The week in public services: 13th May 2020

This week: what we learned from exercise Cygnus; the effects of school closures; and local government financial woes

General

As always, Andy Cowper has a a good overall roundup of health and care news. His take on tests, political communication, and the ‘Sophie’s choice’ decision about whether to discharge older people from hospitals back to care homes without testing for coronavirus in March is gripping and damning in equal measure.

It’s not just the political messaging that’s been lacking, either. My colleague Gavin has written a great blog on the many (really, many, many) problems in the government’s ‘data-viz’ (if we can call it that). Read, and weep for those of us who have to create charts which meet Gavin’s standards.

Looking to the future, Axel Heitmueller’s blog also falls into that category of ‘things-I-wish-I-had-written’. Originally published in mid-April (I missed it — we’re all human), it is clear, non-hyperbolic, stuff about how the NHS could and should change in response to coronavirus. I think his focus on improving transparency of information about service quality and outcomes neatly squares the circle of the ‘if collaboration and not competition, what’s your reason to improve?’ quandry.

Health and Social Care

In pretty big news, the Guardian have obtained the 2017 government report summarising the findings of the 2016 ‘Exercise Cygnus’ planning exercise. Surprised this didn’t get more coverage. Despite Matt Hancock’s assurances, the chief executive of Care England disputes that the government heeded the report’s recommendations to improve social care’s capacity to safely discharge patients from hospital. The chief executive of the National Care Forum has said that care providers were not involved in the planning or lessons from the exercise. You can read the whole thing online — it is linked in the article above.

Looking forward, the NHS Confederation have published a document to start a debate on the future of the NHS. Meanwhile, the changes have already started. The Health Service Journal have discovered that NHS England’s plans for London involve permanently increasing critical care capacity and measuring waiting times “at integrated care system level” (so not singling out individual hospitals, one assumes), to start from November 2021. (Ben Clover is rightly a bit more sceptical and asks some good questions here). An FT scoop from the weekend revealed that the government is considering establishing a permanent ‘reserve’ force of medics after the pandemic passes, following the recruitment of more than 10,000 retired doctors and nurses in response to the crisis. Someone in government has been reading Axel’s blog…

And back in the present Una O’Brien, the former Department of Health secretary, has called for a public inquiry into the UKs response to coronavirus to start setting up now, given how long it takes to set them up and hear evidence. Logistics, man. They matter. I would suggest getting a select committee to take responsibility for checking on progress once the inquiry is finished, too. If prospective committee chairs are wondering how they could make maximise the chances of their inquiry leading to change, they should read this Institute for Government report on just that from 2017 from my colleagues Emma and Marcus.

Back to those testing targets (it’s going to be a theme, regular readers), Tom Chivers got to write his righteous ‘I-told-you-so’ blog following the testing targets shenanigans. According to Tom “the goalpost-shifting and stats-juking was entirely predictable given the very public and simplistic measure”. Fair enough. More importantly, I think, he argues that “relatively simple steps could have been taken to make a more nuanced metric or set of metrics that drive the improvement nearly as well”. That’s the really damning point.

The UK Statistics Authority have also written to Matt Hancock to wrap his knuckles about the testing numbers. According to the regulator, “you will understand that for the sake of clarity and confidence it is important that the target and its context should be set out.” Translation: ‘sort it out, Matt’.

According to a Guardian report, only 7% of the 31,000 tests delivered to care homes to test residents and staff had been carried out so far because no-one is sure who is allowed to administer them (quiet internal screaming). On top of that, results from some tests undertaken by commercial labs are “disappearing into a data black hole” — meaning local public health directors cannot access data to actually monitor the spread of the virus. Revealingly, “the issues come after the testing scheme was hugely ramped up in the run-up to the end of April, to meet a DHSC target of reaching 100,000 daily tests”…

The Guardian also report that the results of many coronavirus tests are still yet to be shared with GPs, and there has been a merry-go-round of passing the buck for providing tests to care homes between Public Health England, the Care Quality Commission, and the Department for Health and Social Care. According to one care home manager, “the left hand doesn’t know what the right is doing”. None of this seems like it’s going well.

A thoughtful blog considers how journalists could have better covered the testing figures, the role of instant-news push notifications, and how to report contentious statistics. Worth a read. Where is the scrutiny of the above problems now that the target deadline has been passed?

Meanwhile, there is another side to getting us out of lockdown before a vaccine arrives — proper, systematic, contract tracing. On which the news is…also not great, to be honest.

Donna Hall, former chief executive of Wigan Council, writes that the government’s approach to tracing — to ‘centralise and outsource’ — has ignored the council workers at the frontline already providing support to the most vulnerable. “Sometimes it isn’t just algorithms and apps that solve global issues. It’s concerted local intelligence followed up by local action.”

If, like me, your only prior understanding of contact tracing came from the film Contagion, this Vox explainer is a handy guide to what it means, and the respective roles of phone technology and human contract tracers. For more detail on the UK’s approach to building a contract tracing app, this Recode piece is also worth a read.

In more positive digital news, hospital outpatient appointments appear to now be changing at the same rate of primary care appointments. Remote appointments undertaken through a single software provider, Attend Anywhere, have increased from around 200 per day to 6000 per day. Let’s set up those evaluations now before we miss an opportunity to understand what remote appointments mean for clinician behaviour and patient experience.

There’s been a lot of focus on acute care of late, but, as always, community care is just as important — if continually under-noticed. Anna Charles’ Kings Fund blog looks at how community services have fared in the first few months of responding, and what they’ll need to respond effectively in the future.

What’s happening with staff? An interesting long-ish blog post from the World Health Organisation compares how different countries are responding to staff shortages, and the policies they’re putting in place. The UK sticks out for just how many different policy levers it’s pulling. The WHO have also compared different countries digital health tools, extra spending, and attempts to get hold of PPE. A very helpful resource.

One concern I suspect some community hospital managers are now puzzling over is how to redesign staff schedules to meet increasing demands post-pandemic, and whether they will have to extend working shifts. Seems a neat way to reduce costs, right? Fewer handovers, less bureaucracy, less expensive? Well, it’s not quite that simple (it never is). New research from the Journal of Nursing Studies suggests that a move to longer shifts — at least for staff in one mental health hospital in England — was associated with an increase in sickness absence equivalent to a complete shift per week in each ward. Elsewhere, ThinkAhead — a graduate scheme for mental health social work — have published an interesting report about how mental health social workers have responded to the pandemic finding that, amongst other things, “teams are embracing remote working, but digital contact with service users creates real challenges”.

And social care? This grim Reuters investigation lays out this (and previous) government’s many failures. A Sky investigation has found out that several councils threatened to withhold funding to help care homes deal with coronavirus unless they accepted untested hospital patients. According to one care home manager “this has undoubtedly caused a huge spike in infections and resulted in deaths that were avoidable”. 70% of the 90 care homes that Sky surveyed said they felt pressured to take patients from hospitals before 15 April.

For a summary of the state of social care before the crisis, and what it might mean for it in the future, you should watch back our event from yesterday. Or read the twitter summary. (Yes, I wrote it, so I suppose that’s self-promotion, but if not here — then where?) Sally Warren and Nick Timmins’ points about the legal regime for provider failure will probably prove important over the coming weeks.

For a more positive take, Samantha Baron has written about what could change as a result of the pandemic, and the possibility of a National Care Service. The Health Foundation have done a similar thing, albeit for social care data and analytics (another important and under-served problem, and equally lacking an interested ministerial sponsor).

Children and Young People

So, now that we have a (very vague) statement of the government’s timeline for reopening schools, what do we think we know about the effects of having closing schools for almost two months?

Lindsey MacMillian has handily summarised an excellent Royal Economics Society seminar on this very question. You can grab the slides from here. The biggest things I took away:

• Survey data from the Netherlands suggests that twice as many middle-class children take part in live or recorded lessons compared to poorer children
• To help children who’ve lost out most from school closures, the best option looks like small-group tutoring between September and December

Gabriella Conti has written a similarly good article summarising the evidence on early intervention, and how best to maintain early interventions during the crisis for Vox.

More practically, a Chartered College of Teaching report on reopening schools concludes that the government “needs to ensure staff are consulted to ensure that any approach to re-openings takes into account the practicalities of schools.”

In non-pandemic news: Education DataLab have investigated whether primary school pupils’ ‘rank’ (their results compared to their classmates) makes a difference to secondary school outcomes i.e. does what position in the class you are matter on top of the grade you receive? The answer: it seems yes.

Over in children’s social care, the government have further loosened children’s social care statutory obligations, including accepting that it may not be possible for children’s residential homes to ensure each child has a monthly visit from an independent visitor. Labour leader Keir Starmer has tabled a motion to annul this change (which was made via statutory instrument).

Law and order

In our recent report about the effects of coronavirus on the criminal justice system, we recommended that the government not rapidly expand virtual courts to hear criminal cases because it could result in unfair treatment — justice delayed is better than justice denied, after all. Some new research from the University of Surrey backs up this concern. Looking at the differences in outcomes for defendants who first appeared on video compared to defendants who first appeared in court, the researchers found that:

• Defendants who appeared on video were more likely to receive custodial sentences
• Defendants who appeared on video were less likely to have legal representation
• Defendants who appeared on video were more likely to be passive or expressionless

Check out this useful summary from Transform Justice.

In prisons, prison reform charities Howard League and the Prison Reform Trust have warned that the government’s current approach to quarantine in prison (solitary confinement) is “unsustainable for any long period”, and called on the government not to abandon the early temporary release scheme.

Local government

Over in the world of local government, local authorities are concerned that the money they spent buying PPE for social care workers will not fall under the narrow definition of ‘essential spending’ that the government has set out. Sarah Calkin argues that the government’s seemingly-blithe response that councils have received more than enough additional funding ignores that council chief finance officers have to assure themselves that their council is solvent in the medium term (so, over the whole financial year) — they cannot assume that government will bail them out month to month, which is what the Secretary of State Robert Jenrick is effectively asking them to do.

In her view, better solutions would either be for the government to (1) suspend the normal ‘Section 114’ bankruptcy rules and allow councils to run deficits, or (2) allow the Treasury to underwrite councils’ pre-coronavirus council tax and business rates projections.

This all seems to fit into a wider debate about centralisation and localism — long-story short, councils have been deeply unimpressed by lots of central government action. Anthony Costello has also made some interesting points about how Korea compares to the UK on testing.

Another week down. Stay safe.