The Week in Public Services: 12th January 2021

This week: hospitals under severe pressure; how to speed up vaccine rollout; and Covid in prisons.

General

A new year, but so far 2021 feels a lot like 2020 — and that means another Week in Public Services dominated by the impact of Covid. One year ago yesterday, newspapers reported the first death in China from a “new type of coronavirus”. I don’t think any of us could have predicted what would unfold in the subsequent year. Although the situation is bleak in the UK right now, the difference this year is that we have the hope offered by vaccines. Indeed, scientists offered us one more piece of good news this week: the new variant causing havoc in England is “extremely unlikely” to evade immune responses generated by vaccines or previous infection.

Another difference to last year is we have 12 months’ experience to learn from. A Resolution Foundation piece examines the “lockdown lessons” from 2020 — such as the impact on the poorest families’ finances, which is the subject of a Resolution Foundation paper this week. The way the pandemic has exacerbated inequalities is also the focus in a summary of the ongoing IFS Deaton Review. Perhaps most starkly, the authors remind us that between March and July, mortality rates from Covid-19 were twice as high in the most deprived areas as in the least deprived. With a full year of data, 2020 can now be compared with previous years in history. Ed Conway wrote a fascinating Twitter thread exploring how Covid-19 compares to previous pandemics. The size of the Covid-19 impact really depends on how the data is presented. When looking at deaths per capita, 2020 doesn’t look too bad compared to the last few hundred years. But if you compare 2020 against a rolling five-year average — which, given improvements in modern medicine, seems like the better option — then it was the worst peacetime year for excess deaths since 1929 (when there was a flu pandemic).

The House of Commons Science and Technology select committee released a report on the use of science advice during the crisis this week. Many of their findings are similar to those of the Institute for Government’s report on the same topic from December. A key point is that SAGE is an ad hoc committee designed for short-term emergencies; the structure needs to be adapted for long, systemic crises like the one we are currently experiencing.

Meanwhile, other writers have focused on why the UK has failed to manage the crisis effectively. The new variant is partly responsible for the third lockdown, but Boris Johnson and the government must also take their fair share of blame. Phil Whitaker, writing for the New Statesman, argues that the government’s choice to allow a low but nonetheless significant number of infections to continue throughout the summer made it more likely that a mutation would appear in the UK, as compared to countries which pursued an elimination (‘zero Covid’) strategy. Tom McTague points out that scientists have been concerned about a winter surge ever since March. But the government does not seem to have planned particularly well for this very predictable scenario. As McTague writes, “Johnson’s reluctance to act and his optimism that he won’t have to in the future have become a pattern.” Coming to a similar conclusion, Catherine Haddon has also written for the Institute for Government on what the crisis has revealed about Johnson’s leadership: “the prime minister’s desire to communicate the optimistic case and his tendency to wait until action is unavoidable still defines the government’s approach in a way that does nothing to improve its chances of success.”

Health and Social Care

Covid is having a severe impact on the NHS in all four nations of the UK, with operations cancelled and staff stretched thin. With the number of infections running at over 50,000 per day, Chris Whitty has said that “the next few weeks are going to be the worst weeks of this pandemic in terms of numbers into the NHS.” One way of understanding the impact is to look at this chart showing the number of Covid-19 patients in hospital. As of 10 January, UK hospitals have a lot more Covid-19 patients than during the first wave:

Of course, data only gives you some understanding of what the situation is like. A harrowing account by a junior doctor recounts what working on a Covid ward is like: “When we think that these patients have suffered enough, and are unlikely to ever recover, we start talking about making them comfortable. It’s partly that we need the beds for patients with a better chance, and partly that we feel it is cruel to keep these people suffering when their chances of survival are slim.” Similarly, an NHS consultant has written an account for The Guardian. They make for grim reading, but are an important motivation for continuing to follow all the restrictions.

It is possible further measures might be required to contain the virus, although at the moment it looks like the government plans to wait for a few more days to see if the current lockdown measures are enough to bring it back under control. The government doesn’t have many levers left to pull. There has been discussion of banning people meeting outside, evening curfews, or closing nurseries. All of these clearly come with serious downsides. The government might be interested in a new research paper which assesses the risk of outdoor airborne transmission. Conclusion: the probability of airborne transmission outdoors is “low, almost negligible, if crowded areas and large gatherings of people are avoided.” This suggests that if further restrictions are needed, the government should target social interactions indoors.

In the short term, the situation is bleak but vaccines offer us hope. The Moderna vaccine became the third to be approved in the UK this week — although supplies won’t arrive until the spring. Nick Triggle helpfully explains the process of manufacturing and distributing the vaccines, and why the rollout so far is slightly slower than the government had initially hoped. This explains why there have been lots of suggestions about how to speed up the rollout:

• The Tony Blair Institute for Global Change proposes increasing the number of sites delivering vaccinations, training more staff, and publishing more data;
• The Adam Smith Institute has a total of 22 recommendations to increase supply and distribution, including using the Armed Forces and creating mobile vaccination centres;
• Robert Peston suggests reducing on-site paperwork.

The UK might want to learn from Israel’s vaccination programme, which has already delivered vaccines to 21% of the population. Early procurement, possibly at higher prices, has given Israel sufficient supplies. And as a commentator pointed out, they offered to share lots of data with vaccine manufacturers — so the country acts as a large, real-world lab. Universal health care and digital medical records have also helped.

In addition to vaccines, there will clearly be a need for a test, trace and isolate system for some time to come. After all, the government needs to make good use of the eye-watering £375m the government has spent on consultants for the Test and Trace programme. (For context, that is just over double the annual expenditure on the whole of HM Treasury.) As covered in previous weeks on this blog, it is the final stage of this process, isolation, which has received the least attention. Devi Sridhar is the latest to call for more measures to help people isolate, both financial and practical — and also argues that the latest lockdown is an opportunity for the government to tighten the testing regime for people travelling into the country from abroad. The additional problems caused by the new variant surely strengthens the case for this to be a priority moving forward.

It’s worth remembering that the UK is not the only country experiencing a sustained winter surge in Covid cases. As Sarah Reed sets out, other countries such as France and the Netherlands are also reducing health care activity due to Covid, although like the NHS they are trying to do so in a more tailored way than in the first wave. Meanwhile in just over a month, Ireland went from having the EU’s lowest infection rate (in early December) to the world’s highest rate by 11 January. The new variant imported from England combined with Christmas socialising appear to have caused the rapid climb.

Away from all the current news, a few other research pieces have looked at different aspects of the pandemic response:

• Full Fact have investigated whether there really was ‘enough PPE’ for hospitals during the first wave. Their conclusion is that we can’t say definitively, primarily because of poor data infrastructure. During March and April, many trusts didn’t accurately record all the PPE they had. It is therefore hard to say whether they actually ran out. However, there is evidence that some PPE items, especially gowns, were rationed. There is good evidence to show that the situation was far worse in social care, where PPE was definitely not available for everyone who needed it. At least this is one area where we are better prepared for the second wave we’re currently in, albeit with some questions over the government’s procurement decisions.
• An article in Prospect highlights the long-term underinvestment in nurses. Lack of staff (a shortfall of over 40,000 nurses going into the pandemic) is one of the reasons why hospitals are under so much pressure now.
• The Lancet published an interesting paper which assess the links between countries’ global health security measures (preventing, detecting, and responding to public health threats, particularly infections diseases), and universal health coverage (providing high quality care to all). The article argues that a key factor in an effective response to Covid-19 has been integrating and co-ordinating both. Countries that have done so have managed Covid-19 relatively well (for example Taiwan, Vietnam and South Korea). Other countries have failed to effectively integrate these two priorities (such as the US, UK and Italy), and have struggled with their pandemic response.

Children and Young People

Lots of discussion this week has focused on how to help children who don’t have access to a device and/or Internet access at home. While telecoms companies have started to provide free access to some educational websites, the government issued guidance that children who can’t access remote learning are eligible to attend school in person. That in turn led to concerns that some schools in more deprived areas might see a surge in pupils attending. The Institute for Government identified improving access to remote learning as a key priority for the government in Performance Tracker 2020. It seems that the commitment to keep schools open has left the government underprepared for school closures, although there have been clear improvements since the pandemic started.

Discussion regarding exams continues. The government committed to end-of-year exams in England, with some adjustments, back in October. The latest lockdown necessitated a change in policy. However, the lack of contingency planning is disappointing. Gavin Williamson confirmed that teacher-assessed grades will be used, but no further details have been released. Ofqual aims to reveal the final plan by the end of February. If that is the case, pupils and schools will have been in the dark for almost two months. It is surprising that Ofqual and the DfE did not have better contingency plans in place for this eventuality. After last year, it was always a possibility that exams would have to be cancelled again. Wales’ approach to exams may also be under threat — it relies on classroom assessments, which will be externally marked. These assessments were due to start in February, and it is not yet clear whether schools will be able to return by then. Alice Bradbury has written a column arguing that the DfE should also cancel the remaining SATs tests in primary schools.

Law and Order

Prisons in England and Wales are currently experiencing a surge in Covid-19 cases, mirroring the rest of the country’s experience during the second wave. As can be seen from the chart below, the number of confirmed cases is far worse that an any previous time during the pandemic. However, it is important to emphasise that this is partly due to increased testing, which wasn’t available in March and early April. Former Chief Inspector of Prisons Nick Hardwick has been tweeting about the accompanying problems: strict lockdown conditions with prisoners locked in their cells for most of the day, and staff shortages.

Courts have also been severely affected by the pandemic. The Guardian highlights that some defendants and victims will have to wait for four years for cases to be heard. The worst backlogs are in the crown courts, due to the difficulty of holding jury trials in a period of social distancing. The Institute for Government highlighted this problem in Performance Tracker 2020. My colleague Tom Pope is giving evidence to the Justice select committee later today. This is an issue that Antonia Romeo will be paying close attention to, after she became the new permanent secretary at the Ministry of Justice. Of course, the IfG has a chart for that (a very good one too).

Local Government

The Local Government Association argue that the current financial settlement for local councils is not sufficient for the new lockdown. They highlight the need for the government to ensure that £500 self-isolation payments are made available to those who need them. During the first months of the pandemic, there were many complaints that accurate and timely data on Covid infections was not being shared with local government. With a sense of déjà vu, this week it was reported that councils are accusing the government and the NHS of not sharing vaccine data with them. Councils want more granular data, so that they can improve uptake in their areas and spot potential problems. Refining local delivery by working with councils is something the government needs to get right to ensure the vaccine rollout is as effective as possible. Finally, a new report by think tank Onward, The Policies of Belonging, advocates empowering local communities. One recommendation is to give every local area a parish or town council — at present only 25% of England is represented by one. Another interesting recommendation is to give local communities “the right to establish a community land trust to provide affordable homes for local people.”

Next week, make sure to come back for Graham’s five predictions for public services in 2021 — though just predicting the next three months is probably hard enough!