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Opportunities for addressing health inequalities in multiple conditions Improve our understanding of communities experiencing inequity and disadvantage Address distance and distrust between communities and health and care Build the right relationships to tackle the social determinants of health Support people to take greater control of their health Promote good health across local groups

National investigation findings In March 2020, demand on the NHS 111 system increased. Demand exceeded the system’s capacity, and around half of calls were answered at that time. Evidence from families indicated that aspects of NHS 111 telephone triage, such as routing all Covid-19-related calls to the Covid-19 Response Service (CRS), did not function as intended. Strong national messaging advised people with suspected Covid-19 to stay at home. This may have impacted on patients’ willingness to seek medical advice from elsewhere, even if their condition deteriorated. The CRS algorithm did not allow for an assessment of caller’s comorbidities to establish whether a clinical assessment would be beneficial. Callers would only be transferred to a clinician/receive a clinical call back if they were “so ill that…[they’ve] stopped doing all of …[their] usual daily activities.” The healthcare system specified that patients with Covid-19 related symptoms and underlying conditions (including diabetes) who went through to core NHS 111 (instead of CRS) should be escalated to a clinician for assessment. However, some patients did not receive a clinical assessment. The intent was that Covid-19-related calls would be diverted to the CRS, which was operationally independent from NHS 111. Many Covid-19-related calls continued to go through the core NHS 111 service. Once callers had reached the core NHS 111 service, there was no way to route them to the CRS. Calls that went via the core NHS 111 service should have been audio-recorded, as per NHS 111 guidance. The CRS contract manager told the investigation that CRS calls were also required to be recorded, and all but one CRS provider were initially set up with a recording function. However, no recordings of CRS calls were made available to the investigation. NHS 111 call handlers do not usually have access to a patient’s medical history. This increases the importance of appropriate ‘safety netting’ – that is, telling a patient or their carer what they should do if their condition does not improve or they have further concerns about their health. Text messages that told a patient they had a positive polymerase chain reaction (PCR) test result included information about isolating and the legal requirements. It did not include sufficient safety-netting advice regarding symptoms to watch for and when and from where to seek medical advice. While this is not related to NHS 111 services, the investigation considers it important to highlight for the future. Ahead of the Covid-19 pandemic, there was limited understanding of the risks of such a novel virus to the healthcare system The decision to redirect the public to call NHS 111 rather than access healthcare advice in other ways (for example, through their GP) shifted the immediate burden of managing patients with Covid-19 in the community. This increased capacity, in the wider healthcare system, but risked disrupting continuity of care for patients with complex health needs. Learning and developments throughout the pandemic have led to improvements in how callers to NHS 111 are assessed and managed. These included recognising the importance of pulse oximetry (that is, measuring blood oxygen levels) to identify silent hypoxia (when a patient has low oxygen saturation levels without becoming breathless) in patients with Covid-19. Safety recommendations for NHS England HSIB recommends that NHS England ensures any Single Service contract or additional services contracts reflects the minimum requirements of the core NHS 111 service for audio-recording calls. HSIB recommends that NHS England reviews the risks associated with increased use of telephone triage in response to national healthcare emergencies. Consideration should be given to applying any recommendations of this review across telephone triage services within the wider healthcare setting. Safety observations HSIB makes the following safety observations: It may be beneficial to review triage software and safety-netting/worsening advice to ensure the language used by health advisors does not deter seriously unwell people from calling back or seeking medical advice if necessary. It may be beneficial, when dealing with a novel virus, for consideration to be given to the benefits of a face-to-face assessment for callers with comorbidities. It may be beneficial for strategic stakeholders in the healthcare system to understand and articulate adjustments in risk tolerance and thresholds in critical situations. Safety actions During the investigation, HSIB became aware of changes the UK Health Security Agency made to processes in a number of areas. These ‘safety actions’ are noted below. The UK Health Security Agency has taken steps to ensure governance arrangements are in place to assure themselves that contracted services are monitored and delivered as intended. The UK Health Security Agency has taken steps to assure itself of the safe and effective delivery of telephone triage for future healthcare emergencies. These have been tested through the delivery of services for Monkey Pox and Avian Flu. The UK Health Security Agency has taken steps to review contractual arrangements to ensure flexibility and the opportunity to implement the most appropriate contract for future public health issue.

In this paper, ARMA makes the following recommendations: Develop multidisciplinary, networked, personalised approaches to pain as standard. Develop more community-based approaches to pain. Everyone with chronic pain should be offered a holistic assessment of their symptoms in primary care reviewing the impact on their physical and mental health, their activities of daily living and their wellbeing, including the ability to work/study, and explore any underlying causes of or contributors to their pain. A public health approach is needed based on community need to design and target effective public health interventions to support those who have chronic pain to improve their health and their quality of life. Take a strategic, integrated population health approach to commissioning pain services ensuring money transcends organisational boundaries, focussed on the provision of a range of chronic pain support options and intervention allowing for personalisation. There should be early access to treatment for painful conditions to minimise pain becoming chronic, including rapid diagnosis, which is important to people. Integrated physical and mental health support for people with MSK pain conditions should be available and every CCG should include MSK chronic pain in IAPT for Long Term Conditions with staff who have joint expertise in both physical and mental health and understanding of chronic pain. Understand health inequalities, discuss and implement levers for change. Systems and services should allow equity in access, experience of using NHS services and equity of outcomes for all groups. Systems and services should be inclusive and culturally sensitivity. Social prescribing to provide supported self-management at scale. Every person with chronic pain should have access to peer support and be signposted to the patient organisations relevant to them. Healthcare professionals education and training to include understanding and management of pain and emphasise the personalised biopsychosocial approach and communications skills training to support them to have good conversations. Public education – including employers, public attitudes to increase health literacy and understanding of pain.

We knew what would be coming at us several weeks ago. Our daughter is a bit of a doomsday prepper and she had been warning us for a while. We had slowly stocked up on a few essentials, nothing ridiculous. We'd also made sure that we had supplies of our medications, and switched away from Boots to a small local pharmacy who promised to do deliveries. We had corded phones, candles, lanterns and lots of batteries in case of power outages. We had some bottled water. We had stocked up the freezer. We hadn't thought the panic buying would start so quickly, or last so long. Toilet paper was a surprise. We hadn't bought any extra of that, so that was an issue, but our daughter managed to find some for us. We are used to working from home. We have done it off and on for over a decade, so this situation is not new for us. We are tech savvy and able to use digital tools to meet our work needs. However, as freelancers, we have been hit hard by work just being cancelled and having much less to do than normal. Less money coming in too, soon. The hardest thing of all has been that while we want to heed the Government's call to stay at home as reasonably high-risk individuals, we cannot book any food deliveries. Tesco, Ocado and Morrisons have no slots available at all. Thankfully we had two already booked with Tesco before the end of this month. After that, the food will start to run out here. With rationing etc already in place, our family who do visit the shops cannot buy extra for us. At some point, regardless of the risk, we may have to leave the house. Wish us luck!!

Recommendations The government should: fully fund a national two-year rehabilitation strategy that ensures people with significantly deteriorated long-term conditions get the therapeutic support they need appoint a national clinical lead to implement this rehabilitation strategy ensure local partners–such as local authorities and Integrated Care Systems (ICS)–develop and deliver their own localised rehabilitation strategy, and that each ICS has a regional rehabilitation lead.

The report highlights how the pandemic has affected people with muscle-wasting conditions, looking at the physical and psychological impact of shielding and disrupted access to healthcare services. Based on the findings of its report, Muscular Dystrophy UK is calling for both short and long-term recovery priorities: Increased investment in the national neuromuscular teams with more neuromuscular consultant, physiotherapy, nurse specialist and psychology time Appointing a full-time network manager with administration support for the Scottish Muscle Network Reduce waiting lists, address the growing backlog of new and follow-up appointments by implementing virtual outreach clinics in local areas Consider flexibilities into the yearly growth of block contracts to reflect the growing neuromuscular population and increase in complex care needs

The update highlights that: there is no automatic recall for a 3-month booster built into the national digital system for patients who are severely immunosuppressed and would be receiving a fourth dose. at present, patients are unable to book a fourth dose via the national online booking systems, because the patient's data shows that a total of three doses have already been administered. The system classifies these patients as having 'received a booster'. severely immunosuppressed people will not be able to book their booster (fourth dose) three months after their last primary course dose using the NHS online booking system. these patients can present at 91 days post-third dose to GPs, pharmacies and services offering unbooked appointments (‘walk-in’ or ‘drop-in’ centres). Some evidence of need for the booster as a result of their high-risk status will be required. It suggests that secondary care doctors will need to: communicate with their own high-risk specialty patient groups to ensure boosters are being taken up. ensure severely immunosuppressed patients have some ‘evidence of need’ for the fourth dose (previous letters issued on the need for third primary dose could be used).