Lack of integration a key factor in speed of Covid response, says NAO

by Seamus Ward

12 June 2020

The nature and speed of the government response to the coronavirus outbreak has been shaped by longstanding difficulties, including lack of integration, and years of underfunding, according to the National Audit Office.

Its report, Readying the NHS and adult social care in England for Covid-19, acknowledged that many of the factors that influenced the effectiveness of the response were outside the government’s control. These included the need to engage with suppliers of personal protective equipment (PPE) and ventilators, nationally and internationally.Gareth Davies

NAO head Gareth Davies (pictured) said that while the report did not seek to evaluate the government response, four important themes had emerged from its work. These were:

  • The onset of a crisis did not mean longstanding difficulties can be solved instantly. The relationship between adult social care and the NHS had been problematic for decades and, though there had been attempts to bring them together, meaningful integration of health and social care had not occurred going into the crisis. This made the response more difficult.
  • Government’s ability to produce an effective crisis response is significantly affected by matters outside its control, including the ability to bring in PPE, ventilators, and additional testing capacity. Special attention to this should be made by those planning for the later stages of this pandemic and for future outbreaks.
  • Health and social care had been under financial pressure since 2010/11, with additional funds used to address immediate needs rather than increasing long-term sustainability. This was particularly true in local government over the last five years. However, public bodies now face the twin challenge of maintaining readiness to respond to Covid-19 while putting other essential services on a sustainable footing. This includes working through backlogs. ‘A realistic, costed and prioritised plan will give them the best chance of succeeding,’ Mr Davies said.
  • A lot of important information on costs and performance has yet to emerge due to the pace and intensity of the response to the pandemic. It would soon be appropriate to assess the cost-effectiveness and effectiveness of the response so lessons can be learnt. In the meantime, he said it was essential public bodies adhere to the principles of Managing public money to the maximum possible extent. So far, the government has allocated £6.6bn from the Coronavirus Emergency Fund to health and social care – just under half £3.2bn directly to local authorities.


Looking at the response in greater detail, the NAO said NHS England and NHS Improvement sent a letter on 17 March, setting out the measures that national and local NHS bodies should take to prepare for the outbreak. Though it did issue various pieces of guidance to the adult social care sector from 13 March onwards, the Department for Health and Social Care did not publish an action plan for adult social care until 15 April. The report added: ‘There have been many other developments throughout the pandemic, but these two documents are key to understanding the government's health and adult social care response.’

Between 17 March and 15 April, around 25,000 people were discharged from hospitals into care homes, around 10,000 fewer than in the same period in 2019. It is not known how many of these patients had Covid-19 at the point of discharge. The 17 March letter had urged hospitals to discharge all medically fit patients to increase capacity in preparation for a surge in Covid-19 patients.

Under then government policy, not all patients were tested for Covid-19 before discharge. However, on 15 April, the Department changed the policy so all those being discharged from hospitals into care homes would be tested – a day later, NHS England and NHS Improvement instructed this be implemented.

Mr Davies said the report demonstrated the enormous efforts of health and care staff. But he added: ‘The speed and nature of the response in health and social care has been shaped by longstanding differences between the sectors and ongoing financial pressures. Government’s ability to increase beds, ventilators, PPE and testing has varied in part because of the number of other bodies, both national and international, with which it has had to engage. All of these issues need to be taken into account as government plans for the later phases of the pandemic and future emergencies.’

Nuffield Trust deputy director of policy Natasha Curry said: ‘It is clear that preparations for the social care sector came too late in the day. A full action plan for the sector did not materialise until mid-April – an entire month after initial guidance and long after hospitals were already discharging patients back into care homes.

‘We will be living with this virus for some time to come. Care providers, already stretched before the crisis, will have to continue to navigate complex infection control, PPE distribution and social distancing measures. This all amounts to greater pressure on a system in desperate need of reform.’

A joint survey by the Association of Directors of Adult Social Services and the Local Government Association warned that adult social services could face more than £6.6bn in additional Covid-19 costs between April and September. The maintenance of staffing levels (£1bn) and provision of PPE (almost £4.2bn) were the biggest drivers of the extra costs, together with enhance cleaning of care homes (£700m).