Where are we now?
The first months of the Covid-19 outbreak have shown many aspects of the health and care system at its best. Health and care workers have responded with outstanding dedication and skill; clinicians and managers have gone above and beyond to rapidly develop new ways of delivering services safely; hospitals have joined forces to offer mutual aid and ensure continued provision of essential services; and in some areas NHS, local government and other local services have worked together like never before to co-ordinate their responses and support communities. The crisis has also underlined public support for the NHS and for care staff, most visibly through the rainbows adorning the windows of people’s homes and the weekly ‘clap for carers’ on doorsteps across the UK.
But the events of recent months have also exposed glaring issues and in some cases exacerbated existing shortcomings.
- People who have been worst affected by the virus are generally those who had worse health outcomes before the pandemic, including people from ethnic minority communities1 and those living in poorer areas. Following on from England’s poor record on life expectancy, Covid-19 has exposed the deep inequalities that exist between different population groups and areas of the country, neglected at significant cost over the past decade.
- Covid-19 has laid bare the weaknesses in a social care system that has been underfunded and overlooked for too long. The sector was neglected by the government at the start of the pandemic, with tragic consequences for service users, families and staff, and unacceptable numbers of deaths. This provides more evidence (if more was needed) that social care is in desperate need of attention, investment and reform. The pandemic has also shone a light on the fault lines between the NHS and social care.
- Years of poor workforce planning, weak policy, lack of national leadership and fragmented responsibilities have resulted in a workforce crisis across both health and social care. Already under enormous strain, staff have now had to work through the demands of the pandemic; the impact on their wellbeing should not be underestimated. Covid-19 has taken a disproportionate toll on staff from ethnic minority backgrounds, who already face higher levels of discrimination and poorer workplace experiences than their white counterparts.
- Following the longest funding squeeze in its history, before the pandemic NHS services were already running hot all year round with little capacity to spare, and deep cuts in local authority budgets had left the social care system on its knees. This meant the system entered the crisis already stretched to the limits; to prevent hospitals being overwhelmed, the only option was to temporarily suspend or reduce the provision of non-emergency care, leaving many people without the level of care or support they could usually expect to receive.
Beyond the immediate impact of Covid-19 on health and care, the lockdown has caused deep damage to public finances and the wider economy. The social and economic consequences of the crisis, and the recession that is certain to follow, will undoubtedly have an impact on the population’s health and mental wellbeing, and risk deepening inequalities further.
The health and care system faces significant challenges to restoring services, not only in hospitals, but also in social care, primary care, mental health and community-based services.
First, at local, regional and national levels, health and care services must be fully prepared for any future waves of Covid-19. This requires the system to quickly learn from what has and hasn’t worked in the response to the first wave, focusing particularly on inequalities and the support provided to the social care sector to avoid a repeat of previous mistakes.
Second, there are major practical challenges to restarting routine care while Covid-19 remains a risk. Changes are already being made to reduce the spread of the virus (including ‘hot’ Covid and ‘cold’ Covid-free areas) and personal protective equipment (PPE) will continue to be required for the foreseeable future. These considerations apply to all health and care settings, not only hospitals. No matter how well they are designed, enhanced infection control measures will slow the pace at which patients can be treated, having an impact on waiting times, and people’s outcomes and experiences of care.
Third, there has been much attention in recent weeks on the growing backlog of demand for hospital care, and the need to safely restart elective procedures and diagnostics to tackle growing waiting times. Despite being less visible in national data and waiting lists, community services and primary care are also facing a significant backlog as much routine care was put on hold. At the same time, these services are dealing with the ongoing health effects of Covid-19, including rehabilitation needs stemming from the virus and prolonged stays in intensive care units, and supporting those whose health has deteriorated as a result of delayed presentations or gaps in routine care. Demand pressures will also extend to mental health services; there is evidence that the mental health of people in the UK has worsened substantially since the start of the lockdown; this has particularly affected those who already reported lower levels of mental health and those with diagnosed mental health problems. Existing inequalities in mental health have been exacerbated.
This underlines the need for a whole-system response spanning acute hospitals, primary, community, mental health and social care services. A whole-system focus also requires attention to the sustainability of the voluntary and community sector, which offers critical support for health and wellbeing both through direct provision of health care services and broader support to vulnerable individuals and communities. Charities have been hit particularly hard by the economic consequences of Covid-19, losing an estimated £4 billion of income in the first three months of lockdown.
- 1. The terms ‘ethnic minority’ or ‘ethnic minority groups’ refer to people belonging to ethnic groups that are in the minority in the context of the population of England.
Where next? Five priorities for renewal
Looking beyond the immediate challenges of restoring services, the disruption caused by the pandemic and the learning coming out of this experience (both good and bad) offer a unique opportunity to renew the focus of the health and care system to create a better, fairer health system for the longer term. The challenge will be to grasp this opportunity at the same time as restoring services during the ongoing risk from Covid-19, to achieve both recovery and renewal.
The approach to renewal should build on the direction already set out in the NHS long-term plan and will need to be delivered through co-ordinated action across the whole health and care system. As part of this, efforts that were already under way to establish local place-based systems of care through integrated care systems (ICSs) and the partnerships within them should be redoubled, with local authorities playing a central role.
The emergency response was, by necessity, characterised by much greater central direction within health and care. However, the limitations of this approach have been apparent in some aspects of the response (such as the development of the test-and-trace strategy). Going forward, there are important lessons here about the need to balance central control with resources, autonomy and support for local leaders.
It is early days, and insights and understanding about the impact of the pandemic response will grow over the coming months. The five priorities set out below provide a framework to help guide the approach to renewal across health and care. We draw on existing evidence and experience as well as early lessons from the pandemic to set out the actions that should now be taken.
1. A step change on inequalities and population health
Covid-19 has starkly exposed the deep inequalities that exist across the nation’s health. Before the pandemic, improvements in life expectancy had almost ground to a halt and already unacceptable health inequalities between the richest and poorest were widening. Men living in the least deprived areas could, at birth, expect to live 9.4 years longer than those in the most deprived areas, while for women, the difference is 7.4 years. Between 2012–14 and 2015–17, this gap increased by 0.3 years for men and 0.5 years for women.
The virus has taken a disproportionate toll on groups already facing the poorest health outcomes. In particular, it has underlined the structural disadvantage experienced by people from black, Asian and minority ethnic communities who have been at much greater risk of contracting and dying from Covid-19. The economic and social consequences of measures to contain the virus risk worsening these inequalities further.
It is time for a reset in public policy to improve the population’s health and tackle deeply entrenched inequalities. This includes responding to the direct impact of Covid-19 and redoubling efforts to reduce health inequalities more broadly, including by addressing socio-economic drivers of health such as housing, education, employment and access to affordable healthy food. This will be a true test of how serious the government is around its ‘levelling up’ agenda.
Sustained and coherent action is needed on the prevention and management of inequalities in health at all levels, including through local place-based partnerships spanning the NHS, local government, voluntary sector organisations and communities themselves.
What can be done?
- As a first step, the government should move quickly to develop a cross-government strategy on health inequalities. This should include binding, ambitious targets to improve the nation’s health and reduce inequalities accompanied by clear accountability for meeting these targets. The strategy should make faster progress across the full range of important social and economic determinants of health. The government should be bolder in using the full range of levers available to improve the public’s health, including tax and regulation.
- Inequalities reduction should be a central focus for all local health and care partnerships, and this should be reflected in how they are constituted, measured and held to account. ICSs, local place-based partnerships and primary care networks should be seen as key vehicles to drive local improvements in population health. ICSs will need to go further than the expectations set in the long-term plan, to create partnerships that span the NHS, local government and voluntary and community sector.
- The NHS should be more ambitious in its approach to improving population health and reducing health inequalities, making good on the promises in the long-term plan for action on inequalities to be central to everything the NHS does. That means investing more in prevention, reducing inequalities in access to care, and leveraging its assets, spending power and role as a significant employer to improve the wellbeing of communities and support local economies.
2. Lasting reform for social care
The scale of deaths in care homes from Covid-19 is a national tragedy. By mid-June, more than 19,000 care home residents had died from the virus across England and Wales, and the total number of excess deaths in care homes compared to the same period last year had exceeded 29,000. A full picture is still to be established for recipients of home care, but there has been a significant impact on this group too. Between mid-April and mid-June the total number of deaths among recipients of home care in England has been more than double the three-year average for this time of year.
Despite the best efforts of staff, it has been difficult for care providers to keep staff and people relying on services safe. A variety of factors contributed to this, including: challenges obtaining adequate PPE, testing and financial support; difficulties in co-ordinating the response across a fragmented sector; longer-term weaknesses resulting from years of under-investment and workforce shortages; and rapid discharges from hospitals to care homes early in the pandemic. Despite strong international evidence that social care settings were at high risk from serious infection, the sector was treated as an afterthought by government at the start of the pandemic, with support measures coming too little and too late.
Even before Covid-19, it was clear that the social care system is not fit for purpose and is failing the people who rely on it, their families and carers. There are also longstanding issues in how social care staff are treated, including low pay and poor terms and conditions. But despite widespread agreement on the need for reform and numerous commissions and inquiries, successive governments have failed to bring forward solutions, opting instead for piecemeal measures and short-term cash injections. On taking office, the Prime Minister pledged to ‘fix’ social care ‘once and for all’, a commitment he has recently repeated.
It is imperative that the experience of Covid-19 be a line in the sand, ending the neglect of social care and the individuals and families who rely on it. At the heart of these efforts should be a positive vision of social care, promoting independence and supporting people to live the lives they want and be actively involved in their communities.
What can be done?
- As a first step, the government must urgently address short-term funding pressures, which have been exacerbated by the pandemic, to prevent further deterioration in access, experience and outcomes for people needing social care support. This needs to be accompanied by immediate steps to stabilise the fragile provider market, including supporting an increase in the amount local authorities can pay for care.
- The government should bring forward proposals for longer-term investment and reform as an immediate priority to create a simpler, fairer system. The proposals should offer a roadmap for reform and commit to significant progress in implementation before the end of the parliament. Importantly, this must recognise that the problems in social care are not just about funding: wider reform is needed to support greater equity of access, improve quality by tackling unwarranted variation, and address fragmentation across the NHS and social care.
- Wider reform must be underpinned by better pay, conditions and training for the social care workforce, bringing these more into line with those seen in the NHS, or there simply won’t be enough staff to deliver care in the future. The diverse nature of the sector and significant independent sector provision means this is likely to require a combination of central funding, regulation and legislation.
3. Putting the workforce centre stage
In recent months, health and care staff at all levels have demonstrated remarkable resilience and dedication to deliver the best possible care for patients and service users. Many have stepped into unfamiliar roles or completely transformed the way they deliver care. The impact of the pandemic on staff wellbeing both in the short and longer term should not be underestimated.
Tragically, across England and Wales more than 500 health and social care staff had lost their lives to Covid-19 by the end of May, with those from ethnic minority groups facing a disproportionate risk of serious illness and death. This follows longstanding disparities, with evidence that NHS staff from ethnic minority backgrounds consistently experience discrimination, higher levels of bullying, harassment and abuse, and fewer opportunities for career progression than their white colleagues.
The workforce crisis was the biggest issue facing the health and care system before the emergence of Covid-19. NHS hospitals, mental health services and community providers were operating with more than 100,000 full-time vacancies. Staff were working under strain with 40 per cent of respondents to the 2019 NHS staff survey reporting they had felt unwell due to work-related stress in the past year. Shortages were even greater in social care, with more than 120,000 vacancies across the sector.
In response to this growing crisis, the government made a series of commitments to grow and support the NHS workforce, including headline pledges for 50,000 more nurses, 6,000 more GPs and large numbers of other primary care staff. At the same time, NHS leaders are developing a national workforce strategy, the NHS people plan. The impact of Covid-19 on the recruitment and retention of staff remains to be seen, but there is a risk that severe staff shortages will continue, particularly as international recruitment has already reduced sharply and the 5,000 additional internationally recruited nurses that our analysis shows will be necessary annually for the next few years looks increasingly challenging.
Work to develop a credible workforce strategy and ensure greater leadership focus through the NHS people plan (delayed by Covid-19) is now even more critical, and equal efforts will be needed to address shortages in social care. Beyond the paid workforce, better use can be made of broader support available by embracing the contributions of voluntary and community sector organisations and volunteers.
What can be done?
- Concrete steps to improve recruitment and retention are needed to address shortages in the short and longer term. This will require an attractive pay offer, opportunities for flexible working and clearer career pathways. Efforts to boost retention should be targeted on those at the beginning or end of their careers and shortage groups and specialties. It is also vital to seize the opportunity to support those who have returned to the service during Covid-19 to stay. No delivery commitments should be made without a clear workforce plan to support them.
- Wider action on the workforce crisis must be underpinned by better support for staff wellbeing to support good patient care and improve staff retention. This should not be seen as a short-term response to the pressures of working through Covid-19, but a sustained commitment to tackle long-term drivers of poor staff experience, health and wellbeing and address chronic excessive workloads.
- Leaders at all levels in health and care must prioritise developing cultures of compassion, inclusion and collaboration to improve care for patients and create high-quality workplaces for staff. Actions to tackle the discrimination and racism faced by staff from ethnic minority backgrounds must be central to this.
4. Embedding and accelerating digital change in the wake of recent progress
Covid-19, and the need to provide care while physically distant, delivered an unprecedented shock to both demand for and supply of digital health services. The results have been substantial. Within weeks of the epidemic taking hold, more than three-quarters of GP surgeries were conducting some patient consultations via video, and nearly half of all consultations in May were conducted over the telephone. Supported by a national platform, remote hospital outpatient appointments surged too. In its recent history, the NHS has never seen such a rapid and widespread channel shift. Alongside, some parts of England have accelerated the roll-out of digital technologies, such as tablet devices, to enable users of social care services to access support and advice from a distance.
This scale of change was enabled by clinical and support staff rapidly changing how they work and sharing learning and good practice along the way; digital suppliers making it easier for care providers to access and afford their services and products; and guidance and funding from national bodies. The focus has been on technology as an enabler to delivering care, not as an end in itself.
The achievements of recent weeks stand in stark contrast to the relatively poor record the NHS has of adopting digital technologies at scale. Longstanding barriers in England’s digital health landscape – including over-centralised decision-making, insufficient investment and infrastructure, lack of staff development, restrictive information governance requirements and poor interoperability – have hampered progress for too long. Likewise, the extent to which social care has been able to capitalise on digital opportunities has been constrained in the past by a lack of dedicated funding, supporting national infrastructure and leadership.
Looking ahead, the task for national bodies and local leaders is to learn lessons from recent months and to make lasting adjustments to policy and practice to create an environment which is more supportive of digital health innovations that improve patient care. As part of this, it will be important to explore how these rapid changes in ways of working and accessing care are having an impact on both patients and staff – including any potential adverse consequences – and to embed standards and interoperability at their core. Importantly, the digital legacy of Covid-19 needs to be durable: it must be built on public consent; work for the broadest possible spectrum of services users; support health and care staff in their roles; and include a proportionate framework of safeguards.
What can be done?
- Rapid evaluation of approaches and measures taken during the pandemic is needed to inform future digital change. This includes understanding the impact of the more permissive environment for innovation – covering changes to funding, procurement, information governance, and staff and peer support – and the consequences of the resulting changes for patients and staff, particularly in general practice and outpatient care, which have seen the greatest shifts.
- Digital infrastructure and tools need to be built with transparency and involvement from the public and health and care staff. Given past blows to confidence from high-profile lapses in this area and concerns about data-sharing with independent companies during the pandemic, a different approach is needed building on existing best practice, such as co-development and deliberative engagement processes.
- It is essential to take steps to prevent digital technologies entrenching or widening health inequalities. This requires greater understanding of the extent and nature of digital exclusion at national, regional and local levels, and for this to be central to decisions about policy, design and implementation. As part of this, it will be important to learn from existing initiatives that seek to address inequalities in access to digital skills and infrastructure.
5. Reshaping the relationship between communities and public services
The Covid-19 emergency has brought an upsurge in community solidarity and activism, underlining the vital role of local communities in supporting health and wellbeing. Hundreds of thousands of people have offered their time and support through local mutual aid groups and the NHS Volunteer Responders scheme, while communities across the UK expressed their gratitude to health and care staff through the weekly ‘clap for carers’.
Channelling community energy to foster a new relationship with public services – creating citizen-led public services – has long been an aspiration in England. Yet while some places have made real strides, overall change has been limited. In the wake of the initial phase of Covid-19, there is an opportunity to truly reshape the relationship between public services and the communities they serve, fostering cultures where public services seek to build on the strengths and assets of communities to improve outcomes.
Changing how health and care services work with people and communities will be one part of this process. It is a different way of working that recognises the role people can play in improving their own health and supporting them to do so. Discrete engagement and consultation exercises on proposed service changes will need to give way to a culture of working with people on an ongoing basis to understand their priorities and needs and work with their strengths. This should include the most marginalised communities and excluded people to guide action to tackle the worst health outcomes and address longstanding inequalities. Given the unequal impact of Covid-19, particular focus should be afforded to involving people from ethnic minority communities including through community participatory research, as recommended in Public Health England’s recent report.
What can be done?
- Health and care services should understand and work with communities’ priorities, needs and strengths. This should be achieved through meaningful local involvement – with a particular focus on those who experience ill health, disability and inequalities – and supporting people to improve their own health. For local systems, embedding this way of working will require sustained cultural change; places which have made progress on this agenda, like Wigan, can point the way.
- Local health and care systems should take steps to safeguard the role of voluntary and community organisations as long-term partners in promoting health and wellbeing. This will require public services to work with, and provide support to, local community leaders and organisations, many of which have been hit financially by the pandemic.
- National organisations cannot mandate these kinds of changes, but they can help remove the barriers that make it harder for them to take root. Government departments and NHS national bodies should seek to support a community-led approach to public services by involving local leaders and communities in policy design, supporting a greater role for local government in shaping local health and care services, and changing the current top-down approach to how health system performance is measured and addressed.
Less than two years ago, the NHS in England outlined its strategic ambitions for the coming decade. At that point, no one could have anticipated the seismic shock the health and care system would soon face. It is now time to renew priorities in light of this, embracing learning wherever it can be found and seizing opportunities to create positive change for the longer term.
The Conservative Party manifesto made the NHS a key priority, promised to solve the problems in social care to give every person the dignity and security that they deserve, and to ‘level up’ every part of the country. Making good on these commitments in the wake of the global Covid-19 pandemic will require change and renewal: creating public services that can work hand in hand with local communities; honouring the sacrifices made by health and care staff by putting the welfare of the workforce at the top of the agenda; and focusing relentlessly on inequalities to turn every dial in favour of better, fairer health. This will require action locally, regionally and nationally.
There are financial implications to some of the actions we have set out. Given the wider economic context, it would be naïve not to recognise the very difficult decisions and trade-offs in public spending that lie ahead. However, if the government wishes to live up to its promises on prioritising health and care, a post-Covid-19 funding settlement will be needed, bringing investment in the health and care workforce, and in social care and public health, where years of austerity have been exacerbated by the pandemic. The measures set out are necessary to make good on the promise to `level up’ society, but they will also need to sit within a wider economic strategy that supports investment in the socio-economic determinants of health. Making progress will also require political courage, not least to push forward potentially contentious long-term social care reform; given its significant majority, the government is well placed to do this and should not duck difficult policy decisions.
In the coming weeks, The King’s Fund will launch a new strand of work aimed at shaping discussion about the changes needed to bring about renewal in the health and care system. Building on our Leading through Covid-19 work, which has provided support to health and care leaders during the crisis, this will showcase new thinking, share ideas and generate debate about the future of health and care.
With thanks to
The authors extend their thanks to colleagues across The King’s Fund who have contributed to shaping this long read, including: Siva Anandaciva, Suzie Bailey, Alex Baylis, Simon Bottery, Dave Buck, Matthew Honeyman, Richard Murray, Chris Naylor, Patrick South, Jo Vigor, Sally Warren, Dan Wellings and Michael West.
Informative and helpful, your observations & conclusions are quite insightful, especially around relationships on communities and public services.
An unintended consequence of COVID on Patient & Public Engagement.....
In my role as a volunteer representing local, regional and national patient groups, I'm extremely concerned about the preference for Integrated Care Systems to create ‘virtual’ Citizens Panels', to replace the established Service User Advisory groups and other patient groups. Disbanding existing patient and community groups feels like a mistake.
Clearly the pandemic has caused a rethink & process redesign and whilst system leaders are encouraging innovative ways of working, we cannot forsake patient & public involvement, for less effective models of engagement. Virtual Citizens’ Panels are not new and work well where the purpose is to raise awareness, make announcements and obtain general consensus via survey from the sample group. It is woefully ineffective when dealing with the public's concerns on complex change and where further discussion and explanation is required. The ability to challenge and support, is an important aspect of patient & public involvement, holding leaders to account and having appropriate oversight is explicit in the relevant provisions of the Act. Virtual Citizens’ Panels are a worrying trend with little, if any, consultation with community groups for this model of engagement.
It would be far better to modify the existing community structures with established patient & public groups, so that they can be more inclusive and representative and could successfully carry out their role via regular video conference panels. This would allow adequate two-way comms with the ability to challenge and support. Based on our collective experience, we believe Virtual groups will not provide effective patient and public engagement for these reasons:
1) Difficult to collaborate and build relationships & trust without visual representation
2) Facilitates one-way comms only
3) Difficult for community leaders and public to discuss & debate key issues in real time
4) Difficult for community leaders and patient representatives to garner public support
5) Survey responses and output are opaque
6) Disbanding established patient groups risks trust and goodwill
7) Autocratic approach will alienate the public
8) Unproven method of reaching under represented / BAME groups. Evidence from the most recent PHE reports show that COVID-19 disproportionally impacts BAME groups as well as having negative consequence to the longer term social determinants of health, It is more important now than ever, to engage effectively with the community.
Your paper is excellent in that it is inclusive and insightful. I worry that the challenges and necessary improvements are just so big that no one knows where or how to start. I worry that government will suggest an overall strategy - which, to me, means no action for years! Action and improvements are needed right now! As you continue your work, could you include a section on what each individual can do to help this process? You note the importance of local and community involvement. People want to help but have no idea how to best move forward in a useful way. As a member of the BAME community, I look forward to more. Thank you.