Recovery JSNA: Health services activity
Health care in England has undergone monumental changes in response to the COVID-19 pandemic. In the early months of the pandemic, some aspects of hospital activity stopped, and staff and resources were redirected to care for acutely ill COVID-19 patients. Outpatient activity was either postponed or took place remotely. Planned non-urgent treatment, including diagnostic care, was also postponed and sometimes closed to new referrals. Changes outside of hospitals have been equally large. Face-to-face care was mostly suspended in the community, unless it was urgent. For services such as general practice, the public were told to phone their GP surgery in the first instance, as practices began total triage and adapted their services to protect patients and staff from infection.
Some changes are a direct result of the crisis response while other changes were less predictable as they were patient-led, including large reductions in people attending A&E and a reduction in desire to seek care. Fears about contracting COVID-19 have played a part in keeping some people away from NHS services, prompting a national campaign in April to encourage the public to use GP and hospital services if they had urgent care needs.
Some of the changes were long talked about transformations and NHS England is keen to learn from the experience of the pandemic and maintain beneficial changes and look to reverse negative changes as circumstances allow.
This report looks at the impact of the COVID-19 pandemic on health care services, in particular:
NHS 111 can help those with an urgent medical problem and are not sure what to do.
Calls to NHS 111 in BSW CCG increased to a peak of around 44,000 in March 2020, this is an increase of around 19,000 calls in the monthly average in rest of 2019-20.
During 2020-21 call volumes have returned to levels which are only marginally higher than those seen in 2019-20.
Emergency attendances and admissions
In Q1 of 2020-21 (April to June 2020) the number of attendances at A&E departments in BSW almost halved compared with the same time the year before.
Activity levels have increased in the following 2 quarters but remain substantially lower than the levels seen during 2019-20. .
In Q1 of 2020-21 (April to June 2020) the number of emergency admissions in BSW was around a quarter lower when compared with the same time the year before.
Admission levels have increased in the following 2 quarters but remain substantially lower than the levels seen during 2019-20.
In response to the pandemic the NHS enacted significant change to the way it sees and treats patients to protect its workforce as a responsible employer but also to maintain services as much as possible.
The has resulted in the faster adoption of remote consultation using reliable and established technologies such as telephone and video consultation.
This has supported improvements in efficiency but this has potentially impacted on patient outcomes. Embedding the changes which improve efficiency and ensure patient outcomes are improved will be an important aspect of restoration and recovery. .
In 2019 the average number of appointments per month was around 465,000, in 2020 this dropped by around 6.2% to around 436,000.
This was driven by a substantial reduction of around 25% in appointments in April and May 2020. The last 6 months of 2020 saw a recovery in the appointments to similar levels to that seen in 2019.
In 2019 the proportion of appointments which were face to face reduced by around 20% from around 80%, in 2019 to around 65% in 2020.
The proportion of telephone consultations doubled from around 15% to around 30%.
The proportion of home visits remained broadly similar while the proportion of video consultations reduced.
The proportion of same day appointments has increased by around 15% from 38.1% in 2019 to 43.9% in 2020.
The number of appointments within a week has also increased by around 10% to 28% in 2020 from around 25% in 2019.
There has been a reduction in the number of appointments made more than a week from the appointment date.
The proportion appointment attended has remained broadly similar at around 90%.
The proportion of appointments where the patient did not attend has reduced by around a quarter from around 4% in 2019 to around 3% in 2020.
The improvement in efficiency is an important gain for primary care but need to be balanced with patient outcomes.
NHS England commission IPSO Mori to undertake a survey of patients on the experience of primary care. This is undertaken annually and was last run in Jan-Mar 2020.
Nearly three quarter of BSW CCG patients felt it was easy to get through to the practice on the phone, which is higher than the England average.
Respondents who indicate they have one or more Long Term Condition are asked:
- In the last 12 months, have you had enough support from local services or organisations to help you to manage your condition (or conditions)?
Over 80% of BSW CCG patients felt they had been provided enough support to manage their condition(s), which is higher than the England average.
The expectation in the NHS Constitution is that patients referred to a consultant for treatment would receive their first treatment within 18 weeks of referral.
As part of the response to the pandemic hospitals cancelled all routine surgery and other associated activities to create surge capacity for patients with COVID-19 infections.
This has resulted in a substantial backlog of activity which is resulting in increased waiting times for patients.
The reduction in primary care appointments has resulted in a reduction in referrals to consultants it is therefore likely that the current backlog is an under-representation of the likely backlog should patients come forward.
The challenge for community based services is to help these patients maintain their condition to allow them to benefit from future treatment.
In January there were around 32,200 BSW CCG patients who were waiting more than 18 weeks for their first treatment. This is around 3 times the number waiting more than 18 weeks in January 2020 which was around 12,000.
This is also the known waiting backlog, it is also believed a larger number of patients who require treatment courses are waiting for subsequent treatments
In December there were around 30,000 BSW CCG patients who were waiting more than 18 weeks for their first treatment.
Over a fifth of them (6,433) were waiting for the Trauma & Orthopaedics treatment. Just over 3,000 patients were waiting for treatment in either Ophthalmology and General Surgery. With a further 2,700 waiting for an ENT treatment.
In January there were around 6,800 BSW CCG patients who were waiting more than 52 weeks for their first treatment. In January 2020 it was only 30 patients more than a year for treatment.
While reducing the backlog is an NHS priority ensuring these patients are managed in the community to prevent deterioration of their condition is also an important aspect of recovery.
In December there were around 5,000 BSW CCG patients who were waiting more than a year for their first treatment.
Around a third of them (1,777) were waiting for the Trauma & Orthopaedics treatment. Around 500 patients were waiting for treatment in General Surgery and a further 400 waiting for an ENT treatment.
In January 2021 there were around 6,800 BSW CCG patients who were waiting more than 6 weeks for a diagnostic test. This is more than 4 times the 1,500 seen in January 2020.
Delays did fall during July to November but have started to increase again as the impact of the second wave of COVID-19 is starting to be seen.
Extracted from (Statistics » Diagnostics Waiting Times and Activity (england.nhs.uk)) on 18th March 2021
In December there were around 6,700 BSW CCG patients who were waiting more than 6 weeks for a diagnostic test.
For the majority of tests the proportion of BSW waiting more than 6 weeks for diagnostic test was greater than the average in England for that test.
860 patients have been waiting more than 6 weeks for an Echocardiogram and 850 for a gastroscopy.
Extracted from (Statistics » Diagnostics Waiting Times and Activity (england.nhs.uk)) on 15th January 2021
In December there were around 700 BSW CCG patients with suspected cancer who were seen within 2 weeks of referral. This is the only area were BSW seems to be worse than the England average.
For 31 days to first treatment the proportion is broadly similar to England. For 62 days from GP referral to treatment the proportion seen within the standard is slightly higher than the England average.
In January 2021 around 600 patients were not seen within 2 weeks of an urgent referral for suspected cancer, this is more than double the number seen in January 2020.
The number of patients not seen within 2 weeks has improved in recent months from a peak in November 2020.
In January 2021 around 25 patients did not received their first treatment within 31 days of the decision to offer treatment. Over the course of the pandemic the number of patients missing this target has increased slightly.
In the most recent months there has been a more gradual increase in the numbers waiting longer than expected.
In January 2021 around 50 patients did not received their first treatment within 62 days of a GP referral. Over the course of the pandemic the number of patients missing this target was lower than usual until September 2020 which saw a big increase. It has now recovered to the levels seen before the start of the pandemic.
Never Events are serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations. These include incidents such as:
–Wrong Side Surgery
–Wrong Implant or Prosthesis
–Retained foreign object post procedure
Never Events are different from other serious incidents as the overriding principle of having the Never Events list is that even a single Never Event acts as a red flag that an organisation’s systems for implementing existing safety advice/alerts may not be robust. They also do not currently include patient deterioration or harm while on a waiting list.
The concept of Never Events is not about apportioning blame to organisations when these incidents occur but rather to learn from what happened.
To support learning from Never Events NHS England are committed to publishing data on Never Events as early as possible. However, because reports of apparent Never Events are submitted by healthcare providers as soon as possible, often before local investigation is complete, all data is provisional and subject to change.
The trend for England shows an increase in September and October 2020 and a rise again in February and March 2021.
Three of the events in 2020-21 occurred at GWH.
NHS White Paper 2021
Prior to the pandemic and under the auspices of the NS Long Term plan the structure of the NHS was evolving, the pandemic has delayed the implementation of the Long Term plan but recently the Government has published a white paper outlining the proposed legislative changes needed for full implementation of the Long Term plan. The main changes proposed are:
Working together to integrate care:
- Legal Basis for Integrated Care Systems as the main NHS Body within an area.
- Establishment of Health & Care Partnership Boards bringing together Public Health, NHS and Social Care.
- Re-affirming the need for JSNA and Health & Wellbeing Boards to support place based commissioning.
- Changing competition requirements to enable the NHS and local authorities to arrange healthcare services to meet current and future challenges by ensuring that public and taxpayer value.
Improving accountability and enhancing public confidence:
- Changes to the NHS England mandate and powers of the Secretary of State.
- Within social care, with a new assurance framework supported by improved data collection allowing us to better understand capacity and risk in the social care system.
Prescribing in the community
COVID-19 has resulted in unexpected immense pressure for community pharmacies but they have continued to support their local communities during the pandemic.
A survey found around 90% of people believe community pharmacies are playing a crucial role during the COVID-19 pandemic. 73% suggested pharmacies could offer more services to “alleviate pressure from other parts of the health service”.
Pharmacies are now delivering services to support wider NHS recovery such at the GP referred community pharmacy consultation service (CPCS) and also a hospital discharge medicine service (DMS).
These 5 chapters of the BNF account for around three quarter of all prescriptions issued by primary care in the BSW CCG.
With the exception of Gastro-intestinal medicines the other 4 chapter see an increase in the number of prescriptions issues in March and April 2020.
This was followed by a relatively normal trend with the exception of August which seemed to show a reduction.
Clincally extremely vulnerable patients
In April 2020 NHS England developed a methodology for identifying patients who were clinically extremely vulnerable should they catch COVID-19.
There are 4 main groups of patients:
–Specific Cancer patients
–Rare Disease patients at higher risk of infections
–GP Managed (Elderly, COPD, Diabetic, CVD & Other)
These patients were asked to shield during the 1st and 3rd National Lockdowns to protect them being infected.
The list of patients is reviewed regularly with an additional 1.7m people added to the list in February 2021. .
In Wiltshire around 18,750 patients were classified as clinically extremely vulnerable (CEV) that is around 3.9% of the Wiltshire population. This was slightly higher than the England average which was 3.2%.
Within Wiltshire over half the CEV patents were female which is broadly similar to the position in England
There are 10,000 CEV patients aged under 70 and around 9,000 aged 70 or over.
Compared to England Wiltshire has fewer CEV patients under the age of 70 and a greater proportion aged 70 and over. This is probably reflective of the population structure within Wiltshire.
Wiltshire has a greater proportion of CEV patients for Cancer, Immunosuppression and Rare Diseases. It has a lower proportion of patients with CKD and Respiratory disease.
The Office for National Statistics undertook regular survey of shielding patients the results of which are reported in the Mental Health Section.