"Central-command system failed to reach around 800k clinically extremely vulnerable people before hundreds of thousands added to local lists," says PAC report

Echoing the government failure to make an economic plan for a pandemic, which PAC reported on last Spring, there was no pre-existing plan for shielding the clinically vulnerable. The Committee says government “took too long to identify some clinically vulnerable people at a time when their need was urgent”. Up to 800,000 people may have “slipped through the net and missed out on much-needed support” - MHCLG still does not know.

Subsequent engagement with local health bodies across the country “introduced a postcode lottery” with huge local variations in those added to the list of people eligible for government support. Those lists grew by 15% up to 352% in different local authority areas, and more than doubled in 33 authorities.

The Committee says “clearly government has learned lessons which have fed into more recent iterations of shielding”, including much greater understanding of the range of covid19 risk factors, where DHSC’s initial, purely clinical approach to vulnerability omitted key characteristics such as ethnicity, postcode and Body Mass Index. The Committee says MHCLG must ensure that local authorities “continue to have the capacity and resilience to support the needs of clinically extremely vulnerable people” given the huge increase in people advised to shield in February 2021 from 2.2 million to 3.9 million people.

Meg Hillier MP, Chair of the Public Accounts Committee “The shielding response in the Covid pandemic has particularly exposed the high human cost of the lack of planning for shielding in pandemic planning scenarios. It also highlights the perennial issue of poor data and joined up policy systems.

“People were instructed to isolate, to protect themselves and others - but the cost of this protection was reduced access to living essentials like food, and an untold toll on the mental health and well-being of the already most vulnerable. There are questions still to be answered about the balance between central decision making and local knowledge – the increase in numbers of those advised to shield demonstrate the challenges of trying to deliver this programme centrally, as well as with the data held by the NHS.

“Plans were eventually, sensibly devolved to local authorities. There needs to be a clear plan ahead for those with serious health conditions so they can access the support they need when they have no other support network.”

PAC report conclusions and recommendations

1. DHSC’s initial clinical criteria for identifying and supporting clinically extremely vulnerable people excluded several factors which it became clear also made people more vulnerable. In March 2020, DHSC developed a list of people who needed to shield based solely on medical conditions that it considered would make a person more likely to become seriously ill or die from COVID-19. The Department recognises that advising people to isolate had risks as well as benefits. Charities have told us how the over 70s and the blind and partially sighted, who were not advised to shield, and therefore not eligible for support through the Programme, struggled to access food. According to the Office for National Statistics survey of clinically extremely vulnerable people, 36% reported worsening mental health and well-being since being advised to shield and MHCLG reports an increasing focus by local authorities on individuals’ mental health. As its understanding of the disease and its impact has grown, DHSC has developed a new risk assessment tool, QCovid, to identify vulnerable people based on wider factors which make them at more risk from COVID-19. These risk factors include ethnicity, BMI, postcode and age. DHSC used this tool to identify an additional 1.7 million clinically extremely vulnerable people in February 2021.

Recommendation: In the event of future epidemics, DHSC should ensure that the way it identifies vulnerable people and the support it offers them, encompasses a broad range of non-clinical factors and personal circumstances that go beyond susceptibility to disease and makes an assessment about what practical support may be needed and how this can be planned for.

2. DHSC and NHS Digital took too long to identify all clinically extremely vulnerable people. Individuals were not formally eligible for the central support of food boxes and medicines delivery offered through the shielding programme until they were on the Shielded Patients List. NHS Digital used national hospital and GP data to identify clinically vulnerable people. However, it took over six weeks for the number of people on the Shielded Patients List to stabilise at 2.2 million people, with 900,000 people added between 18 April and 7 May. The time taken to add people was because of the need to work with GP IT system providers to design, build and gather GP data, which were on different systems to the readily available national data, and then to complete the next necessary step of GPs and hospitals using their clinical judgement to add and remove people from the list. NHS Digital believes that faster access to data in GP records would help. It also suggests that government invest in the digitisation of hospital records, noting that primary care data has been digitised, and is now a richer source of information than hospital data.

Recommendation: Within six months, DHSC and NHS Digital should set out a detailed plan on how they will improve access to and join-up NHS data systems to ensure quick and secure access to all patient records.

3. Huge local variation strongly suggests that GPs were inconsistent when judging who was clinically extremely vulnerable and should therefore be advised to shield and be eligible for support. As well as NHS Digital using national data to identify clinically vulnerable people, GPs and hospital doctors were quite sensibly asked to review those listed, and, using their clinical judgement, add or remove people. The list grew from 1.3 million to 2.2 million largely as a result of GPs adding people. However, the extent to which it grew varied hugely in different areas, with increases in those being added between 12 April and 15 May ranging from 15% to 352% by local authority. DHSC acknowledges that clinicians took different approaches to adding people. DHSC and NHS Digital believe they did everything possible to ensure consistency, where they identified possible over-inclusion or over-exclusion, they have worked with NHS England’s clinical directors to challenge some of the differences. DHSC tells us that NHSE&I and NHS Digital consider that ultimately additions were a decision for local clinicians. DHSC has also provided us with details of NHS Digital’s analysis of the variation as of 11 February 2021. Based on this analysis, DHSC concludes that the level of variation in how local clinicians added people to the list is acceptable. However, and despite the best intentions of all involved, it is not credible to assert that the same criteria and judgements were applied consistently in all parts of the country when the extent of local variation in numbers added was so vast.

Recommendation: Within six months, DHSC and NHS Digital should provide to the Committee a detailed explanation for the local variation in growth for the shielded patient list between April and May 2020 including the extent it was due to appropriate clinical judgements and identify lessons for how to support a consistent clinical approach in future.

4. Government chose a centrally-directed system to support clinically vulnerable people as it did not have confidence all local authorities and supermarkets could meet people’s needs, particularly for food. MHCLG spoke with some local authorities and supermarkets early on to assess their capacity, but could not do a full assessment of local authority capacity to support the most vulnerable because of the urgency of the task. Instead, it used the information it had available to have a centrally-directed supply of food boxes which cost £200 million, as this was likely to guarantee a supply of food to every part of England, particularly given its concerns about shortages in supermarkets. However, some local authorities had queried why government chose a centrally-directed rather than a local system of support, particularly for food, and felt that they would have provided better quality support. Starting in April, as confidence grew in the supply chain and as it developed its understanding of local authority capacity, MHCLG moved to a locally-led model which was in place by summer 2020. This model focused on access to supermarket deliveries and having local authorities offer food to suit the needs of the local population where needed. MHCLG calculates that it has provided local authorities some £4.6 billion in un-ring-fenced funding in 2020-21 to help with COVID costs.

Recommendation: MHCLG should ensure that local authorities will continue to have the capacity and resilience to support the needs of clinically extremely vulnerable people, particularly given the significant increase of people advised to shield in February 2021 - from 2.2 million to 3.9 million people.

5. MHCLG and DHSC do not know whether 800,000 clinically extremely vulnerable people slipped through the net and missed out on much needed support. DHSC explains that it took a ‘multi-channel’ approach to engaging with those affected. Through this approach, it focused first on sending letters, then an email, then calls from the contact centre, which was established at a cost of £18.4 million. 1.8 million people did not register their needs or respond when contacted by letter, so their details were passed to the contact centre for follow-up. However, the contact centre was unable to get in touch with around 800,000 vulnerable people, despite apparently making hundreds of thousands of calls every day. It took central government one month to pass the details of these people to local authorities, so local authorities could check if they needed help. Crucially, MHCLG has no knowledge of whether local authorities then managed to reach any or all of these people.

Recommendation: MHCLG should urgently update the Committee on whether it has now successfully confirmed the support needs of all vulnerable people, including the additional 1.7 million people advised to shield in February 2021.

11. Missing or inaccurate telephone numbers in NHS patient records undermined government’s efforts to contact 375,000 people. The contact centre relied on telephone numbers in NHS patient records when calling people to check their needs. Over 20% of the 1.8 million telephone numbers passed to the contact centre from NHS records, for roughly 375,000 people, were missing or found to be incorrect, with the consequence that when the contact centre needed to rely on phone numbers too many were not right and so people could not be contacted to check they were well and getting what they needed. DHSC argues that NHS records are only as good as the information patients provide and explains that its preference is to contact people by letter first, as addresses are the highest-quality contact records. DHSC notes that it also relies on GPs to make sure that the necessary contact is made with clinically extremely vulnerable people. DHSC is trying to improve contact information by asking those affected to ensure their GP records are up to date.

Recommendation: DHSC and NHS Digital should ensure that different NHS bodies can securely source the most up to date, reliable and complete patient records, including contact details. It should update the Committee on its plan to achieve this progress within six months.