Community services providers are playing an essential role in the battle against COVID-19. Taking on increased responsibility for patients who have left hospital on the discharge to assess pathway will require strict prioritisation of resources, stopping some services altogether so that providers can flex their workforce. As is the case elsewhere across the health and care sector, those staff working outside their usual area of specialism will need training, support, and appropriate protective equipment.
National logistics are also a potential challenge to the community sector, given it is made up not just of trusts but also a range of other providers including social enterprises and community interest companies. Routes for communication and PPE alike may therefore not be straightforward and working with the Community Network, NHS England and Improvement will need to ensure its communications reach all relevant providers.
PPE is of particular importance given the fact many services are delivered in people’s own homes and staff members may be covering considerable distances between seeing individual patients. On 27 April, PHE published guidance for providers and staff delivering care to patients in their own homes.
Community services often form the 'glue' holding a number of pivotal relationships at neighbourhood level with colleagues and primary care. These relationships will be fundamental in coming weeks as the health and care sector battles the virus and reprioritises:
- prior to COVID-19, the continued evolution of primary care networks was a major focus for the sector. However while the Enhanced Health in Care Homes service requirements will continue in line with the dates previously set out, aligning with COVD-19 pathways, some other aspects of the PCN DES service specifications are already subject to change to enable primary care colleagues to prioritise their activities during the crisis
- NHS England and Improvement wrote to primary and community care providers on 1 May, asking them to support care homes during the COVID-19 pandemic by bringing forward some key elements of the Enhanced Health in Care Homes framework, including rapid access to clinical advice (both virtually and face-to-face), proactive support with personalised care and support planning, and monitoring residents with suspected or confirmed COVID-19. NHS England and Improvement will collect weekly sitrep data to understand what support is being provided.
- social care has benefitted from £1.6bn emergency funding to local authorities and a £600m infection control fund for care homes (15 May). However, in some local areas there is real concern about the need to stabilise the care home market, recruit and retain additional staff, and rapidly build overall capacity in a chronically underfunded social care system.
The community network has long argued for sufficient investment in public health across the country – and this has never been more salient that in the current outbreak.
Specific priorities for community services in response to COVID-19
The new COVID-19 hospital discharge service requirements make community series providers responsible for a number of actions, including:
- identifying an executive lead to oversee the implementation and delivery of the Discharge to Assess model in the acute hospitals in their area
- releasing staff from their current roles to co-ordinate and manage the discharge arrangements for all patients from community and acute bedded units on pathways one, two, and three
- having an easily accessible single point of contact which will always accept assessments from staff in the hospital and source the care requested, in conjunction with local authorities
- delivering enhanced occupational therapy and physiotherapy seven days a week to reduce the length of time a patient needs to remain in a hospital rehabilitation bed
- using multi-disciplinary teams on the day they are home from hospital, to assess and arrange packages of support for patients on pathways two and three
- co-ordinating the care for patients discharged on pathways one to three
- ensuring provision of equipment to support discharge
- ensuring patients on all three pathways are tracked and followed up to assess for long term needs at the end of the period of recovery
- maintaining the flow of patients from community beds including re-ablement and rehabilitation packages in home settings, to allow the next sets of patients to be discharged from acute care
- for patients identified being in the last days or weeks of their life, community palliative care teams co-ordinating and facilitating rapid discharge to home or hospice.
An additional letter and annex set out how providers of community services can release capacity to support COVID-19 preparedness and response. This includes guidance on how to support home discharge of patients from acute and community beds, as mandated in the hospital discharge service requirements, and ensure patients cared for at home receive urgent care when they need it.
The document also sets out expectations that providers should use digital technology to provide advice and support to patients wherever possible, prioritise support for those high-risk individuals who will be advised to self-isolate for 12 weeks, and apply the principle of mutual aid with health and social care partners, as decided in local resilience fora.
This guidance was updated on 2 April in line with developing clinical advice, and some services were moved into different categories e.g. community nursing services moved from partial stop to continue.
On 15 April, NHS England and Improvement published a refreshed standard operating procedure (SOP) for community health services, which clarifies how providers should manage patients in community settings during the COVID-19 pandemic. This guidance is aligned with the SOP for general practice, and includes the following key principles:
- use NHS 111 online as the first port of call for people with COVID-19 symptoms (not their local GP practices)
- prioritise support for those at highest risk from COVID-19, proactively managing a comprehensive health and care support package (with general practice and social care colleagues) which draws on volunteers and wider services
- adopt remote triage as default and deliver care and treatment remotely wherever possible and appropriate (based on clinical judgement). Nationally procured virtual consultation platforms are now available
- manage essential face-to-face services (including home visits) through cohorting facilities/premises and teams into COVID-19 positive and non-COVID-19 services to minimise the spread of infection to patients and staff. Follow PPE and infection control guidance if face-to-face care is required, and prioritise visits according to the prioritisation guidance.
- On 3 June, NHS England and Improvement issued a document setting out the restoration of community health services for children and young people, which forms part of the second phase of the NHS’ response to COVID-19. This document supersedes the prioritisation guidance, published on 20 March, and advises community providers to continue essential services and phase back in some non-essential services – either partly or fully, depending on local capacity – while retaining the ability to surge COVID-19 capacity if required.
On 15 April, DHSC launched an action plan for adult social care which sets out how the government will support social care providers and their staff during the COVID-19 pandemic, including controlling the spread of infection in care homes by testing all symptomatic residents and staff (including their households) as capacity increases, continuing emergency drops of PPE for distribution by Local Resilience Forums, and strengthening the national recruitment campaign. Trusts will have a key role to play in implementing the new policy of testing all patients for COVID-19 before discharge from hospital to care homes.
The Local Government Association (LGA) has also released a briefing on protecting vulnerable people during the COVID-19 outbreak. This document is intended to assist councils in developing systems to support and protect people who are vulnerable as a result of the COVID-19 emergency, as well as assisting the NHS, the voluntary and community sector (VCS) and other partner agencies to understand the role and contribution of local government in supporting vulnerable people. While the scope of the document includes the approach to those who have been identified as extremely clinically vulnerable to COVID-19, it also provides a full overview of other work, led largely by councils and the VCS with support from other partners, to protect other vulnerable groups. The document includes an overview of the system for supporting vulnerable people, the types of support needed, key considerations for councils in coordinating local support, and supporting resources. The document is correct as of 30 March 2020 and will be updated as and when necessary on the LGA’s website, with their aim being to supplement it with examples and case studies from councils.
Mental health services
- Mental health trusts have had to ensure their inpatient services are equipped to deal with coronavirus patients. This includes identifying areas, such as wards with ensuite bathrooms, to ‘cohort’ patients with COVID-19 symptoms. There is an issue of the availability of appropriate places in mental health trusts given there are 350 dormitory wards across England and much of the estate is not fit for purpose. This has been a particular challenge for those trusts with patients who are held in secure accommodation, where the flexibility to reconfigure physical space may be heavily constrained. Trusts are working hard to balance keeping people secure whilst separating COVID-19 positive patients from those who have not got the virus.
- We are aware of mental health resources being diverted to care for COVID-19 patients. Mental health trusts have seconded staff to acute hospitals and have been creating empty wards to allow acute hospitals to transfer non-COVID patients. Some patients with coronavirus are also being kept in the care of mental health trusts, and community trusts, where possible to relieve pressure on acute hospitals.
- Mental health staff have been retrained to help provide physical care. One of the more distressing groups of COVID-19 patients to treat are frail, elderly patients with dementia who are suffering from multiple organ failure and need high-quality physical and mental health care as they reach the end of their life. Mental health trust staff who have previously focused on supporting the mental health needs of this group of patients have been rapidly trained in how to support their physical health needs and provide end of life palliative care.
- Mental health trusts have been working hard to create 24 hours a day, seven days a week, mental health emergency services to support those, both children and adults, in mental health crisis. Mental health trusts are also developing and setting up mental health A&Es to help ease pressures on emergency departments whilst ensuring people in crisis are still able to access the support that they need. Coventry and Warwickshire Partnership NHS Trust, Humber NHS Foundation Trust and Northamptonshire Healthcare NHS Foundation Trust made us aware early on that they had plans underway and are open to sharing their learning with other trusts.
- Some trusts are starting to see a surge in demand for unplanned mental health services. COVID-19 is likely to have a significant impact on people’s mental health as a result of having to implement self-isolation and social distancing measures, as well as the knock on effect of the socio-economic impacts of COVID-19 (job losses etc.). The impact on people’s mental health, and thus demand for services, could be more profound and longer lasting than the physical health impact of COVID-19.
- As part of Care Quality Commission’s decision on 16 March to suspend planned inspections of health and care services, visits by Mental Health Act Reviewers were also temporarily paused. On 8 April, CQC published an update on the longer-term arrangements for these visits, confirming that Mental Health Act Reviewers will still be conducting checks remotely, primarily using remote methods to carry out their reviews instead of a regular programme of unannounced visits, and will still complete site visits if they identify concerns. CQC have published an equality impact assessment that provides further details on the key equality impacts for people who use services the regulator has identified and how it will be working to mitigate any negative impacts at this time. CQC has since written to mental health providers regarding coronavirus related deaths of patients subject to the Mental Health Act and announced it is prioritising complaints received from or about people who are currently detained under the Act on an inpatient ward in hospital.
- Welcome funding has been made available to support patients, who are medically fit, move quickly and safely out of hospital and back to their own home or an appropriate care or community setting to reduce risk of transmission. However, there are concerns that some people being discharged from services may have difficulties self-isolating effectively, which not only puts themselves and those they might live with at risk, but could also add further pressure on services as staff find themselves needing to deliver a greater level of care and support to those individuals.
- Personal protection equipment (PPE) and testing capacity have emerged as two key pinch points and problems for the NHS, and both have presented particular challenges for NHS leaders of mental health trusts. For all trust leaders, nothing is more important than ensuring their staff have the PPE they need and access to staff testing is also a key priority. Mental health trust leaders told us that it took too long for national leaders to recognise their needs for PPE and a ‘prioritise hospitals alone’ mentality took time to shift, and they felt they were significantly disadvantaged in the process of rolling out national testing for staff.
- COVID-19 will impact mental health trusts’ ability to implement their adult and older adult community mental health care transformation programmes. Trusts have raised concerns about the feasibility of timescales for implementation notwithstanding the current challenges presented by COVID-19. We know that early implementer sites are already impacted by:
- operational/management staff turning their focus on business continuity and intensive operational management since last week, and numbers of clinical and corporate staff are being drawn back to the frontline.
- community co-production events have had to be cancelled. It has been identified that co-production with older adults will be particularly challenging.
- trust and primary care networks (PCNs) are likely to find collaboration particularly challenging, as PCNs are rightly focusing on COVID-19. A number of areas have been instructed to put all non-urgent plans on hold.
- mental health service users feeling even more vulnerable and anxious given the current situation, so work in early implementer sites to review caseloads and discharges is now even more difficult to progress
- Making sure mental health funding reaches the frontline where it is needed most, and is not diverted elsewhere, is likely to be more challenging.
- The challenges presented by COVID-19 pressures may present opportunities for trusts to accelerate new ways of working and embed innovation – for example extending physical healthcare skills in the mental health sector and making greater use of digital, volunteers, and the third sector.
- NHS England and Improvement has set up a mental health, learning disabilities and autism COVID-19 response cell workspace, which will serve as a repository for all the latest national guidance and resources from other agencies and allow the sector to exchange good and emerging local practice and protocols across the system. Trusts can request access to the workspace here. The workspace is where all the latest information will be held moving forwards, however, we are also regularly updating the section of our website summarising NHS sector-wide national guidance with documents and resources that are particularly relevant for NHS trusts and foundation trusts providing mental health, learning disability and autism services.