Plans for restarting urgent and elective NHS services, announced in a 13-page circular from NHS England to NHS chief executives and accountable officers on July 31, depend upon the rapid roll-out of a new network of Community Diagnostic Hubs – which, according to the HSJ have not yet secured funding, and for which there are as yet no local plans, or staffing so far in place.

The proposals are part of a complex volley of proposals and instructions fired off by NHS England at the peak of the summer holiday period, with impossibly short deadlines for implementation.

The disconnect between NHS England’s voluminous top-down instructions and requirements on local trusts and commissioners on the one hand, and the availability of the resources to make it possible on the other, has seldom been more stark.

But the creation of Community Diagnostic Hubs is only one of many unanswered questions to arise from NHS England’s letter, the subsequent 46-page guidance document  ‘Implementing phase 3 of the NHS response to the COVID-19 pandemic,’ published on August 7, and the even further delayed  ‘Hospital Discharge Service: Policy and Operating Model’ which did not emerge until August 21.

The July letter, headed “Important – for action – Third Phase of NHS response to Covid-19” gave  trusts just the month of August to draw up and implement delivery plans, to run from September 1 through to March 2021, to “restore full operation of cancer services.”

To achieve this, trusts were tasked with:

“Ensuring that sufficient diagnostic capacity is in place in Covid19-secure environments, including through the use of independent sector facilities, and the development of Community Diagnostic Hubs (CDHs) and Rapid Diagnostic Centres.”

However NHS England’s own “blueprint” plans to establish up to 150 new CDH’s, leaked to the Health Service Journal on September 4, does not indicate whether any capital or revenue has yet been made available to set them up, and implies that funding would need to come from the government’s upcoming spending review: so the extra money does not yet exist.

The new Hubs are supposed run for “12 to 14 hours a day seven days a week,”  and to offer a range of diagnostic services including “CT, MRI, ultrasound, plain X-ray, echocardiography, ECG and rhythm monitoring, spirometry and some lung function tests, phlebotomy and, in some CDHs, endoscopy facilities.”

However reality makes a fleeting appearance in NHS England’s partial acknowledgement that few trusts will be able to find the staff to deliver the service: “workforce constraints may make this unachievable in the short-term”.

In another leap into the world of fantasy, given the continued revelations on the disastrous failures of the privatised testing system for Covid19, according to the HSJ NHS England plan assumes that CDHs “will rely upon rapid testing being available at each site.”

The vague formulations, unanswered questions and leisurely progress towards NHS England’s own decision making and development of policy is completely at odds with their demand on July 31 that local cancer services should have begun using the (as yet imaginary) CDH’s from the beginning of September.

NHS England’s own “blueprint” appears to be looking at a longer-term roll-out aiming to establish “three CDHs per 1 million population by 2023-24”.

Redesign – instantly

The NHSE letter went on to call on health bosses to:

“re-establish (and where necessary redesign) services to deliver through their own local NHS (non-independent sector) capacity the following:

In September at least 80% of their last year’s activity for both overnight electives and for outpatient/daycase procedures, rising to 90% in October (while aiming for 70% in August);

“This means that systems need to very swiftly return to at least 90% of their last year’s levels of MRI/CT and endoscopy procedures, with an ambition to reach 100% by October.”

The many questions over whether such ambitious targets can be achieved so quickly given the constraints of post-Covid restrictions, continued staff shortages (with some key staff having been reassigned to different duties), and the complexity of managing (and staffing) capacity commissioned in private hospitals on separate sites, are neither asked by NHS England nor answered. They just send out the orders.

Another seemingly irrational instruction issued on July 31 was to reach

100% of their last year’s activity for first outpatient attendances and follow-ups (face to face or virtually) from September through the balance of the year (and aiming for 90% in August).”

The wisdom and logic of piling up new elective referrals through the rapid rebuilding of outpatient activity while trusts are still struggling with the backlog of urgent and patients who have already waited far longer than target times for treatment is not explained.

Primary care

While the proposals for acute hospital care are vague, there is even less detail in the sections of the letter discussing primary care. Dentists, who have been especially hard hit during the lockdown and face extremely onerous additional requirements for post-Covid hygiene are simply given an assurance of future support:

“Dental practices should have now mobilised for face to face interventions. We recognise that capacity is constrained, but will support practices to deliver as comprehensive a service as possible.”

GPs are given no promises, but simply instructed to keep on doing more: “GP practices need to make rapid progress in addressing the backlog of childhood immunisations and cervical screening through specific catch-up initiatives and additional capacity …

“GPs, primary care networks and community health services should build on the enhanced support they are providing to care homes, and begin a programme of structured medication reviews.

“… All GP practices must offer face to face appointments at their surgeries as well as continuing to use remote triage and video, online and telephone consultation wherever appropriate …”

A huge question mark also hangs over the future resources and staffing of Community health services. NHS England again offers no real steer on how its proposals can be delivered in practice:

“Community health services crisis responsiveness should be enhanced in line with the goals set out in the Long Term Plan, and should continue to support patients who have recovered from the acute phase of Covid but need ongoing rehabilitation and other community health services.”

Continuing Healthcare assessments

For community health and CCGs there is an additional unfunded nightmare for managers, arising from NHS England’s instruction that hospitals “must” discharge patients prior to their needs being assessed (“discharge to assess”). This has been backed up by temporary funding for support packages of up to 6 weeks only to keep patients out of hospital.

This means there are already a large number of patients who should already have been moved on, although there are no additional resources to support those who need continued support or long term care. The NHSE letter cracks the whip demanding rapid action to catch up:

“The Government has further decided that CCGs must resume NHS Continuing Healthcare assessments from 1 September 2020 and work with local authorities using the trusted assessor model. Any patients discharged from hospital between 19 March 2020 and 31 August 2020, whose discharge support package has been paid for by the NHS, will need to be assessed and moved to core NHS, social care or self-funding arrangements.”

The letter makes no assessment of how many patients fall into this category, and no suggestion of where the extra staff should come from to conduct the additional assessments, where patients needing ongoing care should be cared for, by whom or at whose expense.

The process of accelerated discharge that probably seemed such a bright idea to free up hospital beds is now likely to turn into an ongoing crisis six weeks after discharge, with large numbers of patients still not assessed, or left stranded with no facilities nearby capable of delivering the care they are assessed to require.

The NHSE letter’s evasions and vague assurances continue on mental health and learning disability services, and on preparation for winter alongside the continued Covid pandemic (with a promise that “DHSC will shortly be releasing agreed A&E capital to help offset physical constraints associated with social distancing requirements in Emergency Departments”).

There are sections on workforce (ignoring the embarrassing fact that far from increasing GP numbers by the promised 6,000, the latest figures show numbers of fully qualified GPs fell by 651 in the last year), and even more vague suggestions on health inequalities and prevention.

Pressing forward with “integrated care”

But as might be expected, NHS England is unwilling to let a good crisis go to waste, and from page 9, under “Financial arrangements and system working” the letter goes on to press for more rapid implementation of the drive towards the imposition of “integrated care systems”, mergers of CCGs, and new measures to eliminate even the pretence of public consultation.

All “ICSs and STPs” are required to draw up a “development plan, agreed with their NHSE/I regional director” which will “embed and accelerate this joint working.” This must include:

“Collaborative leadership arrangements, agreed by all partners, that support joint working and quick, effective decision-making. This should include a single STP/ICS leader and a non-executive chair, appointed in line with NHSE/I guidance…” (p9).

However this is not the only plan that senior management must work on at once in order to comply with the NHS England letter. Three further plans also need to be drawn up at a rapid pace, with tight timescales across the peak holiday period making it impossible for there to be any local consultation or genuine involvement in producing them:

“Plans to streamline commissioning through a single ICS/STP approach. This will typically lead to a single CCG across the system.”

“A plan for developing and implementing a full shared care record, allowing the safe flow of patient data between care settings, and the aggregation of data for population health.”

“Finally, we are asking you – working as local systems – to return a draft summary plan by 1 September using the templates issued and covering the key actions set out in this letter, with final plans due by 21 September.”

In addition to these three plans, applications also need to be drawn up in the next two weeks in areas where CCGs have not yet merged into larger bodies with even less local accountability: “Formal written applications to merge CCGs on 1 April 2021 … should be submitted by 30 September 2020.”

Once again only the most token consultation will be possible in the timescale on proposals that in some areas have already been specifically rejected by local GPs or as a result of local opposition.

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