The Week in Public Services: 15th December 2020

This week: the tale of two datasets; planning for exams in 2021; and LOTS of new health research!

The tale of two datasets: a Cinderella story

It’s Christmas — permit me this somewhat indulgent Cinderella story. Shortly after the second world war, the Labour government set up a national health service, which came into being in 1948. “If a bedpan is dropped in a hospital corridor in Tredegar, the reverberations should echo around Whitehall”, as the apocryphal quote from Nye Bevan, the then Labour health minister, goes. That same Labour government, perhaps now infamously, did not set up a national adult social care service. Social care has long since been deemed a Cinderella service. Or perhaps it is one of the ugly sisters? Or perhaps Sleepy in the seven dwarfs? I digress; the point is that those divisions still matter today.

On 10th December 2020, the latest NHS waiting times data was published. Sure enough, the figures received stark coverage. “Covid: NHS long waits 100 times higher than before”, the BBC reported. “Covid’s ‘devastating impact’ on NHS services exposed by latest figures”, yelled The Guardian. “Trolley waits in A&E of at least 12 hours up 70 per cent in a month, amid hospital Covid chaos”, screeched The Telegraph. The statistics do, indeed, look very concerning:

On that very same day, the annual statistics about publicly funded adult social care in England were released. Which, in their own way, told a similarly stark story — even if they only covered trends in social care up until the end of March 2020, capturing just the start of the pandemic. Total spending on adult social care is still lower than it was a decade ago in real terms:

Fewer adults received long-term social care packages in 2019/20 than in 2018/19…*:

…despite more people asking for it:

Okay, you might have some objections. NHS funding also grew a lot slower than its historical average in the 2010s. Waiting times for some key services have lengthened (even if activity has increased). What about waiting times for social care — a cleaner comparison — you might reasonably ask.

Well, here’s the rub: I can’t tell you.

It is impossible to know if people are now waiting longer to access social care — whether the length of time between an assessment and the start of services has grown — because that data hasn’t been collected since 2011/12. And as for the media coverage of this new social care data…well, I’m still looking for it (though I applaud Simon Bottery’s summary)

To be clear: I’m not arguing that social care would be better run if it were managed centrally — in fact, there are lots of strong arguments that it wouldn’t be. And some of the difference is simply because social care data is a much more complicated and messier thing to measure than health care.

But social care matters just as much as health care if the ultimate goal is to help people live healthy, fulfilling lives. And there are steps that this government could take — from collecting better data to adequately funding the threadbare social care system exposed by the pandemic — which would make a big difference.

In the meantime, it’d be a good start if our national media tried to cover social care as much as it covered the NHS. We could even call it ‘parity of media coverage’.

Health and Social Care

Lots of new research this week — let’s get stuck in:

• The Health Foundation have analysed the characteristics of people shielding and found that approximately one in three people (31%) who were shielding experienced a reduced level of care for their existing health conditions and one in ten people did not access any care at all. This Guardian article is a good summary.
• The Health Foundation also looked at the nursing workforce in England over the last decade, and found that the number of nurses working in mental health and learning disability settings is actually lower than in June 2010 — despite an 8% increase in nursing staff overall. There was an increase in nurses in all settings over the last year, but some of this may have been from nurses signing up to the temporary register — not all of whom are likely to stay. They conclude that “the government will need to exceed its target of 50,000 new nurses in England by 2024/25 if it wants the NHS to fully recover from the pandemic.” Punchy.
• The Institute for Fiscal Studies have (again) analysed what impact social care spending cuts had on hospitals. The find that “between 2009−10 and 2017−18, the average number of annual A&E visits for a person aged 65 and above increased by almost a third [and] that cuts to public spending on social care explain between a quarter and a half of this growth.” They note that each £100 of cuts to social care only led to £1.50 additional expense for hospitals which…actually isn’t that large (A&E is pretty cheap to run as hospital costs go). It’s worth noting, however, that this analysis was not able to assess the impact of cuts on use of primary care — general practice — services.
• The Institute for Public Policy Research have set out their asks for public health reform in light of Public Health England’s abolishment
• The Institute of Health Equity have published a report on ‘building back fairer’ after coronavirus, which contains a very useful round-up of the various inequalities of coronavirus and its associated restrictions
• The Nuffield Trust looked at how health services in rural parts of England coped with coronavirus. They found that Covid-19 had a more detrimental impact on waiting times in rural hospital trusts than in urban trusts — perhaps because “many national standards and policies were not appropriately adapted to meet the needs of rural areas”
• Helen Buckingham outlined the main challenges facing the NHS as it ramps up to deliver the Covid vaccines
• Sarah Reed analysed how countries are balancing Covid and non-Covid care after the first wave of the pandemic and concluded that “while the NHS may be pursuing similar strategies to balance winter pressures and Covid-19 as other health systems […] our ability to manage Covid-19 and winter while restoring services will likely be more constrained by the challenges with which we entered the crisis” (sidenote: surely a long post by Sarah Reed should be called a ‘Long Reed’ — get on it, Nuffield comms team)

It’s also well worth looking at this Health Foundation summary of NHS activity data alongside Sarah Reed’s piece to understand just how large the reductions in non-Covid care have been.

• Sarah Scobie wrote a helpful Q&A on Covid cases (as of 9th December), comparing the different sources of information available
• The National Audit Office have forensically analysed the Test and Trace programme. There are some bright spots: they recognise that the government has built up capacity very quickly, but they are critical of the lack of co-ordination between central and local government; a lack of focus on ensuring people isolate; and problems ensuring they had an appropriate amount of resources (by 17th June, only 1% of call handlers were being used…)

If you don’t fancy the whole report, Nick’s twitter thread is a good short summary.

• Public Health England have published interesting-looking research on how to ‘engage NHS leaders with whole systems approach to physical activity’

Children and Young People

In social care news, Ofsted’s director for care, Yvette Stanley has summarised the incredibly difficult year for children’s social care. In a sentence? “We are seeing some excellent work with children and care leavers, despite the restrictions but we still have wider concerns about the continued drop-off in referrals to children’s services and the children who have fallen from sight of the authorities.”

And as the prevalence of coronavirus increases, schools are taking more drastic measures. Schools in Greenwich have been asked to close by their local council, although there appears to be confusion about whether the council is legally allowed to do this. Meanwhile, Welsh secondary schools and colleges closed on Monday to stop the spread of Covid.

The UK government has promised that there will be mass testing for secondary school children in London, Kent and Essex, and the Welsh government has said that all schools in Wales will have lateral flow tests from January.

In research news:

• The FFT Education DataLab have analysed data on pupils with a special educational need or disability (SEND) — and found that more than 10% of primary pupils leave the state system by Year 11. Pupils with SEND are more likely to leave the state-run schools system than non-SEND pupils.
• A new Centre for Education and Youth report on disadvantaged pupils in KS3 (age 11–14), shows that absence rates increase from Year 7 when compared to more advantaged children. They suggest targeted support to help pupils transition between primary and secondary school and reduce pupil absence.
• An interesting National Foundation for Education research report on Northern Ireland’s results in the international Trends in International Mathematics and Science study shows above-international average performance for NI in maths, outperforming both England and Ireland (their tweet thread summary is excellent)
• Meanwhile, an Education Policy Institute (EPI) report has found a small positive association between a graduate working at an early years setting, and improved outcomes for children up to (at least) the age of 11 (although the effect is quite small). The link between a child attending early years settings with a graduate and higher attainment scores is bolstered if the child spends more hours in early years education. On that basis, EPI are calling for “the government to focus on a strategy to boost the quality of the whole early years workforce, while also focusing on improving graduate take-up [and] a review of early years degrees, to explore how they can be enhanced”
• Looking over the channel to our friends in Germany, a fascinating economics paper exploits the variation in the start and end dates of summer school terms, and finds that “neither the summer closures nor the closures in the fall have had any significant containing effect on the spread of SARS-CoV-2 among children or any spill-over effect on older generations”. Provocative and interesting!

Looking at the bigger picture, Scotland has cancelled its higher exams for 2021, which continues the divergent approaches for the 2021 exams across the four nations we’ve seen to date. To recap:

Both Wales and Scotland have now cancelled exams, England is currently going ahead with them, and Northern Ireland is yet to announce details, but is planning to keep exams.

The other big story is of course school attendance, where attendance in Wales is now worse than in England; just 70% in were in secondary schools as of 4th December. The latest figures for England provide details of attendance by local authority (which Luke Sibieta has — rightfully — been calling for!) My colleague Andrew and I have analysed this new data, comparing attendance rates with a measure of Covid-19 prevalence around the same time, and we found that local authorities with higher rates of confirmed coronavirus cases had lower attendance rates, particularly in secondary schools (unsurprisingly):

Law and Order

The Centre for Justice Innovation have published a summary of the government’s ambitions to simplify out-of-court-disposals, i.e. the options for dealing with criminals where they are not sent to court — and their view on how they could improve them.

Local Government

No news is good news?

*It’s worth pointing out that there is a debate about whether the reduction in long-term care packages is good or bad. It might represent local authorities rationing care, or it might represent local authorities providing more services at point of first contact and outside the formal assessment process, i.e. signposting people to other sources of information and support rather than referring them on to local-authority- funded formal care. Simon Bottery’s tweet, and the King’s Fund’s 2016 Home Truths report remains the best explanation for the competing interpretations I’ve seen.