How did care providers collaborate to keep people safe?

 

How have providers collaborated to ensure people over 65 are seen at the right place at the right time and by staff with the right skills? We wanted to see how providers have worked together to understand the local population and to ensure care pathways were developed to keep people safe – and how they have worked to ensure people received effective, responsive care.

Before the pandemic, we knew that different parts of the country were at different stages in progress towards better collaborative working between health and social care services, as well as work with other support services.

Across the 11 local areas we found varying success as providers worked to keep people safe by working together. Each local area was different and had localised arrangements for health and social care provision – and while there were some similarities in each area’s reaction to the pandemic, each area had its own strengths and challenges.

Some areas coped better where there were well-established working relationships among local providers – there was better collaboration and decision-making. But the sheer pace of change during the early stages of the pandemic stretched even the most solid working relationships and made it challenging for parts of local systems to consult each other and work together.

System areas benefitted from the pace of effort to secure a regional level grip across communication, support and joint working approaches, in response to confusion from the pace of national guidance

With so much unknown about COVID-19, decisions had to be made at speed, at the same time as receiving a high volume and frequency of changes to guidance from central authorities. Providers said this caused confusion and at times they felt overwhelmed.

We heard that some places found the national messages were conflicting, such as the messages around not overburdening the NHS but people should seek help if they needed it. Providers told us communication and guidance at a national level was not nuanced enough to meet the needs of the local population. They also told us it was often not tailored for non-English speakers.

During the well-publicised issues around the supply of personal protective equipment (PPE) early in the pandemic, there were localised problems. Despite these problems, in each area we visited there were systems in place to try to manage the supply of PPE.

We also heard about varying experiences with approaches to coronavirus testing – some providers and staff had good arrangements in place, whereas others struggled. Providers in some systems reported that COVID-19 testing was a major challenge at the beginning of the pandemic but, at the time we conducted the review, they said it had improved.

System areas benefited from the pace of effort to get a regional grip across communication, support and joint working approaches. This included providing training and support to care homes, and we heard about collaboration between local authorities, NHS trusts, clinical commissioning groups and the voluntary sector to manage the pandemic.

Pathways and services were redesigned to manage people with confirmed coronavirus and non-coronavirus illness, and aimed to reduce pressure on urgent and emergency services. Community hubs and NHS 111 services were crucial in reducing hospital admissions. Urgent dental care centres were set up, although sometimes difficult to access, and some areas told us they adapted dental services to support vulnerable people.

Keeping people safe

Our reviews highlighted that system areas consistently had an understanding of those who were most vulnerable within their populations. Support included services keeping in regular contact with people who needed care, informing them of changes to services, and offering welfare checks and practical support, such as prescriptions and food parcels.

There was support for families and carers and recognition that they were taking on more caring responsibilities. There was also awareness among services that some people may need more emotional support due to the impact of COVID-19, rather than just practical support.

Providers identified people who may be hard to reach or lonely, and supported wellbeing through a range of communication channels, such as webinars on how to manage anxiety and sleep. There was also support from voluntary sector organisations and the wider community, including contacting vulnerable people, delivering supplies, supporting discharge and carrying out tasks to take the pressure off front line health and social care staff.

For people in care homes, staff worked hard to maintain contact with relatives, either virtually or by organising socially distant visits, and to provide residents with stimulating activities.

We heard about many examples of care to keep people safe, including a helpline set up in Lincolnshire for mental health patients, which allowed them to self-refer, rather than needing to be referred by the GP. It worked well to reach vulnerable people. Individual examples included dental support for people who were not on the dentist’s patient list in Bedfordshire, Luton and Milton Keynes ICS.

Understanding local population needs, including cultural differences, was especially important

In previous years, we have reported in State of Care and other local systems reports about how services need work to make sure people are kept safe and seen in the right place, at the right time and by the right person. To do this well, local providers and systems need to understand their populations.

In our reviews, we heard how during the pandemic providers used a range of data, such as daily situation reporting and information gathered by clinical commissioning groups (CCGs), and their work with public health teams to access the latest data on the virus and understand what it meant for local people. This data could be shared across providers to make sure everyone had the most up-to-date information and could ask questions.

We were told about a variety of scenarios in responding to the pandemic where things went well locally, because there was an understanding of the local population. This also included quicker responses where there was an existing understanding of the local community, including population risk factors:

• local leaders and community groups working together to create networks and find solutions
• regular communication to identify needs and respond actively, typically based on existing relationships between partners, but formalising these processes to allow for more robust and faster communication.

Providers told us that local system leaders, such as CCG and council leads, worked with community groups to create networks and find solutions for those most at risk. This included voluntary organisations and members of the local community. Community groups played an important role in getting messages out to the local population as well as feeding back to the system so action could be taken.

We heard how rapidly evolved delivery models presented barriers for those needing to access care. Examples included people not having internet access for online support approaches, and ways of working were not accessible for those with increased communication needs. Some providers worked with voluntary organisations and local groups to make sure communication was accessible to all – such as translating messages and using local radio. Some national directives and communication were described as confusing and difficult to apply at a local level.

Despite the positive examples described above, sometimes there was concern about the ability to identify vulnerable people, linked to the need for clear guidance and access to data. When the pandemic began, local areas worked rapidly to identify people who needed to be shielded and decisions were made to help protect vulnerable groups – this involved PPE provision, shielding and risk assessments, as well as engaging local communities.

Some areas told us there was confusion at first around identifying who needed to be shielded. We heard about a list that was developed nationally and described as 'chaotic'. We were told in some places there were multiple lists of people who were shielding, held by multiple organisations, which caused difficulties. Services had to work quickly to update these lists. We were told that some services, such as ambulances and adult social care, were unable to access the information and so took precautions, such as extra PPE and treating all residents as if they needed to be shielded.

Service changes

Across the 11 areas, we found services were reviewed and redesigned, with risks proactively monitored to keep people safe. Services adapted to reduce people’s interactions with physical healthcare sites. We were told how non-urgent appointments were cancelled and there was a shift to assessing, treating and supporting people in their own home. We heard how this involved:

• Virtual assessment, treatment and support, such as virtual GP appointments; ‘virtual ward rounds’ in care homes; and wellbeing telephone chats delivered by voluntary organisations.
• Enhanced support in the community and care homes. For some people, this included home visits by GPs and district nurses; enhanced use or establishment of community care hubs and mental health hubs; more resources and support for carers and families to assist people at home; and the delivery of medicines, wellbeing packs and other resources.

We were told how healthcare sites were reorganised into hot and cold zones or buildings to reduce the risk of spreading infection. This applied within services and between services. There were separate hospital wards for COVID and non-COVID patients, and GP providers worked together to assign surgeries as hot or cold for transport vehicles.

Providers told us there was more support in the community to reduce the chance of hospital readmission – they said that the Discharge to Assess process helped people to be manged in the most suitable setting, and that integrated care and multidisciplinary teams played a key role.

There was a mixture of experience in care homes. Some services decided to lockdown early, but we were told about concerns about the impact of social isolation for some residents. Some care homes felt very supported by others in the system, through virtual GP rounds and training of in-house staff. But others felt they were unsupported and let down. Tensions arose between providers within some systems, as the pace of the situation could result in confusing communications and changes to people’s responsibilities and workloads.

We heard how services worked together and offered support, such as dedicated GPs for nursing homes, quality teams supporting testing, and coordination around patients’ discharge. Community services also supported other services with PPE.

Where changes implemented because of COVID-19 had a positive impact, providers told us they would like to keep them long-term. This includes keeping the service redesigns, such as virtual consultations and new pathways between GPs and consultants, as well as collaborative ways of working, such as joint agreements for integrated clinical pathways.

The voluntary sector played a critical role in supporting health and social care to keep people safe. System-wide leaders were concerned about capacity to meet the demands of subsequent peaks without this support

Across our reviews, we heard about how important a role the voluntary sector played in supporting health and social care services to help keep people safe. They contacted vulnerable people, delivered supplies, supported discharge from hospitals and did tasks to take the pressure off front line health and social care staff.

However, the voluntary sector struggled to be able to do what they felt was necessary because of a lack of resources. There was a concern that voluntary services might disappear in a second wave, but also that people may not go above and beyond next time because of the impact that the COVID-19 response had had on their own personal health and wellbeing. Voluntary sector staff were reportedly exhausted.

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Part 3: Collaboration between providers