Decision details

The Chair welcomed Dr Amanda Doyle, GP and Integrated Care Strategy lead for Lancashire and South Cumbria and Kevin McGee, Chief Executive for East Lancashire Hospitals Trust and Blackpool Teaching Hospitals NHS Foundation Trust. A report was presented regarding the local NHS response to the Covid 19 pandemic.

The following points were highlighted:

·  There had been a national and local change of governance arrangements, following the declaration of a level four healthcare incident by NHS England. This resulted in NHS England taking control of all healthcare resource. A local governance structure was put in place to oversee local implementation.

·  Phase one was the initial emergency response, involving planning for and managing the impact and subsequent increased demand. The actions at this stage included stepping down non-essential work. The governance arrangements were divided into two cells - hospital and out of hospital, both of which included a range of leaders who worked closely with the Local Resilience Forum (LRF) to effectively manage decision making. Some programme work regarding system development, transformation and commissioning reform had been adjourned in order to focus on the incident.

·  The hospital cell co-ordinated the work of the main hospital sites across Lancashire to support the initial surge of Covid patients, concentrating on increasing capacity for critical care and beds. The considerable numbers that had been initially forecasted for critical care were not realised. The additional requirements for personal protective equipment (PPE) had been met through mutual support across the cells and working collectively as a system.

·  The initial phase required moving staff to support the most urgent areas and this necessitated some temporary service changes to ensure service quality and the deployment of staff to the most urgent areas such as respiratory care and A&E. This included the temporary closure of Chorley A&E, the birth unit at Blackburn and the minor injuries unit at Blackpool. These clinical decisions had to be made quickly and the decisions were communicated widely with stakeholders and the public, emphasising that they were temporary measures required to respond to the crisis. Any permanent change would follow the statutory guidance and fulfil the required engagement process. Other changes included significant visiting restrictions, following national guidance to support infection control. The cell continued to work closely with LRF and other bodies to ensure changes to public services were publicised. This way of working enabled new best practice to be established in terms of sharing data between organisations in a controlled way, which facilitated improved communication and action.

·  The work was now moving toward restoration of services and taking learning points from good practice joint working to develop future practice. There had been a significant reduction in Covid 19 patients across Lancashire, however the hospitals were prepared in terms of capacity for any future surges in cases. Planning for winter was in progress alongside focusing on cancer and diagnostic activity. It was noted that restoration work would be implemented in a planned and considered way to take into account the need for staff to rest and recuperate prior to winter to support their ongoing resilience.

·  A campaign was underway to emphasise the message that hospitals were safe to increase referral levels and to ensure the public could be confident coming into hospitals.

·  The out of hospital cell had concentrated on the redeployment of staff into areas of priority; PPE provision, testing staff and patients and antibody testing for staff. The cell had also worked closely with the care sector in terms of resilience, training, infection control and escalation plans to increase care home capacity to support hospital discharge for Covid patients who often had long term reablement needs. Work was ongoing with social care providers to expedite the discharge process for those waiting for packages of care, which had significantly reduced hospital occupancy. In addition those shielding had been offered food and routine healthcare at home. The mental health cell had provided a rapid crisis response to eliminate A&E presentation by establishing 24/7 urgent treatment centres. The mental health impact of the pandemic on the wider community and staff had been recognised and invested in, including the psychological effects of coping with trauma. An on-line mental health resilience hub had been developed and had been widely accessed.

·  Phase two planning allowed continued response to the crisis and preparation for subsequent surges; alongside increasing referrals, urgent diagnostics, encouraging those with serious conditions to return to typical healthcare settings for treatment and routine elective work. A significant amount of capital expenditure had been required to support the response and ongoing plan. Extra capacity was required for infection control processes, rehabilitation, critical care, screening, diagnostics and reducing the back log. This ongoing requirement for additional workforce was at a time of increased sickness absence and when staff were exhausted. The service reintroduction plan recognised the need to look at health system capacity and a model of healthcare that moved pathways away from critical settings to support infection control. This included a rapid increase in the use of technology, such as video consultations to allow access to services for disease management. All five trusts in the Lancashire and South Cumbria Integrated Care System (ICS) now offered virtual outpatient appointments ('attend anywhere'). In addition remote monitoring at home and in care homes had been implemented, such as the use of oxygen monitoring equipment. The benefits of this would be ongoing, including reducing travel times and providing quicker responses and reviews.

·  Vital next steps included monitoring and evaluation of processes and plans as well as ongoing communication with the public. A second wave of infections were anticipated later this year and preparation was required to protect and risk assess those groups who were more vulnerable to having a severe reaction to Covid. These included Black Asian Minority Ethnic (BAME) communities, the elderly and deprived households with pre-existing poor health. This would include promoting how they help themselves, for example controlling diabetes and managing weight. In addition focus would continue on working with the LRF, particularly supporting resilience throughout winter in the care sector and maintaining the beneficial services, processes and new ways of working that were implemented to manage the pandemic.

In response to questions from members, the following information was clarified:

·  The Lancashire and South Cumbria ICS had managed the mortality rates and spread of infection well, the latter meaning that a large proportion of the population had not come into contact with Covid. No area was immune to local spikes of infection, particularly considering the impact of lock down fatigue, causing people to dissent. The greatest concern lay in areas that attracted high numbers of visitors, such as Lytham and Blackpool. This would be planned for by protecting the vulnerable by enforcing and emphasising the importance of social distancing rules. Systems were also in place to respond to any infection surges, including critical care capacity, at short notice.

·  Early hospital discharge of untested patients to social care settings had been a national issue in the early stages of the pandemic due to limited testing capacity, however Lancashire had managed well in this respect. Levels of testing was no longer an issue and all discharges were expedited with the appropriate level of testing.

·  In terms of sharing data, a single cell co-ordinated data and information to inform cohesive local planning. Comprehensive data sharing agreements were in place to support the pooling and analysis of statistics. The challenge was from extrapolating test data from the two separate testing routes. Access to pillar one NHS test results had been rapid and easy to direct. However pillar two national mass testing, commissioned by the Ministry of Housing, Communities and Local Government's (from for example, drive through sites) hadn’t been accessible locally until very recently. Having access to national test data would significantly aid planning.

·  The private sector had been utilised for NHS patients to increase overall capacity to allow 'green' sites that were Covid free. This would continue to 31 March 2021 to address the backlog of necessary elective work. Beyond that, work was planned to make sections of NHS hospitals 'green' to segregate Covid cases to restore general activity.

·  Members asked if the resources were available for building resilience in preparation for a second spike of the pandemic, specifically targeting identified vulnerable groups.

It was emphasised that prevention in its entirety and improving overall health outcomes, was a long term process. However in terms of the current situation, secondary prevention was targeted at those who were high risk or had a condition, concentrating on reducing complications and managing the risk.  For example working closely with those with diabetes, heart disease, chronic obstructive pulmonary disease (COPD) or asthma to control their condition and to ensure their treatment, prevention measures and medication were correct. The resources were available but the challenge was making sure high risk groups accessed routine chronic disease management and healthcare to ensure their condition was optimised in preparation for winter. The majority of this work could be done remotely.

·  The mortality rate was significantly increased for those with both types 1 and 2 diabetics compared to non-diabetics, however the risk was greater for type 1 diabetics.

·  Members asked for more information regarding methods of communication and engagement with disproportionately affected communities.

It was explained that this would be carried out jointly with the LRF, via the 'warning and informing' cell, who were addressing how best to target groups at greatest risk. Work had been undertaken across the Pennine Lancashire Integrated Care Partnership (ICP) with BAME groups, via a range of media (schools and places of worship) to help people understand their increased risk due to community factors and how to address this. Temporary accommodation had been sourced for the homeless and health issues had been targeted. In addition hospitals had used a range of different ways to communicate to their local communities, such as using websites, social media and local media to target groups and listen to ideas of how to improve.

It was requested that the specific methods of communication be disseminated outside of the meeting via the clerk. A member of a targeted high risk group highlighted that they had not received any information as had been described. It was suggested that methods of communication could be widened to include chief executives of district and county councils to brief their elected members.

It was noted that the NHS did report actions taken to the LRF, which did include council representation.

·  Members highlighted the complex needs of those living with dementia, in terms of physical and mental health and how isolation could impact on this. It was clarified that dementia wasn't initially included as a clinical medical condition that required shielding. However locally, GPs had included them as they recognised the importance for those with complex physical conditions to understand how they could access support and remember how to protect against infection. In addition the withdrawal of contact (necessary due to infection control measures put into place at care homes and day centres) could cause the condition to deteriorate. In response to this support had been provided to those who were isolated in the community by working with carers' support organisations and by offering routine healthcare services at home. It was acknowledged that it was a complex challenge that would need to be addressed for some time.

It was confirmed that the out of hospital cell were planning a consistent offer with sufficient capacity for vulnerable groups in light of the way access to support had changed. This would include social support, access to medication, issuing of flu jabs and monitoring of health conditions. However it was a challenge and all circumstances couldn't be fully mitigated.

Members commented that the strategy to protect vulnerable groups including dementia sufferers and their carers to prepare for another surge in cases needed to be communicated very clearly, as residents of Lancashire had expressed concerns and were unaware of how they would be protected and supported going forward.

·  It was confirmed that borough district councils were also part of the LRF and so were aware of all the actions and responses to the pandemic.

Resolved: That the report as presented be noted.