PAC condemns “slow, inconsistent and at times negligent approach” to social care sector in Covid-19 pandemic

In a report published today, Wednesday 29 July 2020, the Public Accounts Committee says the Government’s “slow, inconsistent, and at times negligent approach” to social care in the Covid-19 pandemic has exposed the “tragic impact” of “years of inattention, funding cuts and delayed reforms”, leaving the sector as a “poor relation” that has suffered badly in the pandemic.

This was illustrated early on by the “appalling error” committed when 25,000 patients were discharged from hospitals into care homes without ensuring all were first tested for COVID-19 - even after there was clear evidence of asymptomatic transmission of the virus.

Thanks to the commitment of thousands of staff and volunteers and by postponing a large amount of planned work, the NHS was - just - able to weather the “severe and immense” challenges to health and social care services in England and meet overall demand for COVID-19 treatment during the pandemic’s April peak – “unfortunately, it has been a very different story for adult social care”.

The Committee is particularly concerned about staff in health and social care “who have endured the strain and trauma of responding to COVID-19 for many months” and who are now expected to “cope with future peaks and also deal with the enormous backlogs that have built up”.

Failure to protect staff by providing adequate PPE has hit staff morale and confidence, while a lack of timely testing led to increased stress and absence. These same staff will be called upon in the event of a second peak and the NHS will need extra staff to deal with the backlog of treatment.

As well as its calls for a “second wave ready” plan, for health and the economy, the Committee expects an account to be provided in September of the spending under “policies designed to create additional capacity quickly” which - while necessary, especially in the haste the Government was acting in - have resulted in “a lack of transparency about costs and value for money”.

Meg Hillier MP, Chair of the Committee, said: “The failure to provide adequate PPE or testing to the millions of staff and volunteers who risked their lives to help us through the first peak of the crisis is a sad, low moment in our national response. Our care homes were effectively thrown to the wolves, and the virus has ravaged some of them.

“Vulnerable people surviving the first wave have been isolated for months, in the absence of a functional tracing and containment system. Yet there were bold and ambitious claims made by ministers about the roll out of test, track and trace that don’t match the reality.

“The deaths of people in care homes devastated many, many families. They and we don’t have time for promises and slogans, or exercises in blame. We weren’t prepared for the first wave. Putting all else aside, Government must use the narrow window we have now to plan for a second wave. Lives depend upon getting our response right.”

PAC report conclusions and recommendations

9.Unclear responsibilities and accountabilities at the outset and a failure to issue consistent and coherent guidance throughout the pandemic have resulted in confusion and poor central control over critical elements of the pandemic response. The health and social care sector had to react quickly, including making necessary changes to the way services are organised and provided, to respond to the COVID-19 crisis. While it was clear that the NHS had responsibility for ensuring there were enough beds, oxygen and ventilators to provide treatment for COVID-patients when required, it was unclear who was leading on the social care response. The Department is responsible for overall policy across health and social care but leads a fragmented system of adult social care, where responsibilities are spread between the Department, local government and care providers. Several bodies, including the Department, Public Health England and NHS England and NHS Improvement (NHSE&I) are involved in COVID-19 testing and reporting, and the provision of Personal Protective Equipment (PPE) for NHS and social care staff. Yet there have been frequent reports of the lack of timely testing for both staff and the public and the inadequate provision of PPE for social care workers and residents, with numerous updates to PPE guidance leading to confusion and stress. We note that Lord Deighton, since mid-April, has taken the lead on PPE supply. This direct accountability is a welcome step and we note there have been fewer issues with supply since then.

Recommendation: The Department should write to us by September 2020 setting out the named individuals who are the Senior Responsible Owners or relevant national leads for all critical elements of the pandemic response, including, for adult social care, an equivalent to the Chief Executive of NHS England; PPE provision and supply; and testing. The Department should ensure these leads work with all relevant local and national bodies and have both the authority and data they need to do their jobs.

10.Discharging patients from hospital into social care without first testing them for COVID-19 was an appalling error. Shockingly, Government policy up to and including 15 April was to not test all patients discharged from hospital for COVID-19. In the period up to the 15th April, up to a maximum of five symptomatic residents would be tested in a care home in order to confirm an outbreak. Belatedly, after discharging 25,000 people from hospitals to care homes between 17 March and 15 April, the Department confirmed a new policy of testing everyone prior to admission to care homes. Public Health England confirmed that it was already becoming clear in late March, and certainly from the beginning of April, that the COVID-19 infection had an asymptomatic phase, when people could be infectious without being aware they were sick. The Department does not know how many of the 25,000 discharged patients had COVID-19. The number of reported first-time outbreaks in individual care homes peaked at 1,009 in early April. Between 9 March and 17 May, around 5,900 care homes, equivalent to 38% of care homes across England, reported at least one outbreak. The Department says that it took rational decisions based on the information it had at the time, but acknowledges that it would not necessarily do the same thing again.

Recommendation: The Department and NHSE&I should review which care homes received discharged patients and how many subsequently had outbreaks, and report back to us in writing by September 2020. The Department along with NHSE&I should develop procedures so that all patients deemed fit to leave hospital are safely discharged into settings in a way which limits the spread of COVID-19.

11.This pandemic has shown the tragic impact of delaying much needed social care reform, and instead treating the sector as the NHS’s poor relation. This Committee has highlighted the need for change in the social care sector for many years, particularly around the interface between health and social care. Despite the intentions of successive Governments, there have been ongoing delays to reforming and integrating the two sectors. The stark contrast between the approach taken towards protecting the NHS compared with the care sector has been highlighted by many since the start of the pandemic. Various pieces of guidance were issued to the social care sector, but it took the Department until 15 April to publish their action plan for adult social care, over 4 weeks after the initial NHS letter on plans to respond to the COVID-19 outbreak. The Department has much better and more timely information in the NHS than for social care. It is simply unacceptable to hear reports of inadequate PPE, lack of testing and insufficient guidance on training. There have been warnings of an increased risk of provider failure in the care sector, and the Local Government Association and NHS Providers have reiterated the need for urgent reforms to put social care on a sustainable footing after years of under-funding.

Recommendation: After years of promises and false starts, we expect the Department to set out in writing to us by October 2020 what it will be doing, organisationally, legislatively and financially, and by when, to make sure the needs of social care are given as much weight as those of the NHS in future. We will be challenging them on this at future sessions.

12.Public confidence is likely to be further undermined without an open and honest debate about current capacity and tangible plans to address gaps, for example, in testing and PPE. Government has had to and will continue to have to make quick decisions with sometimes imperfect information as the pandemic develops. Yet too often the basis for decisions or changes, such as on PPE, has been unclear; sometimes seemingly based upon what the system could cope with, rather than clinical advice and ‘what was right’, and at other times without regard to the reality on the ground. On PPE, guidance was changed 40 times without consulting service providers, leading to confusion on the ground. There has been a lack of transparency around the availability and supply of PPE, and a tendency for Government to over-promise and under deliver. After squandering the opportunity to build up supplies in January and February, it remains to be seen whether the Department can meet its intention to have a 90-day PPE stockpile. Testing for COVID-19 is vital for controlling the virus and informing and assuring the public. It will be essential as ‘track and trace’ is rolled out, yet testing capacity was insufficient for much of the pandemic and, as highlighted by the UK Statistics Authority, public reporting has been inconsistent and lacking transparency.

Recommendation: Among other measures, the Department should assess the capacity it needs, particularly for PPE and testing, and how it will meet this, to cope with a second peak; and report transparently and consistently on progress. It should write to the Committee by September 2020 with further details of its assessment and plans.

13.Staff in health and social care cannot be expected to be ready to cope with future peaks and also deal with the enormous backlogs that have built up unless they are managed well. We are deeply concerned about the frontline workers and volunteers who have endured the strain and trauma of responding to COVID-19 for many months. Failure to protect staff by providing adequate PPE has impacted staff morale and confidence, while a lack of timely testing, until after the pandemic had passed its first peak, led to increased stress and absence. These same staff will be called upon in the event of a second peak and the NHS will need extra staff to deal with the backlog of treatment. While the NHS says it is providing much needed support to staff, details are limited, and we remain concerned about the Department’s ability and capacity to safeguard the mental health and well-being of the thousands of health and social care staff and volunteers from the lasting effects of the pandemic.

Recommendation: The Department and NHSE&I should identify and agree with relevant professional bodies specific actions to support health and social care staff to recover from the impact of the first peak and how they will monitor and provide further support to staff through to the end of the pandemic.

14.Policies designed to create additional capacity quickly, while necessary, have resulted in a lack of transparency about costs and value for money. The NHS boosted its potential maximum capacity for the peak in April by building Nightingale hospitals across the country and signing contracts with independent providers for 8,000 additional beds, which was announced on 21st March. The contract ended on the 28th June. The Department expects to continue these arrangements in anticipation of future peaks. However, we are concerned by the scarcity of information on contracts and costs. When asked, NHSE&I was unable, or unwilling, to provide any estimate of the cost of private sector capacity or the Nightingale hospitals. We are fortunate that the Nightingale hospitals have not been required so far during the pandemic, but it will not be a good use of public money if we continue to let them remain empty while elsewhere the NHS requires additional capacity for normal services.

Recommendation: After failing to provide detail in the session, it is imperative that the Department and NHSE&I write to the Committee as soon as possible – and no later than 1st September 2020 – with information on the cost of private hospital contracts, how these have been used, and their intentions for how private and Nightingale hospitals will be made best use of in the coming months, including:

·details of what the second phase of contracts will provide;

·the total cost and pricing mechanisms; and

·how capacity in these hospitals will be allocated?

They should come to subsequent sessions prepared to disclose cost information on key elements of the pandemic response