The Week in Public Services: 15th July 2020
This week: NHS reform/rewind, show me the (social care) money, and lacking local authority data
General
Tom Chivers has produced a short and stunning summary of a new paper which offers a way to analyse NHS data from 17 million people (that really would be one hell of an Excel workbook). To manage it all, instead of collecting the data, the data stays put in local NHS trusts which receive developed software to essentially do the analysis in house. Clever. What has all this analysis shown? To be honest, not much we didn’t already know but here we can admire the method more than the results. It’s worth reading just for the asides (I learned what ‘collider bias’ is) but if you already know your collider bias from your Large Hadron Collider you can check out the (open source) code and see exactly what machines across the country are running.
Health
I don’t doubt that some of you are still having nightmares about the 2012 NHS reforms. So I can only imagine your reaction to the news that the prime minister is planning a ‘radical and politically risky’ reorganisation of the NHS to reassert more ministerial control. And what has the government done to spearhead this? Exactly what every government does when it wants to be seen vigorously pursuing something: set up a taskforce. Richard Murray, chief executive of the King’s Fund, comments diplomatically what I’m sure we’re all thinking: “any large-scale reorganisation of the NHS comes at a high price as they distract and disrupt the service and risk paralysing the system.” “Not the right prescription” agrees IfG senior fellow Nick Timmins, who reminds us all that the things ministers have had control of have hardly gone swimmingly so far. He also advises listening to what Jeremy Hunt has to say from his six years as Health Secretary (even if some Tories feel they’ve heard quite enough of him). For a well-informed summary of what problems the government thinks it is addressing, check out Paul Goodman’s article on Conservative Home.
Others also have ideas about NHS reform — how about a more marketised system advocated by IEA director Mark Littlewood? This article in the BMJ from Mancunian medic David Oliver argues against this, pointing out (as my colleague Nick observed) that health outcomes are not just the result of the health system, and countries such as Germany, France, Switzerland and the Netherlands (all praised by the IEA) spend much more on healthcare (as a percentage of GDP) than the UK does.
To another piece of NHS history: NHS England’s Vanguard ‘New Care Models’ programme, running from 2015 to 2018, aimed to reduce hospital admissions by taking specialist care out of hospital and providing it in the community. The programme covered around 9% of the population, with the aim of coordinating hospital, social care and rehabilitation services. A new study however has cautioned against relying on it to reduce admissions. Using a difference-in-difference analysis, the authors found that the programme slowed the rise in emergency admissions but did not reduce them. TL;DR — integrated care policies like this can’t really be relied upon to make large reductions in hospital activity in the short-run. Even in the Vanguard areas, there was no significant reduction in bed days.
The Nuffield Trust have published an important stocktake of what’s happened with GP appointments during the pandemic , along with some smart dataviz so you can compare the pattern of GP appointments with last year. While it wont surprise you to hear that appointments haven’t fully recovered from their sharp decline in April, some GPs have used the reduced demand to proactively check up on those with longer term health needs. I don’t think it’s clear to anybody yet just what the post-Covid GP paradigm looks like but the first step is using data and intelligence to assess what is happening — a point this piece both makes and neatly contributes to.
Right now, everyone in the health and care sectors could do with having calm heads. It’s unlikely that this somewhat sensationalist piece from the Telegraph saying dozens of care homes have been urgently inspected over reports of ‘poor care’ is going to help that. Fast-tracked inspections were carried out by the CQC at 50 homes, which Simon Bottery helpfully contextualises as being perhaps 0.003% of all care homes in England. More alarming is a study which suggests that the likelihood of UK care homes being infected with Covid-19 triples with every additional beds, meaning that large homes are up to 20 times more likely to have an outbreak.
On top of this, Amnesty International has published a report on the global failure to protect health and other key workers during the pandemic. It finds that the UK is second in the world when it comes to health worker deaths — at least 540 — and not far behind first place Russia (with 545 health worker deaths). Axel Heitmueller notes that other countries had PPE problems too so maybe this reflects different underlying risk factors…and perhaps it is (sadly) not surprising when you consider the high UK death toll overall.
Researchers at the University of Kent began the year starting some research for the Wellcome Trust on social care regulations. Like us all, they didn’t know what was around the corner, but what did end up happening has made their research all the more important. And to be frank, it’s quite depressing. A survey of 2,600 care workers in more than 1,000 settings has revealed that a large majority of them said their employers were not doing enough to keep them and those who use their services safe. Overall, 80% of care workers said they wouldn’t be paid their wages as normal if they had to self-isolate. It’s a lengthy report but a summary of key findings at the beginning sets the rather sombre tone.
Spectator Editor Fraser Nelson explores why there have been so many care home deaths in an article for The Telegraph . Maybe it was less to do with emptying NHS beds and more to do with allowing care home visitors (some for weeks after lockdown, unlike say Hong Kong) and the use of agency workers in different homes (one on the Isle of Skye was bringing in workers from Kent). It includes the shocking statistic that care homes look after 3% of the elderly population but account for 41% of our Covid deaths.
Meanwhile, researchers elsewhere have published a discussion of what they think as led to the ‘catastrophic’ impact of the pandemic on social care in the UK: a paucity of useful guidance for care homes; the absence of data on care homes; a historical lack of anticipatory care practices and a failure to support care home staff. It’s worth noting how these are systemic failures, produced by the ways in which successive administrations have quite frankly neglected the sector. Much talk of a potential cross-party consensus/sustainable plan for social care but — forgive me for my cynicism — it’s only when the question ‘Who pays?’ is asked when discussions get serious.
It’s not often I get to present some good news anymore, especially in the health section, but this case study from Hertfordshire is heartening. A whole-system response meant hospital bed capacity was secured by opening up two closed care homes within seven weeks and repurposing them as Covid-19 hot sites. As I mentioned above (it didn’t take long) an interesting question emerges when you consider funding. What exactly health and social care budgets pay for when the lines between them become blurred is another problem that areas seeking to adopt a whole-systems approach will need to think about.
So cough up, says Sir Andrew Dilnot, whose 2011 report on social care has spent the last decade gathering dust. Giving evidence to the Commons Health Select Committee he said very simply: “we just do not spend enough money on care” for the current system to work, even before considering measures to cap the risk of individuals facing catastrophic costs such as a lifetime cap on costs. If only he’d said that before…more cash is also the message from Jeremy Hunt.
Children and Young People
Depending on where in the country you are, your oyster is either something you eat or something you tap to get around. Free transport for under 18s in London has meant that young people have not had to worry about the bus fare to and from school. That’s now set to change under the terms of the government’s financial support to TfL, leading to warnings that when schools do reopen in September, some pupils may be forced to stay at home if they can’t afford to make the journey.
Local Government
Analysis from The Guardian spells out the income hit councils face from the loss of commercial income. In the last four years alone, English councils have spent £7.6bn on commercial property as they look to find new income to offset the impact of government funding cuts. English councils estimate they’ll lose over £600m in income from commercial investment as a result of Covid-19 — which the government is refusing to cover. This source makes up at least a quarter of total income for more than 30 local authorities meaning job losses and service cuts look inevitable.
Funding is not the only problem councils are facing. The Guardian also has this insightful piece from former King’s Fund chief Chris Ham and Kate Arden (from Wigan council and lead director of public health in the Greater Manchester combined authority) explaining why the government’s preference to centralise and outsource for Covid-19 testing is causing real headaches for those trying to contain local outbreaks. They argue public health directors should have been involved from the outset to decide how test results would be used and shared. Greater Manchester mayor Andy Burnham is demanding daily updates on individuals testing positive for Covid-19 rather than weekly data without patient details. He says that by failing to provide details, the government could be at risk of not following their own law.
But even anonymised data seems to be causing issues. Arj Singh at the Huffington Post understands that some postcode-level coronavirus testing data is not being published because councils are worried that it will be used to stigmatise certain communities and ‘damage community cohesion’. Local authorities could be in for a tricky balancing act — ensuring that enough information is out there to make a difference to public health without identifying anyone too specifically to make them a target.
