Covid-19 update: 7 August

by Steve Brown

07 August 2020

It has been a long time coming, but NHS England and NHS Improvement finally unveiled their plans for the third phase of the NHS response to Covid-19 at the end of last week. This set out the priorities for the rest of the year – including some stretching targets for increasing elective and outpatient activity – and the financial arrangements for the remainder of 2020/21.

The letter from NHS chief executive Simon Stevens and chief operating officer Amanda Pritchard was ambitious in calling for providers to have elective and outpatient procedures back to 90% of last year’s activity by October. By the same deadline, MRI/CT and endoscopy procedures should be at 100% and outpatient attendance should be at the same level a month earlier.HFMA Covid-19

General practice, community and optometry services are also expected to restore activity to normal levels, catching up on immunisations and screening and enhancing crisis response services. And continuing healthcare assessments must be resumed from September.

The letter also confirmed that current block contracting arrangements would be extended to cover August and September. A revised framework – still based on block contracts but with no retrospective top-ups and with a requirement to breakeven across systems – will be put in place from October.

The NHS Confederation was quick to attempt to manage expectations, suggesting a full return to pre-Covid-19 levels of activity by October may not be possible with just a ‘short window of opportunity’ between now and winter.

‘The service will respond and do everything possible to start tackling the enormous backlog of need but in return it will expect patience,’ said the confederation’s chief executive Niall Dickson. ‘The service will step up as it always does, but we need the public, patients and politicians to understand that switching services back on is much more challenging than switching them off, and it will not be achieved overnight.’

NHS Providers chief executive Chris Hopson (pictured) called for the new financial framework for trusts to be properly funded. ‘We can’t really judge the approach until we know what the financial envelope is for the second half of the year and how that translates into individual allocations for organisations,’ he said. ‘That’s still being negotiated with the Treasury and probably won’t be finalised for at least another month.’Chris Hopson

He welcomed the renewed commitment to system working. ‘But longer term, we need much greater clarity on accountabilities and governance if revenue funding is to be allocated to systems who currently have no statutory underpinning and no formal accounting officer status,’ he said. 

It remains unclear what the long-term arrangements for contracting and financial flows will be after this year. There have been increasing calls for the service not to return to the tariff funding system, with the service seeing benefits in the simpler arrangements put in place as part of the Covid response. However, in reality, many areas had already moved away from pure activity-based payment with the adoption of caps and collars or other risk share arrangements and the use of block contracts.

NHS England and NHS Improvement have also been introducing the idea of blended payments, starting last year. This involves the use of fixed payments with one or more of a quality or outcomes element, a variable payment and a risk sharing mechanism. There is also increasing interest in the adoption of aligned incentive contracts.

According to the NHS Confederation’s July report – The NHS after Covid-19 – chief executives want funding to shift to incentivising a population health approach, rather than focusing on organisational health. While increasing emphasis on system break-even may facilitate more integrated services and some pathway redesign, it stops short of introducing population health budgets with a specific focus on population outcomes.

A further report from the Community Network – set up by both the NHS Confederation and NHS Providers – also raises financial concerns specifically about community services. The impact of Covid-19 on community health services highlights ‘worrying reports’ about local authorities looking to retender community and public health service contracts – which would not be ‘reasonable or feasible’ this financial year.

Community service providers are also still waiting for confirmation that the Agenda for Change pay uplift and pension costs will be fully funded for staff employed on NHS contracts through health services now commissioned by local authorities. And there are fears that local government funding shortfalls will lead to cuts in services commissioned from community providers.

Meanwhile, The Health Foundation has warned that more than 700,000 patients served by GPs at high risk of Covid-19 could be left without access to face-to-face GP appointments if these GPs take the decision to limit direct patient contact. London could be the most affected.

Another Commons select committee this week had its say on the government’s response to the pandemic. This time it was the Home Affairs Committee, which has been examining the Home Office’s preparedness for coronavirus. Its conclusion about border controls was not complimentary. Stronger early measures could have slowed the virus’s spread. And the removal of self-isolation guidance for arrivals in March – while other countries were introducing more comprehensive measures including testing and screening – was ‘highly unusual’.

‘Evidence suggests that thousands of new infections were brought in from Europe in the 10 days between the withdrawal of guidance and the introduction of lockdown on 23 March,’ the report said. ‘It is highly likely that this contributed to the rapid increase in the spread of the virus in mid-March and to the overall scale of the outbreak in the UK.’ It concluded that the failure to have any special border measures during this period was a ‘serious mistake that significantly increased both the pace and the scale of the epidemic in the UK’.

One suspects that if the Commons’ Health and Social Care Committee’s Care Quality Commission-style new assessment mechanism for government commitments were applied to the border control measures, the result would be around the ‘inadequate’ end of the ratings.

The Home Affairs Committee agreed that a testing and tracing system alone was not sufficient to address the risk from overseas travel, but believes more work should have been done to develop testing and screening options alongside quarantine and self-isolation measures.

Meanwhile the NHS Test and Trace service continues to feel the full glare of public scrutiny. Researchers this week effectively gave the service one month to boost its performance considerably before schools reopen if the country is to avoid a second wave of the coronavirus. Writing in The Lancet Child and Adolescent Health, the researchers said that, assuming 68% of contacts could be traced, 75% of individuals with symptomatic infection would need to be tested and positive cases isolated if schools return full-time in September. The figures rise as the number of contacts that can be traced falls.

‘However without these levels of testing and contact tracing, reopening of schools together with gradual relaxing of the lockdown measures are likely to induce a second wave that would peak in December if schools open full-time, and in February if a part time rota system were adopted,’ the paper concluded.

A paper from the Tony Blair Institute for Global Change, published at the end of July, argues that while the government is to be commended for increasing the country’s testing capacity to 300,000 tests per day, far more is required. ‘In the absence of a game-changing solution, such as a vaccine or compelling therapeutic drug, mass testing remains the most viable way to live alongside the virus,’ it said.

This week also saw a further underlining of the difference between the country’s capacity to test and the actual number of tests being undertaken. Speaking to the BBC Today programme on Wednesday, schools minister Nick Gibb said that 330,000 people a day were being tested for Covid-19 under Test and Trace. But independent fact checking charity Full Fact said this was not true, with the real figure for England around 52,000 – although this would be slightly higher for the whole UK and if antibody and surveillance tests are included. (Full Fact’s figures were based on last week’s Test and Trace statistics.)

The latest weekly report from the Department of Health and Social Care on its NHS Test and Trace service in fact reported that 390,242 people had been newly tested for Covid-19 in the week to 29 July, which would be an average of nearly 56,000 a day. From these tests, nearly 5,000 people tested positive, with 4,642 of these transferred to the contact tracing service. Nearly 80% of these were reached – a percentage that has remained fairly constant since the fourth week of the service – leading to the identification of 19,150 close contacts. And of these, 72% were reached and asked to self-isolate – a reduced percentage to last week.

Blackburn with Darwen Council became the latest council to set up its own locally supported contact tracing system this week (Sandwell Metropolitan Borough Council has also set up an additional contact tracing service). The Lancashire district was singled out as an ‘area of intervention’ by Public Health England two weeks ago and was joined by the rest of Greater Manchester last weekend. The council’s new service steps in if the national process has been unable to contact someone within two days.

The district has been testing at a rate of between 250 and 500 per 100,000 over the last three weeks – well ahead of the national average of 94 – and, according to director of public health and wellbeing Dominic Harrison it is now exploring how it can start ‘hyperlocal testing’.

‘This will involve looking at the postcodes of confirmed cases on one day – and on the next day getting swabs delivered house-to-house in that local area, getting the swabs tested, people informed of their results and their contacts traced immediately,’ he said in a column on the council website. ‘If we can do this locally and rapidly we will dramatically reduce the time from infection to self-isolation.’