Coronavirus (COVID-19) initial health and social care response: lessons identified

1. Executive Summary

The purpose of this report is to provide insight from the Covid-19 response including lessons identified from Health and Social Care organisations within Scotland, supplemented by global case studies where appropriate. The timescale of this report has focussed on the first six months of the formal pandemic response, ranging from March 2020 to September 2020. In limiting the scope of work to this timeframe, this report is not intended as a comprehensive review of the full pandemic response, but rather considers what has worked well and conversely what improvements could be made so that Scottish organisations are better equipped going forward for any future waves of Covid-19 response, on-going recovery and remobilisation plans as well as future incident preparedness. It draws on a review of existing lessons identified documentation ^[1] shared from organisations across Scotland, insights from interviews with a limited number of stakeholders within Scottish Government and NHS Scotland, support by external research and engagement with organisations across the globe. The aim is that the insights from the first six months of the response could be used to inform the ongoing response to the Covid-19 pandemic and spread the actions that have worked successfully while flagging any pitfalls that should be avoided. This work also seeks to inform the future work of Scottish Government and health and care organisations, developing systems to retain aspects of new ways of working that should be continued during remobilisation and recovery phases of work.

Lessons identified have been synthesised from a dual perspective, both in terms of learnings gathered directly by Scottish health and care organisations, and supplemented through an additional global lens to lend wider insights into appropriate planning and response. Throughout this process we have refined the overall themes under which lessons have been categorised. Ultimately ten overarching themes have been identified based on this synthesis of international and Scottish findings, within which some further sub-themes have been added to result in sixteen individual categories. The graphic below summarises the ten key high level themes in this report, with the sixteen individual sub-categories shown on the next page.

Illustration 1: Ten Key Themes

01 Diagnosis and contact tracking

• Expanding access to testing and diagnostic services (e.g. remote chat bots, physical labs) and settling up the processes needed to trace contacts

02 Modelling of COVID-19 need, demand and consequences

• Tools to model scenarios if COVID-19 incidence, need and future demand for treatment, supply (beds, workforce, equipment) and the wider economic and social impacts including health inequalities

03 Rapid establishment of extra physical capacity

• Program/project management to stand up massive new care facilities
• Contracting between the public and private sector to provide capacity
• Scaling up social care during social isolation

04 A supply chain that keeps moving

• How to predict, then mitigate against, critical bottlenecks of equipment in the supply chain (ventilators, personal protection equipment etc.)

05 Digital front door is becoming the normal front door

• Call centres to connect patients with families
• Patient to provider communications that are secure
• Telecare/med channels that enable doctors to care for patients in their own homes etc.

06 Programme and project management

• Need for more management and delivery capacity to help clients stand up their emergency COVID-19 control centres and implement essential initiatives rapidly at scale

07 Workforce augmentation

• Identifying and engaging emergency and volunteer resources, and mobilising those people to the treatment locations where they are needed
• Developing portals to support the fluid movement of staff between providers

08 Governance, compliance and risk management

• Procedures that ensure decisions are made by the right people and communications are clear and consistent
• Tracking compliance with requirements such as respiratory protection or cleanliness protocols

09 Public Engagement and Education

• Interacting with patients and service users to ensure services remain appropriate for their needs
• Ensuring the public engage with the health and social care system in the desired way during the pandemic response.

10 New models of care

• Restarting regular care within confinement restrictions
• Managing care backlogs and redesigning services to deliver
• Assessing plan preparedness and effectiveness for future waves

In producing the initial synthesis of documents included in this report, 161 lessons identified documents and outputs have been shared by 30 organisations across Scotland and reviewed. Through this process, a long list of findings and comments were made, which has been condensed down into a total of 97 lessons identified across the sixteen sub-categories below.

Following the production of these sixteen chapters, a targeted follow-up of three additional areas: the role of Public Health, Social Care, and the general Acute response was proposed. Direct engagement in these areas had been limited during the initial document review phase due to the on-going commitments during the pandemic response. This follow-up sought to gain further detail and insights into these three areas of the Scottish response through additional interviews and reviews of documentation. This follow-up continued to focus predominantly on the first six months of the pandemic response, and took place through April and May 2021. In completing this second phase of the work it is acknowledged that these consultations have benefitted from perspectives shaped and contextualised by hindsight and subsequent events. Some of this context is captured in the chapters in Section 5 of this report. Further detail on the scope and approach taken to these additional chapters is available in the main body of the report.

Findings:

From our review of lessons identified documentation available and conversations with identified stakeholders, there is clear evidence that a considerable amount of time and effort has been spent by organisations across Scotland to reflect on the first wave of the pandemic response, and to identify what worked well and what opportunities for further resilience are available as Covid-19 continues to present a challenge to the health and Social Care sectors. There are clear examples of good practice highlighted across individual NHS Boards and also as part of national programmes that should be reviewed and considered by those bodies reviewing this report. Some examples cited in the main body of this report include:

• The multi-disciplinary effort to stand up the NHS Louisa Jordan during the height of the initial response to the pandemic, drawing on support from across many organisations and teams. Teams highlighted the willingness of individuals at all levels within the health service and wider teams to move beyond existing roles and hierarchies and the attitude to make decisions at pace.
• The work of the Health and Social Care Alliance (ALLIANCE), commissioned by the Scottish Government, assessing the impact of the first wave response on targeted patient groups to ensure inclusivity and maximum engagement. The pace of the initial response has limited the scope for significant public engagement as part of service changes and redesign, and this work will ensure person-centred care remains at the forefront of the on-going response plan.
• The work carried out through the Scotland Connect programme to pilot the distribution of both digital hardware and technical support for clinically vulnerable members of the public, to allow them to access digital healthcare during the height of the pandemic. This pilot provides a solid foundation for reducing access concerns with more rural and excluded populations across the country.
• The rapid information governance approval process put in place via Digital Health and Care to allow collaboration between different health organisations, including private hospitals.
• The collective mobilisation of Public Health teams at national and local levels as part of the pandemic response, providing sector-specific expertise alongside local insights. The key example of this highlighted in this report is the design and delivery of Test and Protect, which drew on cross-functional expertise to show the value of Public Health staff within NHS boards, and local outbreak control teams to manage the on-going pandemic response.
• The redesign of urgent care in response to the challenges faced by mobilisation. The Redesign of Urgent Care (RUC) project undertaken during the pandemic has been highlighted as an example of embedding new ways of working virtually, engaging with multiple teams in a collaborative way, and seeking to deliver the right level of treatment as close to home as possible. On-going evaluation of the programme will provide stronger quantitative evidence for its impact but qualitative feedback to date has been promising.
• The collective mobilisation of local multidisciplinary teams from NHS health boards and local authorities to provide enhanced oversight for local care homes and wider social care services was described by stakeholders as a key development during the pandemic. These arrangements, which build on foundations that were in place in many areas through health and social care integration, made a significant contribution to the development of protective arrangements for ensuring mutual aid and support for social care services who provide care to some the most vulnerable of citizens and the workforces supporting their care needs.
• The development and implementation of safety huddle TURAS care management tool within the care home sector. Stakeholders described the use of the tool as a valuable development during the pandemic for Social Care. The key elements of this were that it enabled a consistent approach to data collection, report staffing decisions and permitted early escalation and warning to allow for timely support and interventions for care homes.

We also found areas where stakeholders had reflected on the experiences from the initial response and identified opportunities for improvement as the pandemic continues. As above there are further examples and context cited in the full report, but the following cross-cutting themes were regularly raised by stakeholders:

• The importance of collaborative working beyond existing organisational boundaries. Stakeholders referenced the breakdown of perceived 'silos' as part of the initial response as a key enabler both within and across organisations, and it will be important to embed these ways of working going forward to maintain the reported benefits. Central to this collaborative working will be an on-going recognition that patient care extends beyond Acute provision in hospitals, and closer working with local authorities, primary and Social Care, as well as Public Health teams will remain crucial as the pandemic response evolves.
• The increased role of digital tools in the provision of health and Social Care. While organisations have been working towards digital care prior to the pandemic, this has seen a considerable acceleration. The strong foundations laid by digital teams have been a clear driver during the pandemic, but on-going support will be required. Organisations will have to ensure there is a sufficient level of workforce with the right skills to embed these changes, supported by infrastructure that facilitates increasing use of data across organisations.
• The central role for use of data by health and Social Care teams. From the start of the pandemic, the demand for significant quantities of real-time data from NHS Boards, Social Care organisations, the public, care homes and Scottish Government itself became clear. As with digital tools above, the considerable scale-up within organisations to manage this requirement now provides the opportunity for teams to use this data in a more meaningful way as part of a national data strategy that covers health and Social Care.
• The agility and pace of decision making through governance due to changing roles and responsibilities. Many staff referenced a feeling of autonomy or being empowered to act during the pandemic. While recognising that there is a middle ground between assurance and scrutiny and the pace of decision making, stakeholders regularly referenced a desire to capture what worked well and to not revert completely to previous ways of working. Two key drivers of this have been the experience of working towards one shared goal, meaning objectives were automatically aligned, and a breaking down of existing hierarchies towards a 'flatter' organisational structure where substantive roles became less important.

In completing the second phase of work to review three elements of the Scottish response in more detail, we found the above themes to remain consistent in our additional work. Additional messages that were identified that should also be considered by organisations as they look to recover, remobilise and plan for any future incidents include:

• The importance of consistent and streamlined communications: Across all three chapters, various stakeholders identified that there was much to be commended in the way in which Scottish Government and national organisations were able to manage and streamline communications. Interviewees also suggested that this could be an area for future review, reflecting on ensuring joint positions between organisations prior to issuing communications wherever possible, and providing sufficient time for organisations to be able to agree and act upon mandates. It should be noted that where timeframes for decision-making were constrained, it was not always appropriate or feasible for detailed consultations or joint consultations to take place.
• The strategic use of national assets: Particularly within the Acute response, interviewees referenced the crucial role played by national assets, including the NHS Louisa Jordan and NHS Golden Jubilee. Through the consultations held, we found evidence of how well these assets were used as part of response and early remobilisation. Some stakeholders also noted that there was a lack of initial clarity of the purpose and role of these assets, and that earlier commitments on the role and impact of these organisations would have allowed for a more efficient response. With the benefit of hindsight, clear strategic direction and mandates on how and when such assets should be used therefore could offer opportunities for increased resilience.
• Workforce retention and support: Across all three chapters, we heard of the crucial role played by frontline team members in the pandemic response and recovery. All stakeholders recognised this and the ability of staff to work in a flexible way has been universally commended. As organisations now look towards remobilisation and recovery, the continued support and wellbeing offer for key groups within the workforce, particularly those highlighted through the early pandemic response in Public Health and care homes, will play a crucial role in ensuring the successful recovery of services after the pandemic.

Case studies provided within the main body of this report provide examples of what other countries have done differently both before and during their pandemic response. The case studies are not intended as examples of best practice, and have been chosen to show how other health and Social Care systems have managed different aspects of the pandemic response in the spirit of the 'lessons identified' purpose of this report. These are intended to provoke discussion and reflection on the Scottish response and not to highlight failings either within Scotland or internationally.

Conclusions and Next Steps:

We thank organisations for their involvement in this exercise, particularly where stakeholders have made themselves available for further consultations following the initial document review undertaken. Key findings have been identified above and those reviewing this report should consider how best to incorporate the relevant findings into existing response, recovery and remobilisation plans as well as future ways of working in general.

This piece of work has been intended as an illustrative, rather than comprehensive, examination of the first six months of pandemic response. It is intended to form the basis for longer term programmes of work considering the response to Covid-19, to draw on a wider range of perspectives and experience. The key to maximising the benefit of the lessons identified process carried out here will, therefore, be ensuring that this process continues to take place in some form when key individuals' capacity to engage is less restricted due to on-going management of the pandemic. It is therefore recommended that the ownership of lessons identified over the coming months is centralised within Scottish Government and that this process informs future work in this area. This will require clear definitions of roles and responsibilities between Scottish Government and wider health and care organisations to ensure there is no duplication of effort or overlap in how these exercises are carried out across organisations. Regular engagement with both staff and the public on their experiences as the pandemic response evolves will continue to highlight new learnings and reflections on what is working well and what could be improved. A central repository of these lessons that is easily accessible by any health and Social Care organisation, as well as a formal, on-going approach to lessons learned will ensure that pockets of good practice and suggestions for further resilience will continue to be identified and shared across the country.

We also note that within this report, there are findings and comments from organisations in the scope of this review that are not representative of all NHS Boards or Social Care organisations in Scotland. All efforts have been made to distinguish where comments have been made by only one organisation or by a wider group. While the findings are expected to be of interest to all those reading this report, it is recognised that some of the areas for improvement will not be relevant to all organisations if they have already been implemented or if local circumstances mean suggestions are not appropriate.