The week in public services: 17th April 2020

This week: rising applications to take children into care; social care becomes the focus; and how to make sense of the coronavirus numbers

General

Another long one this week — let’s start big and go small. Looking at the big picture, Geoff Mulgan wrote a really interesting blog about how government should, in general, prepare for big crises, and how the UK could and should have been better prepared to respond to Covid 19.

Tim Harford wrote a predictably excellent article about why, in general, we humans find it difficult to prepare for disasters, and some of the psychology behind our responses. Make yourself a cup of tea, sit down, and give it a read. Worth your time — although the diagnosis is much more extensive than any proposed solutions…

At Unherd, Tom Chivers has written a good article about data, management, and Goodhart’s law. A very, sensible, balanced piece about the benefits and pitfalls of using data in the public sector — particularly on thorny questions like when relax the lockdown. Metrics are useful but, ultimately, they only give you a partial view of what’s going on. Forthcoming Institute for Government work on the use of targets in public services (drafting right now!) will look at some of these very problems — keep your eyes peeled.

Meanwhile, Paul Johnson sets out the tough trade-offs (there is a theme here) involved in deciding when and how to end the lockdown. He argues that policymakers need to be attentive to the risks that they fall prey to predictable human biases to ‘underweight’ the future and focus on the most immediately salient problems (in this case, focussing on deaths caused by Covid 19 rather than deaths emerging as second-order consequences of a long lockdown). This feels like a very important and underrated point to me.

I know I make this point most weeks, but data quality really matters and this helpful ONS blog explains how and why the different death counts are totted up. The latest ONS data tell a particularly worrying story about rising non-covid deaths. It’s too early to say why, but fits with the anecdotes and Accident & Emergency data (described last week) that some people may no longer be going to hospital when they should. The IFS have looked at the wider impacts of Covid 19 on the NHS and found that “disruptions to non-coronavirus care are likely to have most impact on older and less affluent individuals”.

Meanwhile, Dave West has looked at the ONS data in-depth, and found that deaths recorded at home and in care homes are far more likely to not be attributed to Covid — though it’s too early to say whether that is because these deaths are ‘collateral damage’ because of difficulties accessing healthcare, or whether this simply reflects difficulties testing and diagnosing cases of Covid 19 outside of hospitals.

Elsewhere on the labyrinthine ONS website, they have helpfully rounded-up the temporary surveys and other data they are collecting related to coronavirus. And as well as our excellent national statisticians, the Oxford Centre for Evidence-Based Medicine have explained how to reconcile the different data sources. Helpful to read alongside the ONS blog about the different death statistics.

Health and Social Care

Starting off with some overarching news — Billy Palmer has written a great blog on how the government could better report daily numbers during the coronavirus pandemic. He calls for denominators (relative risk matters!), comparing against forecasts, and clearer data on health service capacity. It’s a hard agree from me.

Andy Cowper has, as ever, a useful round-up of the week’s news, including a story that I wasn’t aware of — lots of health digital/tech companies asking for bailouts from the government [insert your own joke about tech entrepreneurship]. He’s right that we should be asking more critical questions about why so many of these companies have been willing to provide their technology for free.

NHS Providers have also published an excellent report about the NHS’ preparation so far, and the likely pinch points in the next few months. Ensuring a consistent supply of personal protective equipment, dealing with potential second or third peaks — and making sure they don’t hit during winter — currently look like the biggest pressures for the next few months.

Elsewhere, the government has confirmed that the £5bn fund it originally announced for public services in the March budget has been increased to £14.5bn, and that the NHS will receive £6.6bn of that to “free up hospital beds, buy new ventilators, diagnostic tests and protective equipment for NHS staff, enable home delivery of medicines and support medical and nursing students and retired doctors and nurses to join the front line”.

In hospitals, one of the emerging big questions is how the NHS will address the rising backlog of people waiting for elective surgeries such as hip and knee replacements (which was already very high pre-Covid 19). The Royal College of Surgeons have suggested that the government will need a five-year strategy to catch up because it will be difficult to find ‘covid-clean’ facilities after the first peak — especially because the NHS has bought up so much private sector capacity to handle a rise in Covid 19 patients.

Of course, it’s not just acute hospitals that are facing problems. Community care has a shortage of nurses to manage patients, and NHS England are considering retraining domiciliary care workers to perform some clinical tasks — reminiscent of the emergency guidance for intensive care unit staff published a few weeks ago.

And is the Care Quality Commission proving helpful during this crisis? A very damning piece from an anonymous NHS worker suggests it is not, arguing that NHS Trusts game their inspections, ultimately to the benefit of no-one. A few choice quotes from a piece worth reading:

• “My trust ensured that we passed our cqc by creating a team specifically for the purpose of managing the inspection, whose principle task was to ensure that our paperwork was perfect […] our cqc team were so brilliant that they created a false view of our trust, one that completely obscured the reality of our inadequacies”
• “During our inspection, we made sure that we were operating under full capacity. This was a monumental achievement but was taken as license for future carte blanche”
• “For [the cqc], a functioning trust is not one that ensures it has the right equipment for staff and patient alike, but one that is financially ‘sensible’, and most importantly has a senior management team who can charm the inspectors”

On a final note — sparked by Anne Collins’ column about NHS staff — I still don’t understand why NHS England are not publishing rates of staff sickness data. What is the logic behind not making this public? It means people end up relying on leaked coverage, such as this HSJ story…

Over in general practice, Beccy Baird argues that GPs increased use of video consultations will accelerate the transformation planned in the 2019 NHS long-term plan (remember that?), which had originally promised every patient “the ‘right’ to digital primary care services by 2024”. She argues that the crisis has made clear how valuable primary care networks are in allowing GPs to share expertise and learning. Of course, it’s not just GP behaviour but patient behaviour — what kind of appointments people are requesting — that is changing, as this new data from AskMyGP makes clear.

Not everyone is universally positive about these trends — the chair of the Royal College of GPs is worried that remote consultations may make it harder for GPs to diagnose and manage patients’ mental health problems.

But It’s social care — in particular shortages of PPE and deaths in care homes — that has been the biggest story this week. This FT piece (£) is a good summary of the main problems (as is this letter from unions).

A survey of 11 major care providers, covering 13% of formal care recipients in England, from data provider LaingBuisson found that there had been 714 Covid 19 related deaths until 15th April — suggesting that, if representative of the other 87%, around 5,300 receiving social care may have already died. Take these figures with a pinch of salt — but that is quite shockingly high.

There have also been reports of the NHS being instructed not to share lists of vulnerable people with councils (and thereby social care providers). I don’t know the full information governance regulations behind this decision, but it’s not a good look, is it?

The government has since published an ‘action plan’ for social care in response to these criticisms. Despite the widespread mockery of the ‘social care badge’ (allowing care workers access to the same discounts as NHS workers in a lot of places), there is some substance in there. Furloughed workers will be allowed to take up paid roles within social care while retaining their furloughed wages — something that Care England and the association of Independent Health and Care providers asked for two weeks ago. The government have also promised a “dedicated supply chain” of PPE for social care providers and reversed their position on testing. All patients being discharged from hospital to care homes will now be tested for Covid 19.

Roy Lilley is (rightly) sceptical though, noting that even if the government is successful in recruiting an additional 20,000 care workers, it’ll still need to work out how it is going to pay them…there were no new funding promises for local authorities in the plan that I could see…

In more constructive news, Chris Hatton has blogged about existing what data the government could be using to monitor death rates in social care and direct resources to the most appropriate places. It’s an important read — in particular for explaining what the government does, and does not, already collect — and one that I hope is being read within Whitehall. John Bolton has also published useful tips for local authorities on responding to Covid 19.

In more ‘normal’ news, the Health Foundation have published a report on what social care for adults aged 18 to 64 looks like. An in-depth data analysis reminding us that social care is not just old people — a point that I worry might got lost when minds turn to reform after Covid 19 passes. The House of Common Library have also dutifully covered changes to the means test for adult social care in England. Holding it flat in cash terms has meant the means test has got meaner since 2010

And the Nuffield Trust have continued their series of blogs comparing the social care systems in the four nations of the UK continues with a comparison of the workforce in the four nations. I did not know that England has that highest proportion of its social care staff working in residential and nursing homes (as opposed to domiciliary care — care provided in people’s homes). Camille Oung has summarised what England can learn:

• England could benefit from a government body to regulate and promote professional development among social care workers — as Wales, Scotland, and Northern Ireland all have. The English equivalent, Skills for Care, is a charitable body
• Registration for care workers could help boost the status of the profession and improve retention — but it is by no means a panacea
• Schemes to support — often-overlooked — informal care workers are vital

Finally, a thoughtful article from Sally Warren looks at what lessons the NHS could learn from Grenfell to better work with the communities they serve.

Children and Young People

The news from the NHS and social care can feel overwhelming — but shouldn’t drown out the many important stories elsewhere. The number of urgent care proceedings in family courts — local authority applications to take children into care — has risen since the start of the pandemic. According to one family lawyer, the rise in cases is due to the pandemic bringing “toxic family relationships […] to the fore”. As few of these cases can be heard at courts, some decisions about whether to separate children from parents are taking place over the phone — which is a pretty brutal reality check about the kinds of decisions closing courts has thrown up.

Last week, I noted that the Department for Education had removed some legal obligations in relation to children’s social care. There has been some concern from family lawyers that not specifying exactly which obligations local authorities can drop is not lawful, particularly as DfE did not ask parliament to approve changes.

Looking internationally, this Institute of Public Care briefing compares how different countries manage placements for children and young people — relevant reading given some of the problems in residential care in England.

And in the academic world, two useful briefings from the UCL Centre for Education policy look at the implications of reopening schools for teachers’ health and wellbeing, and the inequalities that home-schooling is reinforcing. For the overall picture on how Covid 19 will affect education, Simon Burgress’ overview for Vox has you covered.

Law and order

A quieter week — although controversies about how to police the lockdown continue. Nick Tilley makes some interesting points about how crime is likely to change during the lockdown, drawing on research from previous pandemics.

Meanwhile, an FOI from the Times found that the Met police has lost two-thirds of its fraud investigators since 2007/08, even though more fraud is being reported. The number of investigators has declined partly because police forces have focussed on serious crimes like county lines drug trafficking. The fall is particularly concerning given that fraud represented one-third of all crimes committed in England and Wales last year — and fraud is one crime that will probably rise during the lockdown.

In ‘normal’ news, the Police Foundation have published their second paper in their series about reviewing policing in England and Wales, this time focussed on what the police’s ‘mission’ should be.

Local government

I started hitting news overload at this point — there are almost certainly stories I missed. But one thing I did manage to read was David Philips’ analysis of whether the funding formula the government is using to distribute emergency money to councils makes sense. The formula is based on assessment of spending needs in 2013/14, since which things have changed considerably. The formula also bears little resemblance to the current distribution of coronavirus cases — he concludes that “the use of out-of-date and overly-general spending needs assessments may mean funding may not end up where it is ultimately needed most”.

In fairness, the government had to act fast, and spending a lot of time thinking about the right formula would (probably) have been time wasted. So why not instead “loosen the rules to allow councils to borrow to fund day-to-day spending linked to the coronavirus pandemic, allowing them to respond rapidly in a manner they see fit” [with government reimbursement later]? This makes sense to me — if you disagree, @ me on twitter cos I think the benefits of distributing money this way make more sense than using the old formula. In short, I think that the benefit of reducing financial bureaucracy for councils outweighs the risk that not all the borrowing might be for essential spending. What am I missing?