The NHS Wales Operating Framework was issued on 6th May 2020.
COVID-19 has meant, as with many areas of life, a massive change to the way in which the NHS and social care is planned and delivered. The current Operating Framework focuses on short term plans, being developed iteratively for the four quarters of the year.
The new framework also reflects the need to consider 4 types of harm, and do our best to address all of them in a balanced way:
- Harm from COVID itself
- Harm from overwhelmed NHS and social care system
- Harm from reduction in non-COVID activity
- Harm from wider societal actions/lockdown
NHS Wales COVID-19 Operating Framework for quarter 1 (2020/21) and the Essential Services Summary Annex are attached at the respective links below:
The Q1 plans recognise that our NHS continues to support a significant number of COVID patients. They recognise the impact that this has had on people’s behaviour and specifically their reluctance to seek NHS support even for urgent health needs. It is crucial that the NHS continues to embed safer environments and alternative pathways in order to build the trust and confidence of patients so that when more services are available people are reassured to take up the treatments they need. This will not happen overnight as people are naturally cautious, but the NHS is there for everyone as it has been throughout the pandemic.
Health Boards have sought to identify a range of ways that they can use their physical environments and develop new ways of working to keep patients and staff as safe as possible, raise public confidence and ensure that people seek treatment when needed. This includes working with partners to develop alternative pathways in the community, using more technology and considering how to use the additional bed capacity in field hospitals and in private facilities.
NHS organisations have taken a cautious approach to Q1 plans to ensure they remain able to respond quickly to any upsurge in transmission and lockdown is eased.
I have included below some specific aspects of the Q1 plans from each of the health boards that I hope will provide a flavour of the progress and challenges that has come through in the local plans. There are a number of common themes and each organisation has framed the plans to respond to the needs of their local population.
Aneurin Bevan University Health Board
The health board has maintained a significant amount of local surgery and lifesaving medical services are performing strongly, and cancer patients are waiting less time for initial out-patients post COVID. Provision of cancer services across the pathway continues to be a key priority in terms of the Phase 2 planning. However, the situation remains challenging with access to Tertiary surgical/oncology services (despite small numbers) remaining challenging and they have recognised that endoscopy has been a key constraint.
The environment remains fragile and while more patients are attending and being referred, other areas are not increasing as quickly. Safeguarding referrals for children have diminished significantly and the health board is considering the multiple factors that has contributed to this reduction.
Betsi Cadwaladr University Health Board
In north Wales clinicians are pro-actively monitoring waiting lists to identify patients requiring urgent/essential services. In primary care the health boards has provided urgent dental centres (red sites) established along with a network of fifteen optometric practices to ensure patients continue to access services. They have also ensured that alternative pathways that have been introduced through the use of e-consultation and patient initiated outpatient follow up that for example has resulted in 30% reduction in face to face orthopaedic out-patient demand
In addition new video consultations have accounted for 85% GP appointments and a surge in use of ‘my health online’ for pharmacies. As with other health boards Betsi Cadwaladr is monitoring closely those staff that might be at risk, such as older or pregnant staff and is developing guidance for BAME staff.
Cardiff & Vale University Health Board
Cardiff and Vale UHB has described a clear operating model set out, with ability to ‘gear up and gear down’ to respond to potential changes in demand. They have also see much greater adoption of remote consultations and ‘triage first’ in General Practice and this is a trend we are pleased to see across Wales.
The health board has provided additional hospital capacity through the Dragon Heart Hospital is set to support the region in providing a step down facility for COVID-19 patients and is utilising the Spire Independent Hospital for providing cancer surgery, non-cancer surgery, outpatients (including treatments), endoscopy, and cardiology.
The health board recognises that PPE, medical supplies, and testing remain strong enablers and dependencies but their success in recruiting temporary staff has been positive and feels it is well placed going into the next phase.
Cwm Taf Morgannwg University Health Board
Cwm Taf Morgannwg has also set out a clear plan for the use of field hospitals within the locality and clinical consultations with rapid rollout supported by clinical pathways.
Their plans ensure that their emergency medicines supply has been enhanced across whole UHB. They have implemented a delivery service of essential medicines from acute care to home to ensure patients have access to their medications.
It is encouraging that the health board is working with Regional Partnership Boards, third sector and population to understand how to support wellbeing, social prescribing and community resilience safely for example through using technology and promoting self-management. These and other new ways of working have been embedded as far possible. The health board has clear plans to separate COVID and non-COVID patients so that they can continue to bring patients in for the treatments they need.
In common with other NHS organisations, Cwm Taf Morgannwg has robust plans for staff support and wellbeing that include communications and engagement, home working, and recognising that rest and recuperation is paramount for staff that have been at the forefront of this pandemic for many months.
Hywel Dda University Health Board
Hywel Dda health board has provided a detailed cancer services contingency plan that includes chemotherapy available on three sites to ensure access. Their plans show significant emphasis on primary care, using technology to implement new ways of working, including positive virtual or telephone consultations. Hospital Services including General Surgery, Colorectal, Breast, Urology, Gynaecology and Ophthalmology have been relocated to a local private hospital, providing outpatient and treatment services for their Unscheduled Care (USC) and Urgent patients.
Hywel Dda has fortunately not seen the anticipated demand and has taken the decision that field hospitals will be held in reserve for any potential second surge. It is anticipated that these will be utilised as step-down facilities.
Powys Teaching Health Board
Powys has established red /green areas for COVID and non COVID patients and devised clear pathways to support patients. The Powys population will access independent hospital capacity via commissioned services, as they do now, both in Wales and across the border.
The health board is creating a modelling collaborative with NHS and local authority partners that includes developing testing protocols with care homes.
The plan describes good communications with staff, using regular newsletters, and raising awareness of health and wellbeing needs. Importantly given the nature of Powys services they have ensured that capacity is put in place to support hospital discharge process for step up and step down support with care homes.
Swansea Bay University Health Board
The health board has adopted red COVID and green non-COVID demarcation and some tertiary and specialised services have been reactivated in regional partnership with Cardiff and Vale. A full training programme to upskill staff in working in Intensive care functions is underway, and staff have been re-trained as support staff to support the ITU nurses and Cardiac ITU nurses.
The plan reflects how remote working is being maximised via the provision of mobile devices and reinforcement of shielding, self-isolation and social distancing. The plan reports that major digital transformation has been implemented with large numbers of hardware being provided to enable social distancing and agile working, including for those working in social care.
Welsh Ambulance Services NHS Trust
To support the COVID-19 crisis paramedics moved from rapid response vehicles to emergency ambulances. The Trust has experienced improved response times and hospital handover delays reduced significantly, as a result of lower demand for usual conditions.
The plan highlights the need for continuous engagement with health boards to ensure the trust could better support the use of field hospitals and other healthcare facilities. A recruitment and training plan is a priority for the Trust, to deliver additional workforce alongside the response to the COVID-19. The Fire and Rescue Service have also been working closely with the ambulance service and have provided support.
Changes have been implemented such as limits on the numbers of patients per vehicle, the introduction of screens between the cab and saloon of the vehicle and the separating of suspected & confirmed COVID-19 patients. The Trust’s Well-being Team is prioritising wellbeing for its staff, providing support via telephone consultations and virtual, live Question and Answer sessions.
Velindre NHS Trust
The Trust is working closely with the Cancer networks to increase urgent diagnostics and treatment for cancer, radiotherapy for category 1 patients and emergencies. There is greater use of technology for staff and patients, with working from home up 30% with similar increases experienced with video consultations with patients.
The Welsh Blood Service is producing convalescent plasma & involved in the International dispatch of Cryopreserved cells which is a new endeavour. The plan demonstrates a strong approach to ensuring demarcation of areas for managing COVID-19 patients.
The Trust is participating in national trials, evaluating impact for staff and patients. Patients have been recruited for the RECOVERY trial to test potential COVID-19 treatments and to TERAVOLT, a study to follow up COVID-19 patients.
Welsh Health Specialist Services Committee (WHSCC)
WHSSC has worked closely with Health Board providers and clinical teams to reach agreement on the way forward for thoracic surgery. The plan outlines the need to prioritise services to minimise harm through alternative solutions e.g. use of video and telephone consultations for out-patients and follow ups.
WHSSC are undertaking discussions with all Welsh providers to develop plans for progressive implementation of routine activity for specialised services and WHSSC staff have been redeployed to help both the NHS and the central Welsh Government function.
Health Improvement & Education Wales (HEIW)
HEIW have focused on the need to restart education and training as well as the need to re-start rotations and placements for students. The plan recognises the need to review workforce strategy for Health and Social Care which has been developed, in light of COVID-19.
HEIW staff have all been working remotely since mid-March, supported by greater use of online classrooms and the creation of a leadership portal with a wealth of wellbeing resources. The plan references a Quality Management & Assurance Process for field hospitals e-Leading to ensure consistency for staff approach. This has been the product of a four nations conversation,
Managers and staff across the whole NHS are realistic view on the limited possibility of restarting routine work for Q1, and the importance of maintaining a focus on PPE and testing.
Meetings will be held with each of the organisations, over the next two weeks, to follow up on any issues and to begin to plan ahead for the next quarter. To support this a new Operating Framework Two will be developed and issued. The Q2 plans will be iterative and build on the gaps and new issues that emerge. Action planning will be the foundation for the next framework and the Q2 plans will be expected to focus on:
- Greater opportunities for regional healthcare activity
- Moving from discussions to delivery with social care partners to strengthen the integration
- Communication with staff to ensure they are up to speed with future expectations
- Communication with public to ensure the messages are consistent and while supporting staff and patient safety
- Early stages of winter planning, which will be developed further in Q3.
Future updates will be provided as the new Operating Framework for Q2 is available.