EVIDENCE TO THE HEALTH, SOCIAL CARE & SPORTS COMMITTEE
21ST MAY 2020
1. INTRODUCTION
This written submission is made to the Health, Social Care and Sport Committee prior to the Aneurin Bevan University Health Board evidence session on the 21st May 2020.
2. THE COVID-19 PANDEMIC IN GWENT
2.1 Figures 1 and 2 below show the timeline of patients in general hospital beds and critical care beds who tested positive for COVID-19 in Aneurin Bevan University Health Board Hospitals from the 1st March until the 10th of May 2020. The graphs show the rapid increase that started early in March and accelerated, reaching a peak around Easter weekend on 10th – 13th April 2020 following the start of the Government’s lockdown measures on 24th March, two weeks earlier.
2.2 At the peak there were 49 patients in critical care, the normal maximum capacity in critical care within the Health Board being 28 patients. Had the lockdown measures not come into effect when they did, this peak would definitely have been higher in our opinion.
2.3 Prior to the 9th March 2020, the UK Public Health COVID-19 testing strategy required a history of travelling abroad and the Health Board were not authorised to test patients they suspected had COVID-19 who had not travelled to certain countries. Once the guidance changed on 9th March 2020 to allow testing of hospital patients with symptoms of pneumonia, it became quickly apparent that patients without a history of travelling abroad were being admitted with COVID-19 as shown in Figure 1. A subsequent investigation by the Health Board concluded that there was evidence of community spread of COVID-19 in Gwent by 6th March 2020, which is consistent with the rapid acceleration of the outbreak from that time.
Figure 1 – Inpatient Occupied Beds
Figure 2 - Critical Care Occupied Beds
3. STRATEGIC RESPONSE
3.1 The Health Board has set out its approach to managing the pandemic through the ‘Aneurin Bevan University Health Board COVID-19 Response’. The key priorities were:
· Saving lives
· Minimising the spread of COVID-19
· Reducing harm
· Protecting our staff and keeping them safe
· Creating capacity across the system to respond to COVID-19
· Maintaining as many essential services as possible
3.2 In line with our responsibilities as a category 1 responder, under the Civil Contingencies Act 2004, we have worked proactively with Welsh Government through our emergency planning structures to develop our response to COVID-19. The Health Board has organised emergency management and incident command protocols, organising the Health Board’s assets into strategic/gold, tactical/silver and operational/bronze structures for mitigation, preparedness, response and recovery.
3.3 The Health Board is an active partner of the Gwent Local Resilience Forum (GLRF). The GLRF established a Strategic Co-ordination Group to meet in response to COVID-19, from 13th March 2020, and established a number of multi-agency tactical subgroups.
3.4 The Health Board’s COVID-19 Command Structure was introduced on 12th February 2020, and adjusted by COVID-19 Strategic Group on 25th March 2020. It has ensured a dynamic and fluid command and control structure to effectively manage the Health Board’s response to COVID-19 and to adapt as the situation evolved from containment to the delay phase.
3.1 Board Governance
3.1.1 The Health Board’s fundamental role and purpose has not changed during the COVID-19 pandemic. However it was recognised that in such a fast moving emergency, the Health Board needed to be agile and use good governance as an enabler to facilitate an effective response to the pandemic and also maintain oversight. Based on guidance received from Welsh Government, the Health Board adjusted its governance and assurance arrangements, including streamlining its Board and committee structure along with increased remote working, holding shortened and more focused meetings and agreeing temporary changes to the Scheme of Delegation to support rapid decision making through its COVID-19 structure.
4. OPERATIONAL RESPONSE
4.1 Given the need for a swift response in Gwent, due to the early community spread ahead of the rest of Wales, rapid service transformation was triggered, clinically led, to ensure the organisational (& GLRF) priorities were met.
4.1 Primary Care and Community
4.1.1 The Primary Care Team, rapidly established a leadership cell of senior GPs and primary care practitioners to support and guide the redesign of local primary care and community services to support safe service delivery.
4.1.2 Virtual consultation facilities were rolled out across all GP practices within two weeks, to ensure safe access to services for patients and maintenance of primary care services. Typically, 4,000 a day of virtual consultations have taken place across the Health Board area.
4.1.3 Each Neighbourhood Care Network (GP Cluster) developed a COVID-19 ‘assessment hub’, supporting face to face assessment of patients following the deployment of the All Wales primary care pathway. District Nurses and community teams transformed the way they provided services to ensure continued provision of direct patient care at home.
4.1.4 Community Hospitals have played a vital role in the provision of step down care for patients with (and without) COVID-19, requiring rehabilitation, recuperation and palliative care.
4.2 Mental Health and Learning Disability
4.2.1 A senior leadership team co-ordinated the re-design of community and inpatient services across all tiers, including the Road to Well-being Foundation Tier, Primary Care Mental Health Support and Secondary Care Mental Health services.
4.2.2 Pathways have also been designed and implemented in order to provide inpatient and community staff with guidance on how to provide care during this period. Technology has been used to deliver clinical assessments and interventions and there has been extensive work with third sector partners across the Gwent area.
4.2.3 A Community Well-being Information Group was also established to co-ordinate the development of relevant well-being information for both the general population and specific at risk groups, such as those working within Care Homes. The multidisciplinary team have been active in supporting the psychological well-being of patients through the distribution of ‘rainbow activity packs’, which have been well received by patients and the public.
4.2.4 Learning Disabilities services in the community have continued using technology of virtual sessions and group work.
4.3 Children and Young People
4.3.1 Throughout the COVID-19 staff have been prioritised to support vulnerable children through maintaining existing packages of care and support, mitigating the effects of school closures and maintaining essential services. The Health Board has used an integrated service approach to continue delivering the Healthy Child Wales programme, which has included establishing immunisation hubs, increased Sparkle charity support workers to provide respite hours at Serennu Children’s Centre and School Nurses directly contacting 80 young people to support emotional health and well-being.
4.3.2 Children and Adolescent Mental Health Services (CAMHS) developed a 24/7 clinical helpline for any professional who needed advice and support. We have maintained clinical activity in CAMHS using technology to provide support to young people and their families.
4.3.3 Acute paediatric admissions initially reduced but are now starting to increase. Outpatient activity has largely been virtual but ‘hot’ clinics are in place with community consultants.
4.4 Acute Hospitals
4.4.1 The Health Board took immediate action to organise acute services and segregate departments, including:
· Suspending non-urgent surgical admissions and procedures, whilst ensuring access for emergency and urgent surgery
· Introducing hospital/departmental zoning to ensure segregation of COVID-19 and non-COVID patients
· Expediting discharge of vulnerable patients from acute and community hospitals
· Introducing pre-hospital screening for the effective and efficient management of patient admission based on presenting symptomatology
· Defining the role and functions of each of our hospitals in the management of patients with COVID-19 and maintaining essential services
· Moving departments in order to release staff and physical capacity across our hospital system
4.4.2 This resulted in mass repurposing of wards and departments across the three main hospital sites at the Royal Gwent Hospital, Nevill Hall Hospital and Ysbyty Ystrad Fawr. Despite the challenging times, teams worked innovatively to provide outpatient services for the most vulnerable and have delivered 86,530 outpatient assessments. This has been through a combination of face to face appointments for those with cancer, very urgent patients or those needing a physical examination. For other patients there has been a combination of telephone appointments, and virtual/skype assessments.
4.5 Demand and Capacity Modelling
4.5.1 During March the Planning Team undertook a significant piece of work, in liaison with Welsh Government, to understand the best and worst case scenarios and potential patient demand impact, enabling an early and clear understanding of the bed capacity that may be required across the Health Board in order to respond to projected demand from COVID-19.
4.5.2 This work was based on a number of mitigation factors and emerging research and led to a detailed surge capacity plan for hospital beds, including ventilated capacity. This work included surge plans within existing hospital sites, the commissioning of St Joseph’s Hospital for continued elective work, and the decision to prepare for the early opening of the ward areas of the Grange University Hospital, which was initially planned to be opened at the end of April 2020. Multi-agency planning was also undertaken for the consideration of health and social care capacity via the International Conference Centre. However, as a result of public compliance with lockdown measures the Health Board has managed COVID-19 within its existing bed base (circa 1,500 beds) and in response to the peak of COVID-19 infections, the Health Board increased its ventilated bed numbers, from 28 to 49 at its peak over the Easter weekend.
5. PUTTING PEOPLE FIRST
5.1 The Health Board’s approach to keeping staff safe mirrors the priorities of the Welsh Government Preparedness Framework and is summarised below:
5.2 Testing
5.2.1 The Coronavirus Testing Unit (CTU) for testing of key healthcare workers was set up in Llanfrechfa Grange Hospital site on 14th March 2020. Two other Testing Units were commissioned, ahead of the move to Rodney Parade in Newport on 26th March 2020, in preparation for mass testing. The Rodney Parade Unit, managed by the Health Board, is designed as a drive-through population-sampling centre and has capacity to accommodate 600 tests a day, together with home testing for certain groups. Following agreed governance arrangements, testing of GLRF partners at Rodney Parade commenced on 17thApril 2020, in line with request from Public Health Wales. As at 14th May 2020, 3,193 Health Board staff and 1,334 GLRF key workers have been tested. Of this number, 31% Health Board staff and 17% GLRF have had a COVID-19 positive result.
5.2.2 We have also introduced rapid testing at the front door of Emergency Departments and wards at the Royal Gwent and Nevill Hall Hospitals. In total 30 tests a day can be undertaken; 20 at Royal Gwent Hospital and 10 at Nevill Hall Hospital.
5.3 Personal Protective Equipment and Fit Testing
5.3.1 A Personal Protection Equipment (PPE) Operational Cell was rapidly established on 16th March 2020 in recognition that PPE, procurement and distribution, was vital for staff and patient safety and having confidence through robust arrangements for infection prevention and control. There has been effective liaison with National Shared Services Partnership for Wales, the establishment of PPE hubs at key strategic places across Gwent and the allocation of an Executive Lead for PPE. The Health Board has established clear processes for procuring, securing, flow and delivery of PPE. In addition, a mass training programme for PPE Fit Testing of staff was established 17th March 2020.
5.3.2 The Health Board has also benefitted from the expertise of the Military, who have undertaken a local review of PPE end to end supply chain, which has enabled improvements to be made. Whilst PPE has been a key national issue, frequently reported in the media, the Health Board has felt the management and supply of PPE has been effective, with any risks well managed through escalation processes.
5.3.3 The Health Board has consistently worked to the national PPE guidance and the multiple nationally driven changes in PPE guidance have been centrally co-ordinated through the Health Board’s Infection Prevention and Control Team. The team has worked tirelessly to ensure local interpretation and development of visuals for staff, working with Medical Illustration, to ensure diligent compliance with guidance.
5.4 Staff Well-being
5.4.1 The Health Board’s staff response to COVID-19 has been truly remarkable. They have been receptive, proactive, agile and professional despite the unknown and a natural fear factor.
5.4.2 The Health Board has had considerable success with an external COVID-19 recruitment campaign which resulted in over 750 offers of employment, including doctors, registered nurses and healthcare support workers. The Health Board has worked with partners to engage students, facilities staff, had mutual support from other Health Boards and an excellent response from volunteers.
5.4.3 Over 200 existing members of staff have been redeployed to provide additional capacity on the front line. 317 Registered Nurses have received clinical skills training to enable them to be redeployed and/or return to practice.
5.4.4 Staff absence has been monitored and reported weekly to ensure that the right support is in place for all staff, whether that is access to testing, occupational health advice or well-being services. Overall absence peaked at 16.9% in early April and reduced to 10.89% during May.
5.4.5 An evidenced based well-being plan has been introduced offering psychological well-being support through a hub and spoke model across the Health Board which includes a well-being helpline.
5.4.6 The Health Board has ensured our staff side representatives are involved and updated, including weekly skype meetings involving representatives from the British Medical Association and the Royal College of Nursing.
5.4.7 The Health Board is working with Public Health Wales on the increased risk of poor COVID-19 outcomes for BAME communities and seeking to communicate with BAME communities across Gwent in their first languages. As a Health Board a BAME risk assessment has been put in place for staff, as part of the COVID-19 integrated vulnerable groups risk assessment, to identify any staff at risk and to ensure effective mitigating actions to protect staff.
5.5 Supporting Ethical Decision Making
5.5.1 A National Framework for ethical guidance was received from the Chief Medical Officer and discussed by COVID-19 Strategic Group on the 14th April 2020. The Framework offers useful guidance and has been adapted locally, resulting in the development of an Ethical Framework for clinicians, as well as the establishment of a Health Board Clinical Ethics Committee as a support mechanism to guide decision-making in challenging times.
5.6 Patients and Families
5.6.1 The Patient Centred Care Team has held a key role in the management and engagement of communities, as well as working collaboratively with third sector partners. This work stream has been vitally important to ensure families remained connected with their loved ones, particularly in light of the imposition of ‘no hospital visiting’ as a result of lockdown. Patient and family connectivity has been facilitated by the use of technology in hospitals to enable face time and telephone contact, with kind donations from local companies. The Health Board has also established a messaging service, called ‘Messages from Home’, where family members send emails into the Health Board and these are downloaded and taken to patients.
5.6.2 The generosity of the public has been tremendous and a dedicated Donations Cell has been established to manage and distribute all donations for patients and staff.
6. THE MANAGEMENT OF AND SUPPORT FOR CLOSED SETTINGS - CARE HOMES AND PRISONS
6.1 Care Homes
6.1.1 At the beginning of the pandemic the Health Board issued COVID-19 guidance to care homes and independent contractors and has been responding to frequently asked questions and facilitating operational support to care homes and care for people with dementia. Care Homes are equipped with Attend Anywhere for remote video consultations with many GPs now undertaking virtual ‘ward rounds’.
6.1.2 Care Homes are working with GPs, community teams and frailty consultants to review Anticipatory Care Plans and are having discussions with residents about how COVID-19 may cause residents to become critically unwell and supporting residents to make decisions about whether hospital admission is what they want if they become ill with COVID-19.
6.1.3 The Health Board has produced Standard Operating Procedures for patients being discharged from hospital to care homes, for new admissions from the community and transfers between homes.
6.1.4 The Health Board has been working with local Environmental Health Officers (EHO) who have a key role to play in supporting care homes to address the challenges of COVID-19. The Health Board has organised a series of training briefings for EHOs provided by Infection Prevention & Control and Complex Care clinicians and the Integration and Professional Development Team.
6.1.5 The Health Board and Local Authority Commissioning Teams undertake a SitRep twice a week to ensure shared situation awareness across the care home sector and rapid and effective local response. The Health Board has an Executive led Closed Setting Group who provides strategic direction along with a Community Care Sub Group of the GLRF which brings together local authority partners in social services and environmental health.
6.1.6 Symptomatic care home staff are currently offered appointments for testing at Rodney Parade through GLRF partners. Since the change in Welsh Government policy to test all care home staff and residents this has been scaled up with a Care Setting Testing Hub established allowing care homes to directly contact the Health Board to arrange testing.
6.1.7 In addition to the lead role that Public Health Wales has for investigating and managing outbreaks in care homes, the Health Board’s registered nurses in Complex Care and Infection Control nurses have undertaken a number of site visits to support care homes that have been managing outbreaks.
6.1.8 Since the recent change in policy the home testing team have tested 459 staff and residents across nine care homes. A schedule has now been agreed to test the remaining 11 larger care homes with more than 50 beds. Additional care homes that have had outbreaks in the previous 28 days will also be offered testing by the Health Board.
6.2 Prisons
6.2.1 The first reported case of COVID-19 at Her Majesty’s Prisons (HMP) in Gwent was at Usk prison on 30th March 2020 and was an in-mate. The first Prison Officer testing positive was on 18th March 2020 and was at Prescoed Prison. Testing of inpatients and prison staff commenced on 9th April 2020 in line with national guidance. To assist with control of the outbreak, GLRF and the Health Board provided a 6 bedded enhanced care suite at Usk Prison on 13th April 2020.
6.2.2 Both Prisons have been stable with no COVID-19 positive patients since 19th April 2020. The Health Board’s Prison Health Care Team are working with the HMP team and Public Health Wales and following the approved COVID guidance.
7. STAKEHOLDERS AND COMMUNITY ENGAGEMENT
7.1 The Health Board’s Corporate Communications Team, alongside Public Health Wales, have been very actively conveying communications/messages throughout the progression of the COVID-19 pandemic in Gwent. There has been daily communication with communities, stakeholders and staff, often using clinical staff to convey messages. With a significant amount of the population at home and with inaccurate information circulating, the Health Board identified the need to increase social media followers and to be seen as a trusted source for health information in Gwent. Working with GLRF partners, followers on the Health Board’s Facebook page increased from 22,000 to 92,000. Conversations are taking place 7 days a week, 9am to 9pm through social media channels, with the average reach for posts being over 300,000.
7.2 There is a daily commitment to engage with Community Health Council colleagues. Members of the Senedd are being briefed on a weekly basis by phone by the Chief Executive and Medical Director, with a written brief that follows. Local Authority, Police, Ambulance and Fire partners are briefed through the GLRF structures.
8. SHARING LEARNING
8.1 Through a wide range of professional networks there have been considerable opportunities for sharing learning across the spectrum of settings and professions. These have included sharing learning and advice on governance, streamlined recruitment processes, risk assessments for vulnerable groups including pregnant women and a specific BAME staff protocol and risk assessment, revised scheme of delegation and the Health Board shared with others our approach to developing capacity, workforce and financial plans.
8.2 Research, Development and Innovation
8.2.1 Research and clinical trials is one of the four elements of the UK COVID-19 Action Plan published in March 2020. The Health Board is playing an active part with Health Board patients participating in 11 national COVID-19 clinical trials offering different drugs in randomised, controlled trials. All patients admitted to Intensive Care are participating in at least one clinical trial and in an 8-week period, 618 Health Board patients were recruited to these clinical trials. The Health Board is also undertaking a 100 cases series review, which seeks to examine the illness trajectory and healthcare contacts of 100 patients admitted to Gwent Hospitals during the COVID-19 pandemic.
8.2.2 The Health Board is also co-ordinating a project that will capture the significant novel and innovative practice taking place across the NHS during the COVID-19 pandemic. With interest and support from Welsh Government, the project has now been extended across all NHS Wales organisations. This will enable the capture of innovation at local, organisational and national levels, which has the opportunity to provide significant learning and value. This work involves a range of partners such as the Welsh NHS Confederation, Bevan Commission, Life Sciences Hub Wales and innovation leads from all NHS Wales organisations, who are adding significant breadth and depth to the project.
9. WHERE IS THE HEALTH BOARD NOW?
9.1 Impact on non-COVID-19 work and reintroduction
9.1.1 Since the beginning of the pandemic, there has been a reduction in the number of people accessing health services generally. Additional communication has been put in place to remind the public that the Health Board is open for business.
9.1.2 The Health Board has used the Welsh Government’s Essential Services Framework to assess each of our services and provide a service status on whether essential services are being maintained. Our assessment is that the majority of services are being maintained, albeit there are some impacts on services such as endoscopy, cancer services and some surgery.
9.1.3 In April 2020, Urgent Suspected Cancer referrals were down to 61% compared to April 2019. In May 2020, to date, referrals continue to be lower than last rate, but are increasing (48% month to date).
9.1.4 During the period of the pandemic we have seen an improvement from 48% to 82% in patients on the cancer pathway being seen within 10 days from receiving the referral. Virtual clinics are in place for all tumour sites and there are regular discussions between patients and their clinicians regarding care and treatment plans. Compared to before the pandemic we have also seen the average waiting time for those on the cancer pathways needing an MRI or CT scan reduce from 12 days to 7 days.
9.1.5 The British Society of Gastroenterologists recommended that only emergency endoscopy should take place during the early stages of the COVID-19 crisis. The Health Board has developed new pathways to manage the risks, and patients are being sent a Symptomatic FIT test and clinically assessed for an alternative radiological investigation.
9.1.6 The Health Board is currently preparing a revised non-COVID activity plan to reintroduce services where it is safe to do so. This will be based on the principles outlined by the Welsh Government Operating Framework, with a focus on safely reintroducing services with a clinical risk managed approach. The Health Board’s Reset Plan will cover:
· Ongoing safe and resilient management of COVID-19 including operational case management, capacity, equipment and staffing
· Resilience of surge planning especially within critical care
· Workforce wellbeing and protection
· Delivery and ongoing review of essential services
· Evaluating and embedding new ways of working including transformation of outpatients and digital solutions
· Safe streaming and separation of COVID-19 and non-COVID to deliver more elective activity across outpatient, diagnostic and treatment pathways – between and within sites, and using the independent sector
· Confirming the role that the Grange University Hospital will play
· Agreeing governance arrangements for evaluating the effectiveness and risks of the plan
9.2 Preparing for community ‘testing, track and protect’
9.2.1 On 24th April 2020, Welsh Government published the ‘Leading Wales out of the coronavirus pandemic: A framework for recovery’, and subsequently the ‘Test, Trace Protect’ Plan was published on 13th May 2020. Within these documents, it sets out the plan for contact tracing which includes case identification and contact management.
9.2.2 Contact tracing is an essential measure as part of the COVID-19 response, in conjunction with active case finding and testing, and wider measures such as social distancing. The swift set up and on-going operation of the Contact Tracing Service will be a major factor in enabling the social and economic recovery in Gwent.
9.2.3 Health Boards and Local Authorities working together were asked to prepare a high level draft operational plan for Contact Tracing. A task and finish group involving the five Local Authorities, Health Board and local Public Health Team has been established underthe auspices of the Gwent Strategic Coordinating Group to develop a draft operational plan. The group is working to develop the operational plan to set out how the Contact Tracing service could be implemented and fully scaled up pending decisions by Welsh Government, including the interface with community testing programme, a national Data Management System, and confirmation of funding for workforce and premises costs.
15th May 2020