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Covid-19: Poor links between NHS and social care weakened England’s response, says NAO

BMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n1279 (Published 19 May 2021) Cite this as: BMJ 2021;373:n1279

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  1. Elisabeth Mahase
  1. The BMJ

Pre-pandemic issues such as severe budget cuts to local government and poor integration between the NHS and social care weakened England’s ability to respond to covid-19, the public spending watchdog has said.1

The National Audit Office (NAO) assessed the government’s response to the pandemic and also found many issues with transparency around personal protective equipment (PPE) contracts, provision of PPE for the social care sector when compared with the health sector, and inconsistencies between what providers and frontline staff were reporting in terms of having protective equipment.

Responding to the findings, the NHS Confederation’s chief executive, Danny Mortimer, said, “This report re-emphasises the long term issues that severely weakened the foundations of health and care, which meant the country was not better prepared to deal with the pandemic and its fallout . . .

“Importantly, this report also highlights the ever more pressing need to make sure reform of the social care sector is swift and far reaching. The two are sister services, and when one is hit hard, so is the other. Our members stand with their colleagues in social care in their dismay that the experiences highlighted so starkly in this report did not result in the promised action by the prime minister and the chancellor.”

Social care

Despite repeated efforts to integrate adult social care and the NHS—in the form of 12 white papers, green papers, and consultations, as well as five independent reviews in the past 20 years—relations between the two are still challenging, and this poor integration has hindered the pandemic response, the NAO reported.

For example, early in the pandemic there was a far greater emphasis on health than on social care, which led to NHS trusts receiving about 80% of their estimated PPE requirement while social care providers received just 10% of theirs (as of 31 July 2020).

However, some improvements have been made in response to covid-19. The Department of Health and Social Care has increased the data it obtains on care providers, and it plans to legislate for new powers to collect more. It has also re-established a director general post with sole responsibility for social care.

Local government

Local government is another key area where unresolved pre-pandemic issues affected the covid-19 response. Local authority budgets fell by 28.7% in real terms from 2010 to 2020, and public health grants to local authorities decreased by £0.5bn (€0.58bn; $0.71bn) in real terms from 2015 to 2019. These cuts forced authorities to reduce or end services, many of which were related to or affected health, and the pandemic has worsened the situation.

The report said, “Local authorities’ finances have been scarred by the pandemic and will not bounce back quickly once the pandemic ends. As of early December 2020, three quarters of local authorities have a reported funding gap in 2020-21 between their forecast pressures and estimated government support, and 94% of chief finance officers from single tier and county councils we surveyed expected to make cuts in service budgets in 2021-22.”

The NAO has called on the government to place the NHS and local government on a “sustainable footing, to improve their ability to respond to future emergencies.”

PPE

As of January 2021 the Department of Health and Social Care had spent £10.2bn on PPE, and this is expected to rise to around £15.2bn. However, the government’s Counter Fraud Function has identified a “high risk of fraud in the procurement of PPE.” The size of this potential fraud has not yet been estimated.

The NAO said that other schemes, such as the ventilator programmes, had sufficient records of rationale, key spending decisions, and the information that departments held to base decisions on, but this was not the case with PPE procurement. “There was not always a clear audit trail to support key decisions, such as why some suppliers which had low due diligence ratings were awarded contracts,” the report advised.

Additionally, many of the contracts awarded during the pandemic were not published on time. Three quarters (75%) of contracts worth over £25 000 (1644), awarded across government up to the end of July 2020, were not published on the Contracts Finder website within the 90 day target. More than half (55%) had still not been published by 10 November 2020.

Looking at the rollout of PPE, the report said that although NHS provider organisations told the NAO that they were always able to get the required equipment in time, this was not the experience reported by some frontline workers, particularly minority ethnic staff. Public Health England’s stakeholder engagement reported deep concerns on this issue, including that “safeguards were not applied equally across ethnic groups.”

PPE guidance was also changed very frequently, with 30 different versions up to 31 July 2020. While updates were needed to reflect new information, the high frequency made it confusing for those who had to enforce and follow the guidance, the report said.

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