The Week in Public Services: 19th November 2020

This week: promising vaccine news; second lockdowns across most of western Europe; and so. Much. New. Research!

General

Lots and lots of news (maybe you’ve noticed!?) over the last few weeks — let’s start with an undernoted but important problem during the pandemic: enforcing health and social care regulations in places where people were still going into work. The Resolution Foundation argue that the pandemic “highlights weaknesses in the general approach we take to labour market enforcement in the UK […] without adequate resourcing, a more systematic use of employee intelligence and in some circumstances, a more precautionary approach to enforcement, poor and unlawful employer practice could continue unchecked” — which is clearly a problem where there are genuine concerns about poor workplace practices leading to high coronavirus transmission. For the key points, check out this summary thread.

As we are in a second period of reasonably high prevalence of coronavirus, Sarah O’Connor’s FT column (£) clearly outlines what the government should do to better protect key workers this time round. She argues that the Health and Safety Executive should undertake more inspections and collect more data on Covid-19 cases and deaths in workplaces.

Props to Kai Kupferschmidt for writing the article I’ve been wanting to read: how did most of Western Europe end up in second lockdowns? (And what does that tell us about UK-specific failures?) His answer is — broadly — that there were failures in Test, Trace, and Isolate systems, increasingly lax physical distancing, and few if any, border restriction measures. The big unanswered question: what is the strategy for exiting lockdown? Can Western European countries do better than ‘reduce, relax, repeat’? I hope so. Andy Cowper has written about the second national lockdown in England specifically, and argues that it, again, came too late — and that failures in Test-and-Trace were the principal cause.

In better news, the big story is that of Pfizer’s success in an initial trial of a Covid-19 vaccine. Likewise, the Oxford vaccine for coronavirus and Moderna vaccine are also reporting good early results. The big concern now is take-up, logistics, and roll-out. Andy Cowper set out some useful practical things to look out for including whether and how specific vaccine rollout centres will need to be set up to keep the vaccines cold enough. (Tim Harford is hosting a wonderfully insightful series called ‘How to Vaccinate the World’ about how vaccines are developed, which I cannot recommend enough).

In a last bit of research news, Reform’s always-interesting State of the State report has been published — worth skimming the quotes from interviews with public sector leaders about what has enabled fast reforms.

Health and Social Care

Right, in health and social care news — lots of analysis, so let’s try to set a few things to straight:

The ‘other’ NHS England press conference was on 4th November — and a lot clearer than the government one on the 31st October. An important thing to remember when thinking about the consequences of this lockdown for health treatment is that the lockdown is different this time round — NHS England is (rightfully) trying to keep other health services going where hospitals are not overwhelmed with coronavirus patients. See this summary for more detail. This makes sense given the large backlogs of elective care that have built up, although it reduces the margin for error — keeping these services open gives less scope for hospitals to respond if coronavirus hospitalisations rise quickly, so for this to work, the UK will need to keep case numbers lower than they were in the spring. Which, as Chris Cook rightly points out, means that the argument that this national lockdown in England will increase deaths by reducing use of hospital services is…utter nonsense. It is, of course, the virus which causes the need to shut off other health services — not the lockdown itself. National lockdowns of course have a range of other negative consequences — but this time, shutting off health services ain’t one of them.

This Nuffield Trust summary about how the first and second waves compare in England is also very helpful. It’s hard to compare the waves because we had so little information back in March, but models estimating the prevalence of cases in March suggest that the peak of new cases per day in the first wave was somewhere between 99,000 and 178,000 . This compares to an ONS estimate of 39,500–58,600 cases per day in the week after the lockdown was announced, 31st October — 6th November. The prevalence of Covid-19 is (probably) lower than it was in the spring but that is no reason for complacency — particular if we want to keep other health services open, as the strategy now seems to be.

Unfortunately, keeping other health services isn’t as straightforward as just keeping coronavirus cases low. Staffing is going to be a massive problem too, as Shaun Lintern has noted. The nursing: patient ratio has been diluted in critical care units, again, to cope with the second wave. Perhaps most concerningly, the number of staff saying that they intend to leave the health service has been rising — retention will be a big problem even if immediate vacancies are solvable in the short-term: NHS England announced all patient-facing staff would get lateral flow tests twice a week on 9th November, which should help reduce the need for pre-emptive isolation. As well as reducing staff vacancies, asymptomatic testing should hopefully reduce surprisingly — at least to me — high rates of hospital-acquired coronavirus. The Health and Safety Investigation Board’s review into hospital-acquired coronavirus over four months this year makes for sobering reading. As well as the obvious (lack of PPE, lack of tests), hospital building design also contributed to transmission. Looks like Jeremy Hunt put himself on the right side of history by calling for mass staff testing early on…

Vaccine news has somewhat overshadowed mass testing plans. What’s going on there? A pretty withering article in the BMJ concludes that mass testing for Covid-19 would be “an unevaluated, underdesigned, and costly mess”. The authors conclude that it would be better to focus on increasing adherence to self-isolation rather than embarking on a mass screening programme because around half of asymptomatic people go on to develop symptoms anyway. Then, there’s the false positive problems (if you test positive on a quick turnaround lateral flow test, you’re still asked to self-isolate — which means many people will be self-isolating without having had coronavirus). Incredibly, the Innova test’s instructions — the test being used in Liverpool — suggest that asymptomatic people should not use it. Perhaps most frustratingly, the prevalence of Covid-19 was already declining in Liverpool prior to the introduction of the mass testing programme so it will be very hard to say what effect it has had! For more detail, see these helpful threads on this mass testing programme compared to how mass screening programmes are normally run from Stian Westlake (check how sensitive and how specific the tests are) and Angela Raffle (research design and the false positives/negatives dilemma are still important, no matter how quickly you roll a scheme out).

In other news, stories about PPE procurement are getting more bizarre and scandalous by the day. Yes, it was an emergency with incredibly high demand for PPE, but some of the shortcuts to normal process seem unjustifiable. A lot of these stories have come out of the NAOs report about procurement in the first phase of the crisis, which found that only 3% of £18bn of contracts were awarded competitively (and lots of failures in documentation and transparency, too). For a 30-second summary of why this is important given wider concerns about cronyism, see my colleague Tom’s points on the Daily Politics.

There was an absurd amount of new research over the last two weeks (seriously, I cannot read this much — slow it down, wonks), including:

• Nick Timmins on what kind of health secretary Jeremy Hunt was — one who tried to ignore the 2012 Health and Social Care Act “as far as we [the Department of Health and Social Care] could”
• Nuffield Trust’s analysis of what progress has been made on the government’s staffing promises (worth combining with this blog about problems retaining GP staff)
• The Health Foundation’s analysis of the backlog of elective care caused by Covid-19 and how to address it (a 32% reduction in elective care pathways completed between January and August this year…with the biggest falls in oral surgery, trauma, and orthopaedics — there is some scope for the independent sector to help with the catch-up, but only for some specialities)
• Joint Institute for Fiscal Studies and Nuffield Trust analysis of how the pandemic disrupted health and social care services for older people (those living in the most deprived areas were most likely to experience a disruption to their care — partly because they use more care — and, surprisingly, there were few disruptions to access to routine medicine)
• Policy Exchange’s take on how to reform the public health system (which recommends moving Public Health England’s health improvement functions back into the Department for Health and Social Care, and linking the public health grant to the NHS budget — which would likely make funding a lot more generous…)
• The Association of Directors of Public Health on how the government should reset its coronavirus strategy (be straight with the public and make the support available to people self-isolating more generous)
• The King’s Fund on eight technologies which will change health and care (no, the pager is not one of them — good list from Pritesh Mistry)
• A Health Foundation longread about inequalities in health care for people with depression and/or anxiety, which found “a higher proportion of people with long-term conditions, more complex prescribing and higher rates of unplanned care use among people with depression and/or anxiety living in more deprived areas [but] rates of primary care consultation and planned secondary health care are not higher in more deprived areas than less deprived areas”. Concerning — this suggests that people with more complex needs in more deprived areas may not be using the most appropriate care
• If you fancy a proper dense read, this edition of Eurohealth compares how health services in different countries responded to Covid-19 (I know I’m a huge nerd but this chapter on changes to the way hospitals were paid was super-interesting; I did not know that England was atypical in suspending its normal payment system entirely during the pandemic)
• And last-but-not-least, Nuffield Trust have charted changes in urgent care in England

The world of adult social care has changed a lot, too:

• The Latest round of local authority covers additional spending and lost income in September 2020. Local authorities project that 45% of their additional unplanned spending in 2020/21 is forecast to go on adult social care…

• The Local Government Association have summarised digital innovations in adult social care…
• …and interesting examples of local health promotion
• New research from the health economists at York found that public spending on adult social care has limited observable impact on hospital outcomes. Or, more specifically, “no conclusive proof that reductions in social care budgets have led to the expected rises in hospital admissions, hospital stays or uptake of NHS Continuing Health Care”

It’s worth expanding on this finding. On the one hand: what!? All the lobbyists say that more social care spending would reduce pressure on acute healthcare? On the other hand — this is actually not that surprising. It takes a long time for preventative strategies and investment to lead to observable differences. And the data is noisy — there is just a whole lot of other things getting in the way. A few years ago, the IFS found this cuts to social care spending increased older people’s admission to A&E, but that the net cost of was not as high as you might think — “increasing A&E costs by an additional £3 per resident for each £100 cut in social care funding”. My boring take: I think this shows is that you can’t expect quick reductions in acute activity from bunging cash at another part of the system that’s often thought of as ‘preventative’. It’s just hard to get results from investing in ‘prevention’ quickly.

• Finally, a good article about what care providers thought about the government’s support for social care in the first wave of the pandemic, and what it was like on the ground, based on a survey of English care home providers — “despite policies that were put in place, care homes amongst our survey respondents were still unable to access sufficient funding, testing, PPE, workforce support and practical support to isolate residents by the end of May and early June”

Children and Young People

In schools wonk world, the 2021 exams are still the big focus. The Education Policy Institute recommend that if exams do go ahead there should be more optionality in exam papers, and some grade inflation should be allowed. If they do not go ahead, they instead recommend “benchmarking assessments”, and to pursue research on the impact of using teacher-assessed grades. (The report also covers recommendations for pupils who lost learning time).

An alternative solution might be to use mock exams as back up option for 2021…but if these mocks were held in January, that would give disadvantaged pupils even less time to catch up.

Of course, whatever happens will have big implications for university admissions. This UCL research about reforming university admissions and the problems with making admissions before A-level results (disadvantaged kids are systematically under-predicted high grades) suggests another way forward — a post-qualification admission system. In fact, the Department for Education now plan to review this — they should definitely read this excellent blog from Dr Gill Wyness on why and how a post-qualification applications system could be implemented.

Elsewhere a brilliant, depressing, study summarises learning loss among primary school pupils in the Netherlands. Even in a country with limited lockdown measures and exceptionally high broadband access, “primary school students lost on average 3 percentile points in the national distribution relative to a normal year, equivalent to 8% of a standard deviation. Measured as progress in a typical year, this implies that students lost out on a fifth of a year of quality-adjusted schooling”. What I take away from this is that it is really, really, hard — if not impossible — to do remote teaching effectively…which is why it’s so important that schools stay open. To be fair, the government did allocate some extra cash for schools to help pupils catch-up, and for a national tutoring scheme, but it’s unlikely to fully compensate for all the learning lost. There are some concerns about the way the tutoring platform will work, as well.

In reaction to Marcus Rashford’s campaign, the government announced a new policy to support low-income families — there will be a £170m winter grant for councils to help with food and bills, lasting from December to March. The holiday food and activities programme will also be expanded with £220m to cover Easter, summer and Christmas in 2021. The government also pledged £16m for food banks but did not give a time scale for that. Some might say that this is a tacit acknowledgement that Universal Credit doesn’t provide enough financial support to some families…

In children’s social care, a Guardian article argues that the work children’s social workers have done has gone under-noticed during the pandemic, and three new children’s commissioner reports criticised instability in care placements, private involvement in care, and the quality of unregulated homes.

Law and order

The Lord Chief Justice’s Report 2020 was published this week. Two key points are that remote technology has been effective in many cases, and that the “reform and modernisation programme must be seen to its conclusion, with appropriate funding made available to complete the job.” Second, funding arrangements for HMCTS in the future needs to make it possible to deal with backlogs: “the starting point should be a realistic assessment of the outstanding work which needs to be done together with an evaluation of the likely work coming into the system.”

And what has happened to the numbers of people in prison and supervised by probation services this year? The latest stats back up our projections from earlier this year — slight reductions in both, owing to the reduction of inflow (fewer court cases heard means fewer people being sentenced to prison and/or probation).

The second wave is going to be different in prisons this time, too. The government has published changes to the prison regime in second wave, which primarily seems to be introducing routine testing of staff and prisoners being transferred.

Finally, Nick Hardwick, the former HM Chief Inspector of Prisons, has written a good paper on what went right in prisons during the first wave of coronavirus. Despite the poor state of prisons on the eve of the crisis, infections and deaths have been kept low, and there has been a notable decline in assaults and incidents of self-harm. Nick cites the importance of locking down quickly and harshly, and the reduced prison population. However, the latter is almost entirely due to the reduction in the number of cases processed in the criminal courts and the paper rightly warns that reducing the case backlog will mean a rising prison population and greater difficultly managing the second wave. Although the report has been written for Crest Advisory, it’s notable that no mention is made of the company’s dubious projections for the case backlog published three weeks ago.

Local government

The big news was the Croydon council became the first local authority in England to issue a ‘Section 114’ (bankruptcy) notice during the pandemic…for more on which — read my blog which will be out soon(ish). In the meantime, Adam Lent wrote a polemic for the Guardian here.

Elsewhere, Reform have published five case-studies about Resilience in Local Government: Lessons from Covid-19.