The Week in Public Services: 21st May 2020
This week: social care dominates headlines, how lockdown is increasing educational inequality, and finance woes in local authorities.
General
Lawrence Freedman, Emeritus Professor of War Studies at King’s College London, has taken a look at coronavirus planning and strategy at large and produced a really good piece. At around 50 pages there’s a lot to take in but a few things in particular stand out:
· “The government was not so much following the science as particular scientists, and then always had to consider the implications of their advice with reference to major non-scientific considerations, such as the economy and personal freedom.”
· “In retrospect, it is clear that the strategy developed during the first week of March assumed that the UK had more time to implement its responses than was available and more control over the development of the epidemic than was realistic. It was Johnson’s responsibility, along with the relevant ministers, to interrogate this advice.”
Freedman concludes that “the case to examine is not whether a bit more imagination could have pushed the government to take drastic steps before the hit was apparent, but whether sufficient notice was taken to get in more ventilators, build up testing capacity and ensure stocks of personal protective equipment.”
And of course, with an article that long, here is the obligatory accompanying twitter thread.
Too little, too late, too flawed is the verdict of this editorial in the BMJ saying the country’s response has “so far neither been well prepared nor remotely adequate” and that “system failings are being exposed brutally by covid-19”.
Ian Leslie writes in the New Statesman on the UKs coronavirus planning, and the apparent difficulties the government had breaking away from its 2011 pandemic flu plan. I was struck by the point that “countries that incorporate scientific advice into their policy process, like the UK, Spain and the Netherlands, were on average more likely to have responded slowly.” Read on to find out more about decision-making in an emergency, which all sounds perfectly sensible now — but how many would have thought so beforehand?
Suzanne Raine, former Head of the Joint Terrorism Analysis Centre, asks what’s wrong with evidence-based policy making and argues that waiting for scientific evidence before taking a decision means “always being behind the curve on risk.” She draws on her experience to draw parallels with the terror threat level judgements arguing that by definition they are not based on scientific evidence: “If you knew enough detail about a terrorist plot before it took place, you could stop it. Therefore the threat would not exist.” I’ll leave it to you to decide how transferable lessons from one are to the other.
Health
Here’s a smart take from Richard Coker, arguing that if the strategy at the beginning was ‘herd immunity’ it needed to be accompanied by islands of protected elderly people to avoid what is grimly known in epidemiological circles as harvesting — excess deaths to you and me. He argues that the initial strategy of developing herd immunity in the community while failing to protect the most vulnerable resulted in harvesting as de facto policy. On that topic, check out this clear and simple breakdown of the issues involved in measuring mortality during the pandemic. For a similarly simple international comparison check this out from the International Long-Term Care Policy Network.
Chris Giles at the FT reminds us of the peril of Goodhart’s Law — when a measure becomes a target it stops being a useful measure — and argues that the ‘protect the NHS’ slogan from the government created incentives which cost lives elsewhere. Although ‘protect the NHS’ wasn’t a numerical target, the point Giles makes about prioritisation and subsequent consequences is an important one. If all this interests you there’s good news: the IfG will be publishing a whole report on the use of targets in the coming months so stay tuned!
This pretty damming article into PPE procurement is well worth a read. Big Four firm Deloitte has been accused of presiding over a “useless” system for supplying PPE to NHS staff. Some of the stories in it are not pretty: one manufacturer with the capacity to make 100,000 gowns a week has been “passed around” for two months and still waiting for a contract. Tom Sasse at the IfG has produced five questions the government should answer on coronavirus contracts. And yet, hospitals are being told not to secure their own critical care equipment because of an “exceptional increase in national demand”. Sigh.
The Economist looks at the role of Public Health England amid criticisms that it abandoned contact tracing too early, didn’t work well with local authorities, and didn’t give useful, timely explanations about changes to PPE guidance to the NHS (or other sectors). It describes the organisation as “in the worst of all worlds: without the connections needed to make things work on the ground or the medical heft at the top to lead the national response.”
“Necessity has been the mother of invention in the response to the Covid-19 pandemic” with many lessons to be learned for the future. Here’s a rapid evaluation of some of the changes that have already taken place in hospitals, from PPE to task shifting in ICUs.
There was jaw-dropping news last week with the revelation that A&E attendances had halved since the coronavirus outbreak. A joint letter from the three health think tanks to the government called for “an understanding of the full extent of unmet health and care need”, measures to ensure staff safety in hospitals, a public information campaign to reassure the public that health services are safe to use, and, perhaps most importantly, support for health and care staff who’ve experienced stress and exhaustion.
Data from NHS England shows that 98% of GP practices now have a system in place for video consultations. If Sankey diagrams are your thing take a look at what data analyst Stephen Black has put together, analysing workflow and patient behaviour in general practice during the pandemic. As you might expect, contact methods that patients requested and what practices have delivered “both changed radically to minimise the need for face-to-face contact.” However, some are also frustrated that they can’t test suspected patients.
There’s an increasing focus on what a ‘new normal’ will look like when it comes to the NHS reintroducing other services alongside the sustained risk posed by covid-19. NHS Providers have published a briefing examining the issues involved, saying that trusts will need “realism and robust prioritisation about what can be delivered in what timescales” along with a coordinated national effort to return to a more normal service provision alongside coronavirus. What will the future look like for social care? Kathryn Smith, Chief Executive at the Social Care Institute for Excellence spells out the key questions, from creating a new contract between the citizen and the state to asking whether care homes of the future need to be smaller or have a different staffing structure.
And finally in a rare piece of non-covid news, the NAO’s report on digital transformation in the NHS makes for uncomfortable reading. It’s hardly impressed with the track record of digital transformation so far (needless to say the target of a paperless NHS by 2018 has not been achieved) and says local NHS organisations face “significant challenges”. One of many of these is financial investment “but the government does not have a reliable understanding of how much funding is required.”
Social Care…
…gets its own section this week. If you need reminding of everything that’s happened in social care in the past two months 1) I don’t blame you, and 2) the BBC have produced a handy timeline.
Data released by the ONS showed a higher death rate among social care workers (nearly twice as high) compared to health workers. Sally Warren at The King’s Fund said that the figures “suggest that social care workers are being disproportionately exposed to the virus and need more protection” and that social care staff “staff need to be prioritised and protected accordingly.”
Alarmingly, it seems as if nobody’s sure who’s in charge of coronavirus testing in care homes. One social care provider was “told eight times by PHE that CQC was responsible for the programme and four times by CQC that it was PHE’s job.” Eek.
Take some time out for this damming Tortoise investigation into care homes. “Just as a recession reveals businesses in bad shape, so this pandemic has exposed the disastrous state of the social care system”. Some very interesting points about consolidation (individual care homes having more beds), and the disparities in pay between management and care workers. Summed up in one sentence? “In the eyes of this firm [Runwood], one top earning executive is worth almost 200 carers. Even now. Even in this deadly crisis”. Provocative…
Over 200 care providers contributed to this survey from the National Care Association which tells “a story of utter despair as providers have had to fight their way through this pandemic with little information support from government.” While 80% of services had reported no incidences of Covid-19 (more you might think), providers reported that they have spent 323% more on average on stocks of PPE since the beginning of the pandemic. Behind the numbers are a myriad of human stories, including this grim tale of what it’s been like for one care home in Nottinghamshire.
How can we prevent infection in care homes? The International Long-Term Care Policy Network has produced a report looking at international examples of measures to prevent and manage coronavirus outbreaks in residential care and nursing homes. It opens with a helpful summary of key findings including the observations that while most countries have restricted care home visitors, this alone doesn’t prevent homes from infection and that staff pay and living conditions (e.g. crowded accommodation) may be “an important barrier to effective infection controls.”
The truth is that the social care sector entered the pandemic “badly in need of long-promised reform”. This explanation of the social care provider market from Camille Oung and Natasha Curry at the Nuffield Trust completes a set of explainers going through adult social care in the four nations of the UK.
When all of this is over, one of the biggest areas of focus is likely to be on hospital discharges to care homes without guarantees that patients were coronavirus free. Former Health Secretary Patricia Hewitt has said that the focus on emptying acute beds in hospitals in anticipation of a coronavirus surge “came at a high price” by those either in or discharged into social care — although clinician David Oliver argues that (1) this was already happening locally before NHS England issued advice on it, and (2) this was a reasonable decision given the state of testing and expectation of a wave of hospital Covid 19 patients at the time
What did and didn’t exactly happen could come out in an inquiry specifically into adult social care, which Bob Hudson at the University of Kent has called for. He suggests the fragility of provision, the policy salience of social care, and unethical practice as three areas it could look at. This piece from Anita Charlesworth and Sarah Deeny (both at the Health Foundation) spells out the problems (both long and short term) in social care that coronavirus has exposed.
A report by the Association of Directors of Adult Social Services (ADASS) in 2018 warned ministers of the exposure of care homes to pandemics. ADASS called for better supply plans for personal protective equipment but isn’t aware of if government departments picked up on any of the recommendations. DHSC haven’t yet said they did. ADASS also put out a good blog on allocating more money for social care: more funding is needed but is only part of the answer.
Sally Warren also has a very strong blog emphasising that social care has long been neglected by politicians and if/when they do finally get round to sorting it out after all of this there’s a real risk that they’ll create a system “fit for a crisis but not fit for its purpose.” Moving social care into the NHS is a simple solution but carries with it some real risks. Read on to find out more.
Meanwhile, Paul Corrigan argues we need to be building a moral crusade, not seeking a technical solution. The crisis has stirred people’s emotions, but many remain very unaware of the whole sector: there’s evidence to suggest that nearly half of the population doesn’t know what ‘social care’ means and when they discover it, they don’t think it’s funded fairly.
Children and Young People
Coronavirus is turning out not to be a great leveller in quite a few ways. The IFS have produced a masterful briefing using real time data on children’s experiences during home learning. Their research shows that children from better-off households are spending 30% more time each day on educational activities than children from the poorest fifth of households. That means If schools do not go back until September and current rates of home learning continue, the gap between the best and worst off families be 15 full school days’ worth of extra learning time.
Stephen Bush at the New Statesman has written an excellent article on the reopening of schools, saying it’s a question of logistics rather than risks. Even he admits that in probing the issue he may have “opened a door into a seemingly endless administrative nightmare”. It goes through issues from teachers’ visas to the ratio of sinks to students and does a thorough job of setting out just how hard reopening with social distancing would be. Tom Chivers’ piece is equally good, taking a broader look at the arguments for and against and neatly summarising what we currently know about the medical risk to children too.
Law and order
There have been some big changes to crime since lockdown including a 35% reduction recorded by the Met Police in London compared to the same period in 2019. The Met are using this time to target the 1,000 most prolific violent offenders in London. But police fear an “explosion of violent crime” as the lockdown eases. As some lawbreakers obeyed the government’s stay at home message, rivals have seized the opportunity and swooped in. Dr Simon Harding, director of the National Centre for Gang Research, has also warned that an increased usage of face masks in society could assist criminals in street crimes such as robberies.
In prisons, it emerged that prisoners with coronavirus symptoms were locked in cells for up to two weeks with exercise or access to showers after a snap inspection at HMP Wandsworth. It appears as if the government hasn’t released as many prisoners as it planned with almost 2,000 electronic tags purchased for released inmates remaining unused. Some Tory MPs certainly weren’t happy at the prospect of releasing some offenders earlier to ease pressure on the system. Opening the back door hasn’t worked — so how about shutting the front? Good blog from Rob Allen. The current (harsher) conditions in prison should be added to the list of factors for courts to weigh up whether to send someone there in the first place, he argues. Of the 76,000 sentences of immediate custody passed by courts last year, nearly 60,000 were for two years of under (so capable of being suspended sentences). It’s a suggestion but I’m not sure one that some Tory MPs will like the sound of that either…
And lastly, jury trials are coming back this week. A small number will initially take place at courts such as the Old Bailey as more courts are being considered against extensive safety criteria which have been drawn up. Social distancing will mean that some won’t be sitting where they usually do in the courtroom. The Justice Secretary Robert Buckland has said that courts will need to “sweat [their] assets to get back up to speed” and deal with the inevitable backlog. We also have some thoughts on the backlog, and the best ways for the government to tackle it.
Local government
With some local authorities feeling the pressure financially, here is a good summary of the debate between local authorities and government on what ‘reasonable cost pressures’ are.
Labour have claimed that local authorities are facing a £10bn black hole as they face the twin pressures of coronavirus spending and the drying up of some of their revenue streams. The party reckons cuts of 21% might be needed to balance the books. Leeds City Council and 21 other Yorkshire and Humber councils are warning the government that they do not have the reserves to see themselves through the current crisis, and that they will have to issue ‘Section 114s’ (bankruptcy notices) unless the government takes radical action. Not a good sign.
Meanwhile a leaked review of the government’s relationship with Local Resilience Forums found that “central government excluded local partners from key intelligence and failed to share enough information, hampering the response to coronavirus”. Richard Vize, writing in the Guardian, has said that over centralisation has undermined the country’s ability to respond to the pandemic. He claims that “attempting the impossible task of running everything from Whitehall” and poor political leadership has compromised the coronavirus response.
