Reducing burden and releasing capacity at NHS providers and commissioners to manage the COVID-19 pandemic


Publications approval reference: 001559 / C0113

Chief executives of all NHS trusts and foundation trusts
CCG Accountable Officers

Copy to:

Chairs of NHS trusts, foundation trusts and CCG governing bodies
Chairs of ICSs and STPs
NHS Regional Directors

28 March 2020

Reducing burden and releasing capacity at NHS providers and commissioners to manage the COVID-19 pandemic

We wrote to you on 17 March 2020 setting out important and urgent next steps on the NHS response to COVID-19. Following this letter and detailed guidance to GPs we are writing today to provide further guidance to support you to free-up management capacity and resources.

During this challenging period NHS England and NHS Improvement is committed to doing all it can to support providers and commissioners, allowing them to free up as much capacity as possible and prioritise their workload to be focused on doing what is necessary to manage the response to the COVID-19 pandemic. Further information is provided on the following pages.

We will continue to review and monitor the situation and will remain agile in making further changes where necessary.

We appreciate the incredible amount of commitment and hard work going on across the NHS in these challenging times.

Yours sincerely

Amanda Pritchard | Chief Operating Officer | NHS England & NHS Improvement

The system actions

Changing NHS England and NHS Improvement engagement approaches with systems and organisations

Oversight meetings will now be held by phone or video conference and will focus on critical issues. Teams will also review the frequency of these meetings on a case-by-case basis. For our improvement resource, we have reprioritised their work to focus on areas directly relevant to the COVID-19 response:

    • GIRFT visits to trusts have been stood down with resources concentrated on supporting hospital discharge coordination
    • The outpatient transformation work is focused on video consultation and patient-initiated follow up
    • We have prioritised our special measures support in agreement with CQC to ensure we support the most challenged in the right way to help them manage the COVID-19 pressures.

1)  Governance and meetings

No. Areas of activity Detail Actions
1. Board and sub-board meetings Trusts and CCGs should continue to hold board meetings but streamline papers, focus agendas and hold virtually not face-to-face. No sanctions for technical quorum breaches (eg because of self-isolation).

For board committee meetings, trusts should continue quality committees, but consider streamlining other committees (eg Audit and Risk and Remuneration committees) and where possible delay meetings till later in the year.

While under normal circumstances the public can attend at least part of provider board meetings, Government social isolation requirements constitute ‘special reasons’ to avoid face to face gatherings as permitted by legislation.

All system meetings to be virtual by default.

Organisation to inform audit firms where necessary.
2. FT Governor meetings Face-to-face meetings should be stopped at the current time1 but ensure that governors are (i) informed of the reasons for stopping meetings and (ii) included in regular communications on response to COVID-19 eg via webinars/emails. FTs to inform lead governor
3. FT governor and membership processes FTs free to stop/delay governor elections where necessary.

Annual members’ meetings should be deferred.

Membership engagement should be limited to COVID-19 purposes.

FTs to inform lead governor
4. Annual accounts and audit Deadlines for preparation and audit of accounts in 2019/20 are being extended. Detail was issued on 23 March 2020. Organisation to inform external auditors where necessary.
5. Quality accounts – preparation The deadline for quality accounts preparation of 30 June is specified in Regulations. We intend it will be deferred. NHSE/I to inform DHSC
6. Quality accounts and quality reports – assurance This work can be stopped Organisations to inform external auditors where necessary.
7. Annual report We are working with DHSC and HM Treasury on streamlining the annual report requirements – further guidance forthcoming. NHSE/I and DHSC to prepare guidance in due course
8. Decision-making processes While having regard to their constitutions and agreed internal processes, organisations need to be capable of timely and effective decision-making. This will include using specific emergency decision-making arrangements.

2) Reporting and assurance

No. Areas of activity Detail
Constitutional standards (eg A&E, RTT, Cancer, Ambulance waits, MH LD measures).
See Annex B
Friends and Family test
Stop reporting requirement to NHS England and NHS Improvement.
3. Long-Term Plan: operational planning. Paused
4. Long-term Plan: system by default. Put on hold all national System by Default development work (including work on CCG mergers and 20/21 guidance).

However, NHSE/I actively encourages system working where it helps manage the response to COVID-19, providing support where possible.

5. Long-Term Plan: Mental Health NHSE/I will maintain Mental Health Investment guarantee.
6. Long-Term Plan: Learning Disability and Autism As for Mental Health, NHSE/I will maintain the investment guarantee
7. Long-Term Plan: Cancer NHSE/I will maintain its commitment and investment through the Cancer Alliances to improve survival rates for cancer. NHSE/I will work with Cancer Alliances to prioritise delivery of commitments that free up capacity and slow or stop those that do not, in a way that will release necessary resource to support the COVID-19 response.
8. NHSE/I Oversight meetings Be held online. Streamlined agendas and focus on COVID-19 issues and support needs
9. Corporate Data Collections (eg licence self-certs, Annual Governance statement, mandatory NHS Digital submissions). Look to streamline and/or waive certain elements.

Delay the Forward Plan documents FTs are required to submit.

We will work with analytical teams and NHS Digital to suspend agreed non-essential data collections.

10. Use of Resources assessments With the CQC suspending routine assessments, NHSE/I will suspend the Use of Resources assessments.
11. Continuing Healthcare Assessments. Stop CHC assessments.

Capacity tracker, currently mandated for care homes, is now also mandated for hospices and intermediate care facilities.

12. Provider transaction appraisals

CCG mergers

Service reconfigurations

Complete April 2020 transactions, but potential for NHSE/I to de-prioritise or delay transactions appraisals if in the local interest given COVID-19 factors.

Complete April 2020 CCG Mergers but delay work post April 2020.

Expect no new public consultations except in cases to support COVID-19 or build agreed new facilities. We will also streamline or waive, as appropriate, the process to review any reconfiguration proposals designed in response to COVID-19.

13. 7-day Services assurance Suspend the 7-day hospital services board assurance framework self-cert statement.
14. Clinical audit All national clinical audit, confidential enquiries and national joint registry data collection, including for national VTE risk assessment, can be suspended.  Analysis and preparation of current reports can continue at the discretion of the audit provider, where it does not impact front line clinical capacity.  Data collection for the child death database and MBRRACE-UK-perinatal surveillance data will continue as this is important in understanding the impact of COVID-19.
15. Pathology services We need support from providers to manage pathology supplies which are crucial to COVID -19 testing. Trusts should not penalise those suppliers who are flexing their capacity to allow the NHS to focus on COVID-19 testing equipment, reagent, and consumables.

3) Other areas including HR and staff-related activities

No. Areas of activity Detail
1. Mandatory training New training activities – refresher training for staff and new training to expand the number of ICU staff – is likely to be necessary. Reduce other mandatory training as appropriate
2. Appraisals and revalidation Recommendation that appraisals are suspended from the date of this letter, unless there are exceptional circumstances agreed by both the appraisee and appraiser. This should immediately increase capacity in our workforce by allowing appraisers to return to clinical practice.

The GMC has now deferred revalidation for all doctors who are due to be revalidated by September 2020. We request that all non-urgent or non-essential professional standards activity be suspended until further notice including medical appraisal and continuous professional development (CPD).

The Nursing and Midwifery Council (NMC) is to initially extend the revalidation period for current registered nurses and midwives by an additional three months and is seeking further flexibility from the UK Government for the future.

3. CCG clinical staff deployment Review internal needs in order to retain a skeleton staff for critical needs and redeploy the remainder to the frontline.

CCG Governing Body GP to focus on primary care provision.

4. Repurposing of non clinical staff Non-clinical staff to focus on supporting primary care and providers.
5. Enact business critical roles at CCGs To include support and hospital discharge, EPRR etc

Annex A

Whilst existing performance standards remain in place, we acknowledge that the way these are managed will need to change for the duration of the COVID-19 response. Our approach to those standards most directly impacted by the COVID-19 situation is set out below:

A&E and Ambulance performance – monitoring and management against the 4-hour standard and ambulance performance (Ambulance Quality Indicators: System Indicators) will continue nationally and locally, to support system resilience. Simultaneously, local teams should maintain flexibility to manage demand for urgent care during the emergency period.

RTT – Monitoring and management of our RTT ambitions will continue, to ensure consistency and continuity of reporting and to understand the impact of the suspension of non-urgent elective activity and the subsequent recovery of the waiting list position that will be required. The wider announcements on suspension of the usual PBR national tariff payment architecture and associated administrative / transactional processes mean that, financial sanctions for breaches of 52+ week waiting patients occurring from 1st April 2020 onwards will also be suspended.

Recording of clock starts and stops should continue in line with current practice for people who are self-isolating, people in vulnerable groups, patients who cancel or do not attend due to fears around entering a hospital setting, and patients who have their appointments cancelled by the hospital. The existing RTT recording and reporting guidance is recognised across the country as the key reference point for counting RTT activity and specific clarification of how this should be applied, in the scenarios described above, will be provided in due course.

Cancer – Cancer treatment should continue, and that close attention should continue to be paid to referral and treatment volumes to make sure that cancer cases continue to be identified, diagnosed and treated in a timely manner. Clarification has already been released to the system through the COVID-19 incident SPOC to confirm that appropriate clinical priority should continue to be given to the diagnosis and treatment of cancer with appropriate flexibility of provision to account for infection control. We have also confirmed modifications to v10 Cancer Waiting Times guidance to allow for this to be appropriately recorded. In addition, it has been agreed that the 28-day Faster Diagnosis Standard (which was due to come into effect from Wednesday 1 April) will still have data collected, but will not be subject to formal performance management. The Cancer PTL data collection will continue and we expect it to continue to be used locally to ensure that patients continue to be tracked and treated in accordance with their clinical priority.

Annex B

Data collections/reporting

NHS Digital maintains a significant volume of data which is mandated for return from commissioners and providers2. Much of this data is routinely submitted and imposes minimal burden on local systems.

It will be important to maintain a flow of core operational intelligence to provide continued understanding of system pressure and how this translates into changes in coronavirus and other demand, activity, capacity and performance – and in some areas it may be necessary to go further to add to and extend existing collections. For this reason, and to ensure effective performance recovery efforts can begin immediately after the intense period of COVID-19 response activity has subsided, the majority of data collections remain in place.

Notwithstanding the above, a subset of the existing central collections will be suspended, and these returns will not need to be submitted between 1 April 2020 to 30 June 2020:

    • Urgent Operations Cancelled (monthly sitrep)
    • Delayed Transfers of Care (monthly return)
    • Diagnostics PTL
    • RTT PTL
    • Cancelled elective operations
    • Audiology
    • Mixed-Sex Accommodation
    • Venous Thromboembolism (VTE)
    • 26-Week Choice
    • Pensions impact data collection
    • Ambulance Quality Indicators (Clinical Outcomes)
    • Dementia Assessment and Referral (DAR)

Annex C

Data Security and Protection Toolkit Submission 2019/20

It is critically important that the NHS and Social Care remains resilient to cyber-attacks during this period of COVID-19 response. The Data Security & Protection Toolkit helps organisations check that they are in a good position to do that. Most organisations will already have completed, or be near completion of, their DSPT return for 2019/20.

However, in light of events NHSX recognises that it is likely to be difficult for many organisations to fully complete the toolkit without impacting on their COVID-19 response. The submission date for 2019/20 DSPT has for that reason been extended to 30 September 2020.

The cyber risk remains high. All organisations must continue to maintain their patching regimes and Trusts, CSUs and CCGs must continue to comply with the strict 48hr and 14 day requirements in relation to acknowledgment of, and mitigation for, any High Severity Alerts issued by NHS Digital (allowing for frontline service continuity).

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