Checking the system’s blind spots: prioritising the community response to Covid-19

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It is well recognised that health and care services delivered in the community do not enjoy the same profile and attention as hospital services. Despite longstanding ambitions to rebalance the health care system to deliver more care closer to home, this rhetoric hasn’t translated into reality. There are many reasons for this, including a lack of robust data on activity and outcomes, the absence of prominent national targets, and the fact that care delivered in people’s homes and communities isn’t visible in the same way as the activity taking place in accident and emergency (A&E) departments or on hospital wards. The result has been a systemic blindness to services delivered in the community over many years, whether that be NHS community health services or social care. So what has been the experience of community services in the first months of the Covid-19 outbreak?

Before Covid-19 rose to the top of the national agenda, there were encouraging signs of community services being brought in from the cold. Two new national standards – the first of their kind – were to be rolled out nationally by 2023 to improve response times for crisis and reablement care, alongside a commitment in the NHS long-term plan to increase the share of the NHS budget going to community and primary care services and the appointment of the first national director for community health. Meanwhile, social care was still awaiting meaningful proposals for long-term investment and reform.

'There is evidence that significant numbers of excess deaths are occurring in homes and care homes'

In the first days and weeks of the national response to the Covid-19 outbreak the NHS responded with breath-taking speed. Bolstering hospital capacity – particularly in intensive care – was the primary focus, and this was done to great effect. Hospitals substantially increased their intensive care capacity and new field hospitals have been created in converted conference centres across the country. Elective operations were cancelled, and patients who were well enough were discharged from hospitals, freeing up an estimated 30,000 beds. Contrary to some predictions, beds did not run out and hospitals have been able to cope with the peak of critically unwell patients.

Although not as prominent in the headlines, services in the community also underwent rapid transformation. Community health services were reprioritised to focus on supporting people discharged from hospitals and preventing avoidable admissions; a large proportion of routine and non-urgent care was put on hold; and digital technology has been used to provide advice and support to patients wherever possible, echoing the rapid adoption of digital consultations in general practice. These changes, and the hard work of the staff who enabled them, are no less remarkable than those that took place in hospitals.

But concerning signs are emerging about the impact of Covid-19 in the community. There is evidence that significant numbers of excess deaths are occurring in homes and care homes (including many which do not have Covid-19 listed as a cause). The capacity of some community services risks being stretched to breaking point as they support a high volume of complex early discharges from hospitals. Meanwhile, a backlog of need is building up due to routine long-term condition management and preventive care being paused. While the backlog in acute services will be evident in burgeoning waiting lists, unmet need for community services won’t be visible in the same way. There is a very real risk that these issues will go under the radar.

Plans and preparations for the next phase of the system’s response to Covid-19 are now underway. There will be a strong imperative to clear the build-up of delayed elective operations. This might involve keeping private sector capacity and temporary field hospitals open for a limited period of time – which would be the most significant expansion of NHS acute capacity seen for decades. But an increase in elective surgery would also have significant consequences for community capacity – it is community nurses, occupational therapists, physiotherapists, and wider intermediate care teams who will be responsible for providing the post-operative wound care, discharge support and rehabilitation that will be required by many.

'An effective recovery will require a systemic approach that pays attention to the priorities and challenges for community-based services alongside those of hospitals'

At the same time, community services will be clearing their own backlog; catching up on routine care that was put on hold, dealing with the consequences for people whose conditions have deteriorated, and supporting individuals who have been worst effected by prolonged social isolation as well as those who may experience long-term effects of Covid-19 infection and intensive care stays.

An effective recovery will require a systemic approach that pays attention to the priorities and challenges for community-based services alongside those of hospitals. This is easier said than done for a system whose default is to focus first on the acute sector, driven by the lack of data and standards in other parts of the system. It will require leaders from community health services, social care and general practice to be brought into the heart of design and prioritisation decisions about the recovery period, seeking and listening to the experience of staff, and making use of all the available data that can help shine a light on these all-too-often neglected areas.

This really matters; if the system is blind to the needs of community-based services, it will be staff and patients who suffer the consequences.

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Comments

James

Organisation
Local Goverment
Comment date
12 May 2020

Hi Anna
Very intresting blog post.
Although you mention that there is a lack of data in this field, is there a particular area you would focus on or data point you would use to help prioritise decisions in this area, to look at the area's effected and needing the most support?

Paula Burke

Position
Carer,
Comment date
13 May 2020

Why does everybody forget about #Carers in the community? Usually found caring for family members in the home. We don’t do shifts as we are on call 24/7 - 365 for years on end. We get no formal training, little or no support, no recognition, yet mention that you care for somebody and that automatically disqualifies the cared for from any ‘extra’ help. Cared for by a family member & shielding - no food parcels, no prescription collections, no other help at all - the #Carer can do it all. Washing, cooking, cleaning, personal care, medications, shopping, lifting, listening, talking, arranging & attending health appointments, all personal admin, anything online, banking, bills, decorating, changing beds etc. Everything a trained Carer does plus so, so, much more. Some of us don’t even qualify for the paltry Carers Allowance. We are doing it because we love our family member. It does not mean that we should just be ignored, continually, by the rest of society. We provide the most important social care, after medical care, every single day. Why does everybody treat us as though we don’t exist?

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