17 March 2020
IMPORTANT AND URGENT – NEXT STEPS ON NHS RESPONSE TO COVID-19
Thank you for your extensive work to date to prepare for this rapidly increasing pandemic, following the NHS declaration of a Level 4 National Incident on 30 January.
Last night the Government announced additional measures to seek to reduce the spread across the country. It is essential these measures succeed. However as the outbreak intensifies over the coming days and weeks, the evidence from other countries and the advice from SAGE and the Chief Medical Officer is that at the peak of the outbreak the NHS will still come under intense pressure.
This letter therefore sets out important actions we are now asking every part of the NHS to put in place to redirect staff and resources, building on multiple actions already in train.
• Free-up the maximum possible inpatient and critical care capacity.
• Prepare for, and respond to, the anticipated large numbers of COVID-19 patients who will need respiratory support.
• Support staff, and maximise their availability.
• Play our part in the wider population measures newly announced by Government.
• Stress-test operational readiness.
• Remove routine burdens, so as to facilitate the above.
Please therefore now enact the following measures:
1. Free-up the maximum possible inpatient and critical care capacity
The operational aim is to expand critical care capacity to the maximum; free up 30,000 (or more) of the English NHS’s 100,000 general and acute beds from the actions identified in a) and b) below; and supplement them with all available additional capacity as per c) below.To that end, trusts are asked now to:
a) Assume that you will need to postpone all non-urgent elective operations from 15th April at the latest, for a period of at least three months. However you also have full local discretion to wind down elective activity over the next 30 days as you see best, so as to free up staff for refresher training, beds for COVID patients, and theatres/recovery facilities for adaptation work. Emergency admissions, cancer treatment and other clinically urgent care should continue unaffected. In the interim, providers should continue to use all available capacity for elective operations including the independent sector, before COVID constraints curtail such work. This could free up 12,000-15,000 hospital beds across England.
b) Urgently discharge all hospital inpatients who are medically fit to leave. Community health providers must take immediate full responsibility for urgent discharge of all eligible patients identified by acute providers on a discharge list. For those needing social care, emergency legislation before Parliament this week will ensure that eligibility assessments do not delay discharge. New government funding for these discharge packages and to support the supply and resilience of out-of-hospital care more broadly is being made available. (See section 6f of this letter). Trusts and CCGs will need to work with local authority partners to ensure that additional capacity is appropriately commissioned. This could potentially free up to 15,000 acute beds currently occupied by patients awaiting discharge or with lengths of stay over 21 days.
c) Nationally we are now in the process of block-buying capacity in independent hospitals. This should be completed within a fortnight. Their staff and facilities will then be flexibly available to you for urgent surgery, as well as for repurposing their beds, operating theatres and recovery facilities to provide respiratory support for COVID-19 patients. As soon as we have the detailed capacity map of what will be available in each part of the country we will share that with you via Regional Directors. NHS trusts and foundation trusts should free up their own private pay beds where they exist. In addition, community health providers and social care providers are asked to free up community hospital and intermediate care beds that could be used flexibly within the next fortnight. These measures together could free up to 10,000 beds.
2. Prepare for, and respond to, large numbers of inpatients requiring respiratory support
Emerging international and UK data on COVID-19 patients suggests that a significant proportion who are hospitalised require respiratory support, particularly mechanical ventilation and to a lesser extent non-invasive ventilation.
a) Work is well in hand nationally to secure a step change in oxygen supply and distribution to hospitals. Locally, hospital estates teams have now reported on their internal oxygen piping, pumping and bedside availability. All trusts able to enhance these capabilities across their estate are asked to do so immediately, and you will be fully reimbursed accordingly. The goal is to have as many beds, critical care bays, theatre and recovery areas able to administer oxygen as possible.
b) National procurement for assisted respiratory support capacity, particularly mechanical ventilation, is also well under way in conjunction with the Department of Health and Social Care. In addition, the Government is working with the manufacturing sector to bring new manufacturers online. These devices will be made available to the NHS across England, Wales, Scotland and Northern Ireland according to need. Mark Brandreth, chief executive of Agnes Jones and Robert Hunt foundation trust is now supporting this work.
c) In respect of PPE, the DHSC procurement team reports that nationally there is currently adequate national supply in line with PHE recommended usage, and the pandemic influenza stockpile has now been released to us. However locally distribution issues are being reported. Michael Wilson, chief executive of SASH, is now helping resolve this on behalf of the NHS. In addition if you experience problems there is now a dedicated line for you: 0800 915 9964 / 0191 283 6543 / Email: firstname.lastname@example.org.
d) A far wider range of staff than usual will be involved in directly supporting patients with respiratory needs. Refresher training for all clinical and patientfacing staff must therefore be provided within the next fortnight. A crossspecialty clinical group supported by the Royal Colleges is producing guidance to ensure learning from experience here and abroad is rapidly shared across the UK. This will include: a short education package for the entire NHS workforce; a service guide, including for anaesthetics and critical care; COVID-19 clinical management guides in collaboration with NICE.
e) Segregate all patients with respiratory problems (including presumed COVID19 patients). Segregation should initially be between those with respiratory illness and other cases. Then once test results are known, positive cases should be cohort-nursed in bays or wards. f) Mental Health, Learning Disability and Autism providers must plan for COVID19 patients at all inpatient settings. You need to identify areas where COVID19 patients requiring urgent admission could be most effectively isolated and cared for (for example single rooms, ensuite, or mental health wards on acute sites). Case by case reviews will be required where any patient is unable to follow advice on containment and isolation. Staff should undergo refresher training on physical health care, vital signs and the deteriorating patient, so they are clear about triggers for transfer to acute inpatient care if indicated.
3. Support our staff, and maximise staff availability
a) The NHS will support staff to stay well and at work. Please ensure you have enhanced health and wellbeing support for our frontline staff at what is going to be a very difficult time.
b) As extra coronavirus testing capability comes on line we are also asking Public Health England as a matter of urgency to establish NHS targeted staff testing for symptomatic staff who would otherwise need to self-isolate for 7 days. For those staff affected by PHE’s 14 day household isolation policy, staff should – on an entirely voluntary basis – be offered the alternative option of staying in NHS-reimbursed hotel accommodation while they continue to work. Sarah-Jane Marsh, chief executive of Birmingham Women’s and Children’s foundation trust is now supporting this work.
c) For staff members at increased risk according to PHE’s guidance (including pregnant women), if necessary, NHS organisations should make adjustments to enable staff to stay well and at work wherever possible. Adjustments may include working remotely or moving to a lower risk area. Further guidance will be made available and the Royal College of Obstetrics and Gynaecology will provide further guidance about pregnant women.
d) For otherwise healthy staff who are at higher risk of severe illness from COVID-19 required by PHE’s guidance to work from home, please consider how they can support the provision of telephone-based or digital / videobased consultations and advice for outpatients, 111, and primary care. For non-clinical staff, please consider how they can continue to contribute remotely. Further guidance will be made available
e) The GMC, NMC and other professional regulators are also writing to clinicians who have relinquished their licence to practice within the past three years to see whether they would be willing to return to help in some capacity.
f) Urgent work is also underway led by chief nursing officer Ruth May, NHS chief people officer Prerana Issar and Health Education England, the relevant regulators and universities to deploy medical and nursing students, and clinical academics. They are finalising this scheme in the next week.
g) All appropriate registered Nurses, Midwives and AHP’s currently in nonpatient facing roles will be asked to support direct clinical practice in the NHS in the next few weeks, following appropriate local induction and support. Clinically qualified staff at NHSE/I are now being redeployed to frontline clinical practice.
h) The four UK chief medical officers, the national medical director, the Academy of Medical Royal Colleges and the GMC have written to all UK doctors stressing that it will be appropriate and necessary for clinicians to work beyond their usual disciplinary boundaries and specialisms under these difficult circumstances, and they will support individuals who do so. (see https://www.aomrc.org.uk/wpcontent/uploads/2020/03/0320_letter_supporting_doctors_in_COVID-19.pdf ) Equivalent considerations apply for nurses, AHPs and other registered health professionals.
4. Support the wider population measures newly announced by Government
Measures announced last night are detailed at: https://www.gov.uk/government/publications/covid-19-guidance-on-social-distancingand-for-vulnerable-people/guidance-on-social-distancing-for-everyone-in-the-uk-andprotecting-older-people-and-vulnerable-adults
a) Ministry of Housing, Communities and Local Government (MHCLG) and local authorities in conjunction with their Local Resilience Forums (LRFs) have lead responsibility for overseeing support for older and vulnerable people who are going to be ‘shielded’ at home over the coming months. Community health services and voluntary organisations should engage with LRFs on how best to do this.
b) A number of these individuals would be expected to have routine or urgent GP, diagnostic or outpatient appointments over the coming months. Providers should roll out remote consultations using video, telephone, email and text message services for this group as a priority and extend to cover all important routine activity as soon as possible, amongst others. David Probert, chief executive of Moorfields foundation trust, is now leading a taskforce to support acute providers rapidly stand up these capabilities, with NHSX leading on primary care. Face-to-face appointments should only take place when absolutely necessary.
c) For patients in the highest risk groups, the NHS will be identifying and contacting them over the coming week. They are likely to need enhanced support from their general practices, with whom they are by definition already in regular contact. GP services should agree locally which sites should manage essential face-to-face assessments. Further advice on this is being developed jointly with PHE and will be available this week.
d) As part of the overall ‘social distancing’ strategy to protect staff and patients, the public should be asked to greatly limit visitors to patients, and to consider other ways of keeping in touch such as phone calls.
5. Stress-test your operational readiness
a) All providers should check their business continuity plans and review the latest guidance and standard operating procedures (SOP), which can be found at https://www.england.nhs.uk/coronavirus/.
b) Trust Incident Management Teams – which must now be in place in all organisations – should receive and cascade guidance and information, including CAS Alerts. It is critical that we have accurate response to data requests and daily sitrep data to track the spread of the virus and our collective response, so please ensure you have sufficient administrative capacity allocated to support these tasks.
c) For urgent patient safety communications, primary care providers will be contacted through the Central Alerting System (CAS). Please register to receive CAS alerts directly from the MHRA: https://www.cas.mhra.gov.uk/Register.aspx.
d) This week we are undertaking a system-wide stress-testing exercise which you are asked to participate in. It takes the form of a series of short sessions spread over four days from today. Each day will represent a consecutive week in the response to the outbreak, starting at ‘week six’ into the modelled epidemic. We would strongly encourage all Hospital Incident Management Teams with wider system engagement (including with primary care and local government representation) to take part
6. Remove routine burdens
To free you up to devote maximum operational effort to COVID readiness and response, we are now taking the following steps nationally:
a) Cancelling all routine CQC inspections, effective immediately.
b) Working with Government to ensure that the emergency legislation being introduced in Parliament this week provides us with wide staffing and regulatory flexibility as it pertains to the health and social care sector.
c) Reviewing and where appropriate temporarily suspending certain requirements on GP practices and community pharmacists. Income will be protected if other routine contracted work has to be substituted. We will issue guidance on this, which will also cover other parts of the NHS.
d) Deferring publication of the NHS People Plan and the Clinical Review of Standards recommendations to later this year. Deferring publication of the NHS Long Term Plan Implementation Framework to the Autumn, and recommending you do the same for your local plans.
e) Moving to block contract payments ‘on account’ for all NHS trusts and foundation trusts for an initial period of 1 April to 31 July 2020, with suspension of the usual PBR national tariff payment architecture and associated administrative/ transactional processes.
f) Additional funding to cover your extra costs of responding to the coronavirus emergency. Specific financial guidance on how to estimate, report against, and be reimbursed for these costs is being issued this week. The Chancellor of the Exchequer committed in Parliament last week that “Whatever extra resources our NHS needs to cope with coronavirus – it will get.” So financial constraints must not and will not stand in the way of taking immediate and necessary action – whether in terms of staffing, facilities adaptation, equipment, patient discharge packages, staff training, elective care, or any other relevant category.
COVID-19 presents the NHS with arguably the greatest challenge it has faced since its creation. Our health service – through our skilled and dedicated staff – is renowned for the professional, flexible and resilient way that it responds to adversity. Please accept our sincere thanks for your leadership, and that of your staff, in what is going to be a highly challenging period.
This is a time when the entire NHS will benefit from pulling together in a nationally coordinated effort. But this is going to be a fast-moving situation requiring agile 8 responses. If there are things you spot that you think we all should be doing differently, please let us know personally. And within the national framework, do also use your discretion to do the right thing in your particular circumstances. You will have our backing in doing so.
With best wishes,
Sir Simon Stevens, NHS chief executive and Amanda Pritchard, NHS chief operating officer