, where possible, and to explain where the approach in Wales differs from other countries.  As a result, they have worked closely with Welsh Government officials to ensure that the response in Wales is in line with UK and Welsh Government policy and advice; and that this direction of travel is appropriately and effectively communicated to organisations and their staff.

 

 

Primary care

17. Health and care staff have created and embraced new ways of working to respond to COVID-19 challenges. Innovative new care models have been developed to continue the delivery of vital services in primary care settings. These include the significant shift in terms of digitally supported ways of working such as cluster models, virtual clinics, triage processes, and remote consulting. These effective models have been developed to support delivery of safe services in primary care settings, with significant leadership and cooperation from independent contractor colleagues.

 

18. Health Boards (HB), working with each of the 64 Primary Care Clusters, have established hubs for people presenting with symptoms of COVID-19. A Directed Enhanced Service (DES) was established for GPs to open over the Easter weekend with over 50% of practices opened and 111/OOHs data showing a positive, significant impact. A video consultation platform for GP appointments (in and out of hours) has been rolled out by TEC Cymru and a communications platform to enable GPs and others to access specialist advice and reduce the need for secondary care referrals is in place. GP Practices are working from home with patient consultations via telephone or video. The process has been further enhanced by providing access to the Digital Health & Care Record, enabling all recent diagnostic results and documents to be readily available. 

 

19. Community pharmacy services have been under significant pressure and have introduced new ways of working to manage patient care safely and efficiently and to continue essential services including dispensing services, emergency medication services, emergency contraception and advice, and treatment for common ailments. All routine dental care, treatments and check-ups have been cancelled with 15 emergency dental centres put in place across Wales. In optometry services, a number of practices remain open for emergency and essential eye care services within each cluster. This enables Independent Prescribing qualified practitioners to manage more cases and reduce the need for secondary care intervention. 

 

 

Testing

20. As highlighted within Public Health Wales’s written evidence to the Committee, in the delay phase Public Health Wales has been working with partners, including the Life Sciences Hub and the Welsh Government, to expand the antigen testing capacity in Wales. Starting off from a baseline capacity of 350 antigen (PCR) tests per day they have now increased it to 2350 per day. The testing capacity will continue to increase over the coming weeks. We welcome the development of testing centres throughout Wales and the mobile testing spots which are likely to form a crucial part of increasing our capacity to test and our response to COVID-19.

 

 

Personal protective equipment (PPE)

21. Currently the NHS has enough supplies of PPE across Wales. Through the work led by NHS Wales Shared Services Partnership (NWSSP), the current PPE situation is stable and NWSSP have secured reliable pipeline of orders to meet demand from both health and social care sectors. Given that a high demand for PPE in the health and social care sector is likely to continue over the longer term, and with increasing need for PPE in other community settings, NWSSP will continue to work with Life Science Hub to ensure that adequate stock levels are maintained in Wales. As of the 12th of May the total number of items issued across health and social care since the 9th of March is 88m, with 14million of those having been issued in the last 7 days. The total number of items in stock is over 37m and 227m further units of PPE have been ordered. This will be reassuring to staff on some level as they will be able to get the PPE they desperately need, but staff will want to hear this supply is sustainable for what promises to be a significant period of time.

 

22. In relation to future supply needs, Deloitte have been supporting the Finance Delivery Unit and NWSSP in the development of supply and demand reporting and modelling for PPE. Supply dashboards and KPI’s have been completed and now form part of the daily reporting process. Given the changing variables on PPE demand, including disease progression, and system choices in relation to future service and activity provision, this model will continue to iterate and refine as system choices become clearer over forthcoming weeks.

 

23. Finally, we are calling on Welsh manufacturers to come forward and produce PPE for our NHS using the Life Sciences Innovations Hub. The Hub has recently been developed to enable industry to upload offers of support and supply items, including face masks, visors, gowns, shoe covers, gloves, hand sanitisation, beds and mattresses etc.

 

 

Health inequalities

24. There is emerging evidence to suggest COVID-19 is having a disproportionate impact on staff and patients from Black and Minority Ethnic (BAME) groups. The Intensive Care National Audit and Research Centre have found that around 34 per cent of more than 3,000 critically ill coronavirus patients were from a BME background. NHS organisations in Wales are exploring emerging evidence to better understand the reasons behind this and are providing information to the Welsh Government. NHS Wales Employers recently released a statement with ADSS Cymru and Welsh Government to clearly highlight that as employers there is a duty of care to our health and social care workforce and the need to ensure that robust policies and support services guidance is in place. This includes ensuring that employers are able to undertake proper risk assessments for those individuals who may potentially be more vulnerable in the workplace, including those from a BAME background.  

 

25. In addition, the recent report published by the Office of National Statistics highlights that people living in Wales' most deprived areas are more likely to die of COVID-19 than those in more affluent places. The report highlighted 44.6 COVID-19 deaths for every 100,000 people in the poorest 20% of communities in Wales compared to 23.2 deaths per 100,000 people in the wealthiest 20% of communities.

 

26. Public Health Wales NHS Trust is currently undertaking a Health Impact Assessment of COVID-19, considering the population groups who could be more impacted than others by the social distancing measures introduced e.g. gender, age etc It will build a picture of the range of impacts (both positive and negative) of COVID-19 and the policy responses on health and well-being for the short, medium and longer term.

 

 

Mental health, wellbeing and loneliness and social isolation

27. This period of lockdown will undoubtedly be challenging for a large section of society and we understand those anxieties and concerns. Maintaining connections with friends and family is vital during this difficult time.

 

28. As highlighted in the recent report published by the Wales Centre for Public Policy, Loneliness in Lockdown, the ongoing COVID-19 pandemic and current lockdown means that issues of loneliness and social isolation are more pressing and likely to become more widespread than ever before in the coming months. Furthermore, conventional approaches to tackling loneliness and social isolation are challenged by the social distancing measures in place across the UK, creating a need to look at the opportunities and challenges associated with the role technology can play in connecting people and communities.

 

29. Mental health services and support continues to be available as far as it is possible to do so. The Welsh Government has established the Mental Health Incident Group (MHIG) to support Health Boards and Trusts by providing advice and guidance on managing and delivering mental health services and supporting staff wellbeing at this very difficult time. In relation to supporting the public’s health and wellbeing, Public Health Wales has recently launched a wellbeing campaign, How Are You Doing. The campaign has been created to support people to look after their physical and mental wellbeing and ensure public health is protected during the isolation period.

 

 

Non-COVID patients accessing NHS services

30. While health and care organisations are focused on managing the response to COVID-19, there are widespread concerns that patients with very serious health conditions may not be using the NHS during this pandemic, a trend that has also been experienced in other countries. We are seeing significant decreases in people accessing services, for example a reduction in Emergency Department attendance by 60%, which may mean that people are not presenting when they should. This could lead to late diagnoses which in some situations could lead to severe complications or even prove to be fatal e.g. a drop in the number of people presenting with heart, respiratory and stroke symptoms.

 

31. Health Boards across Wales are delivering most essential services throughout this pandemic and working internally and regionally to reinstate essential services. Effective delivery of pathways for delivering most essential services have ensured that non-COVID patients are protected. There is also the need to be cautious and agile when delivering services, given the risks associated with bringing these services back. The message to the public is that the NHS is still open for business. If people can manage their condition at home, then they should do so, but if people have experienced a serious issue then they must go to the hospital and access the care they need.

 

 

Post-COVID planning

32. NHS leaders agree there is a need to deliver essential health services for the population and where possible recommence more routine care. However, this needs to be done progressively, and with caution, through ensuring flexibility and agility that NHS leaders have evidenced over recent months. While capacity does exist in some parts of the system to support the re-introduction of routine services, this is a local operational decision for Health Boards and Trusts in conjunction with relevant partners. A clear set of factors need to be in place to inform these local decisions.

 

33. Furthermore, the system transformation that we have seen over the last two months must not stall. The outbreak has shown the benefit of a whole system approach and coordinated action. For example, the rapid acceleration of digital transformation in primary and secondary care due to COVID-19 needs to be embedded.

 

34. Finally, the resilience and dedication of the health and care workforce needs to be recognised because it will take time for the NHS and social care to fully recover. A significant number of health and social care vacancies will struggle to be recruited internationally due to the proposed policies within the future points-based immigration system. The social value of these roles, currently highlighted as ‘key workers’ in response to COVID-19 pressures, indicate the importance of continued overseas supply post January 2021.

 

 

Consistent messages and communication

35. Across NHS organisations there has been consistent messages and communication. Throughout the pandemic NHS organisations Heads of Communication have worked closely together to ensure clear and consistent messages, both at a national and local level. There has been a range of guidance and public facing campaigns developed by Public Health Wales NHS Trust and implemented across health and social care, and wider sectors. These messages have included raising awareness of the signs and symptoms of COVID-19, the guidance around what is deemed essential travel and raising awareness of the COVID-19 tracker.