Talking to my colleagues across the country in mid-November, it was clear that there is a sizeable regional variation in how the second wave of COVID-19 is impacting on NHS services. The variation in demand is placing significant pressure on an already tired workforce, whose resilience is low, and this is proving to be a complex area for our regulators.
Lintern (2020) provided an example of such pressure, sharing an internal message from a medical director in a hospital trust in the north-west of England, which stated:
‘We are effectively running at 100 per cent occupancy in terms of available staffed beds.’
And that:
‘[The Trust] is now essentially overwhelmed by the demand. We cannot maintain patient flow and usual standards of care.’
The message also revealed that the trust had been threatened with enforcement action by the Care Quality Commission (CQC) in a move that the medical director said failed to appreciate ‘the extraordinary pressure that the hospital was facing’.
Lintern (2020) reported that in response to the criticism, Professor Ted Baker, chief inspector of hospitals for the CQC, said:
‘We carried out a focused inspection of [the Trust] in response to serious concerns shared by staff and members of the public, we found evidence of risk, and have instructed the trust to take immediate action.’
The CQC has faced a good deal of criticism over the years around its inspection methodology. Professionally, I have experienced times when the outcome of snapshot visits coupled with what seemed like very little triangulation has felt unfair and not representative of either the service or the context in which the teams are practising.
This month, however, I took part in a new process being rolled out by the CQC: a review meeting on the ‘Patient FIRST’ support tool. This approach has involved the CQC working with a team of senior emergency department clinicians to develop the Patient FIRST support tool (CQC, 2020a). The tool was designed by clinicians, for clinicians, and includes practical solutions that all emergency departments could consider. The implementation of the solutions supports good, efficient and safe patient care, for both adult and paediatric settings. It also includes guidance for senior leaders at trust and system level.
FIRST stands for:
It did take some time for us to work though the tool—my Trust, although busy, is not currently under the pressure of some others—and the ability to have some time to work through our own self-assessment was critical. I found both the application of the framework and discussing our position with Trust and CQC colleagues a very useful exercise.
In its latest publication on ‘The State of Care’ the CQC (2020b) does recognise that many problems that existed before COVID-19 have not gone away, and the fact that the impact of COVID has been felt more severely by those who were already likely to have poorer health outcomes makes it all the more critical for services to be designed around people's needs
The Patient FIRST review meeting was very focused on acute providers, and I did feel that the opportunity was missed to have feedback across the health and social care system (a comment I have made to the CQC). The CQC State of Care report does recognise the positive impact of system working, and the opportunities of using the learning from the pandemic to lock in positive changes and drive a new way of working that is supported at a national, regional and local level by the whole health and care system.
Applying the context of care delivery during a pandemic and its associated pressures to individual services is critical, as is the important triangulation in relation to how a service is performing coming from our patients, so it is very encouraging that the CQC has joined forces with Healthwatch England to launch a joint new campaign ‘Because we all care’ to help shape health and social care (CQC, 2020c). The campaign aims to support and encourage more people in England to give feedback on health or social care services that they or a loved one have experienced, and it will be critical that we work alongside these organisations to promote to patients how to share their experiences for us to learn and shape future care.