The Week in Public Services: 26th January 2021

This week: how to use rapid tests; problems with remote learning; and a legal battle with the Home Office.

General

As ever, there’s a lot to cover this week, so my introduction is going to be very short. In fact, just one recommendation: ‘Insights 2021’ from the UK Household Longitudinal Study, which brings together summaries of research papers using their survey data. Lots of interesting material here, including papers on health care, and on teacher recruitment and retention.

Health and Social Care

After a grim start to the year, there is at last some good news to report in this section — case numbers are slowly falling, and the number of patients in hospitals across the UK has stopped growing. Adam Briggs has a helpful summary of the current situation. The latest REACT study from Imperial College caused confusion a few days ago, seeming to suggest that cases might still be rising. Case numbers were higher in early January than in early December. However, as John Burn-Murdoch and Oliver Johnson both pointed out on Twitter, the REACT study only has limited data from December. On this basis we don’t need to be too alarmed — but it is a reminder of how high infections still are despite several weeks of restrictions. Some are starting to turn their attention to when we might be able to lift restrictions, but with case numbers so high there are serious risks to loosening restrictions too early. Chris Hopson, chief executive of NHS Providers, argues that “there are a number of reasons to be very cautious at this point”, especially in light of the new variant. Hospitals certainly remain under serious pressure. There were 37,899 Covid-19 patients in UK hospitals on 21 January, and hospitals have been forced to utilise private hospital capacity in some areas. To try to ease these pressures, the Treasury has agreed in some cases to underwrite insurance for care homes so they can accept patients from hospitals. The funding was welcomed by NHS Providers, although the fact it is time-limited (until mid-March) may prevent the policy achieving its objective.

There have been quite a few good pieces about current or future Covid-19 policies:

• As I write this, there is an ongoing discussion about hotel quarantine, with some kind of announcement expected soon. Good idea or bad idea? You won’t be surprised to hear that it’s rather more complicated than that: my Institute for Government colleague Sarah Nickson covers the implications well in this blog, drawing on Australia’s experience of this policy.
• Another excellent piece this week comes from Tom Chivers, writing about how to use lateral flow tests (rapid turnaround, ‘pregnancy’ style tests, as everyone keeps saying). These tests have been controversial among scientists and the wider public. I recommend reading the whole piece, but here’s my summary: lateral flow tests can be helpful in some circumstances, but we should be cautious because sometimes they miss infectious cases. A good use is for mass testing to identify asymptomatic cases which would otherwise be missed; a bad use is to allow entry to care homes, because the consequences of a false negative could be very harmful. As they are used more frequently, we must make sure we’re also using them wisely. The Health Foundation’s Test and Trace performance tracker has a useful summary of the latest data on testing — the finding that really caught my eye is that 5% of England’s population (2.9 million people) had a Covid test in the week 7–13 January (including PCR and lateral flow tests).
• Stuart Ritchie from King’s College London wrote last week about the government’s communications. He persuasively argues that the government has placed too much emphasis on handwashing, and not enough emphasis on airborne transmission (droplets and aerosols). In fact, one survey found 16% of people in the UK said that Covid-19 was “mainly” spread by touching objects with the virus on them — even though there is little evidence for people catching Covid by touching things. Emphasising handwashing at the beginning of the pandemic was reasonable, but nearly a year later the government should have changed its messaging.
• The Observer had an interesting interview with Jeremy Hunt on Sunday. Hunt argues for self-isolation payments to encourage people to comply with isolation requirements — a topic covered in last week’s blog. He also suggests the UK should follow the lead of Austria and Germany, by making higher-grade FFP2 masks mandatory. On social care, he says he regrets that it was not better protected during the period of austerity: “It was the silent cut that people didn’t notice until too late. […] You can’t possibly have a 1948 moment for the NHS without addressing the problems in social care.” Those involved in delivering social care might be disappointed he did not prioritise it more during his time in office.

There are also a few Covid-related pieces looking back:

• The Health Foundation’s excellent Policy Tracker has been updated to include policy changes up to the end of 2020.
• Deidre Heenan has written about how the governments of Northern Ireland and the Republic of Ireland have worked together during the pandemic — or not worked together. “It has been asserted ad nauseam that ‘this virus doesn’t respect borders’ and ‘the disease does not discriminate’, but without meaningful political action. […] Co-operation to date has been woefully inadequate.”

Let’s move on to research and news that isn’t Covid-related (there is some, I promise!)

A research paper, published in the Journal of Integrated Care and co-written by authors from the NHS Strategy Unit, examined the effects of integrating community nursing services with hospital care, using data from 2006–2016. The authors find no difference in emergency hospital admissions between the trusts that did structurally integrate community nursing, and those that did not. They conclude that their research “suggests that mergers and organisational changes should not be confidently promoted or pursued as a means of reducing hospital activity. […] Other factors appear to play a more significant role in determining levels of emergency hospital admissions, and more effort should therefore be applied to identifying those critical ingredients robustly.”

The findings from the paper are pertinent at the moment, as NHS England and NHS Improvement are currently consulting on another structural reform in a paper called ‘Integrating Care’. This envisions collaboration, integrated care systems and a greater emphasis on localism, as described in Fraser Battye’s blog for the Strategy Unit.

Rare good news in this section: the number of students on nursing training courses rose in 2020, most likely as a result of greater funding for clinical places and the reinstatement of the maintenance grant. In time, these students will fill vacancies which existed before the pandemic, as well as helping the NHS as it deals with the consequences of a year of enormously difficult conditions for staff.

As we all know, health spending in the UK continues to rise. Why is this? A great paper from health economists at the University of York examines this question. Take a deep breath for the upcoming sentence: the paper argues that “decomposition of patient level expenditure in England between 2009/10 and 2016/17 suggests efficiency gains in treatment across the full distribution of expenditures, but that these were outweighed by structural changes towards a greater proportion of patients presenting with high-dimensional comorbidities.” Or — the NHS is doing operations more cheaply, but still spending more money overall because a greater number of patients with multiple, expensive-to-treat conditions are coming forward. Or even more simply — higher health spending is a consequence of higher health needs.

Finally, a Nuffield Trust report examines emergency hospital admissions for children under the age of five. Between 2009/10 and 2018/19, the emergency admission rate for children aged under five increased by 18%. Admission rates were highest for infants, and for children from the most deprived areas of England. The key policy recommendation states: “Sustaining the focus on the first 1,000 days of life is vital as unacceptable inequalities in emergency admission rates persist. Targeting interventions at specific groups in addition to universal policies might help to address the drivers behind the use of emergency hospital care by young children such as infants and by level of area deprivation.”

Vaccines

In recognition of their importance, vaccines are getting their own subsection…

• Nearly 10% of the UK population has received a first dose of the vaccine, with England ahead of other three nations of the UK so far.
• Early data from Israel looks encouraging, with a reported 60% drop in hospitalisations for those aged 60+ three weeks after the first vaccine dose.
• Health Foundation charts show the variation within England of the proportion of over 80s who have had the vaccine so far — although given the speed of the vaccine rollout, this is a constantly changing picture.
• It is that variation that has led to the government’s decision to reduce vaccine supply to those regions, such as the North East and Yorkshire, which have given vaccines to the highest proportion of the most vulnerable — a contentious decision, but perhaps justifiable in the context of insufficient supply.
• The BMA has expressed concern about the 12-week gap between the two vaccine doses. This is another area of medical disagreement: many, such as Deborah Dunn-Walters and Sheffield Director of Public Health Greg Fell, support the current approach.
• Beccy Baird has written for King’s Fund about the role of GPs in the vaccine rollout.

Children and Young People

Inevitably we start with Covid and schools. There is a lot of ongoing discussion about when schools might be able to return to in-person learning, with a multitude of suggestions — primary schools before secondary schools; exam year groups before other year groups; or teachers selecting vulnerable children. Robert Halfon, chair of the education select committee, has asked the government for a “routemap”. But with infections still high, the government has thus far resisted calls to commit to a particular date or approach. It is also important to remember that schools are not entirely closed at the moment: in England on 13 January, attendance was 21% in state primary schools, 5% in state secondaries, and 30% in state special schools.

A new paper for the Education Policy Institute by Luke Sibieta analyses Covid-related teacher and pupil absence rates in England in the 2020 autumn term. Teachers were more likely than pupils to be absent due to a confirmed case of Covid-19, but conversely pupils were more likely than teachers to be absent due to other Covid-related reasons (a suspected case or close contact with a confirmed case). This is because more pupils were asked to self-isolate. FFT Education DataLab have also analysed the same dataset. A key finding is that in secondary schools, teachers were about as likely to self-isolate due to external contact, as they were to self-isolate because of in-school contact. “This re-emphasises the degree to which infection in schools reflects infection in the broader community, and that the dangers to teachers’ health are not only, perhaps not even mainly, to be found within schools.”

Regarding 2021 exams in England, we are currently in the middle of a consultation period. UCL’s Centre for Education Policy and Equalising Opportunities published a blog which summarises their submission to that consultation: they argue that Ofqual/DfE’s approach must take account of differential learning loss. They also recommend that exam boards play an important role in providing external quality assurance and taking on responsibility for the appeals process.

There are several pieces of research on remote learning this week:

• A Sutton Trust report ‘Learning in Lockdown’ highlights various aspects of remote learning which are likely to increase the disadvantage gap. For example, a survey in January 2021 found that “32% of teachers in the most deprived schools report more than 1 in 5 lacking devices, compared to just 5% at the most affluent state schools and even lower, 3%, at private schools.”
• …that makes the DfE’s handling of laptops all the more important. In general, the government has improved the situation gradually during the pandemic, but significant gaps remain, according to survey data. New data on laptops and tablets distributed by the DfE is being released today: one to keep an eye on.
• Ofsted released new research on remote education, summarising some of the research we’ve covered on this blog over the past months. They also have new survey data. On the positive side, 61% of teachers say they are confident they are providing a “high quality” of remote education. On the other hand, parents overall said the biggest challenges were their children’s lack of “focus” and “motivation to engage” with remote learning. This was especially true of pupils with SEND: “59% of parents of a pupil with SEND said that their child has been disengaged with remote learning, compared with 39% of parents of children without additional needs.”
• A blog by Natalie Wexler reviews a book by Daisy Christodoulou on technology in education. Christodoulou makes the argument that technology can help students learn, by increasing their knowledge and moving information into long-term memory. However, if technology is used to teach skills, rather than knowledge, it doesn’t work so well. An interesting (but controversial) argument. Personally I wonder if the blog’s point about digital distraction — i.e. children playing a video game on their iPad instead of learning — is an even greater problem.

Away from remote education, there are a few other interesting pieces to cover:

• The IFS explain why this month’s early years census (which took place on 21 January) is likely to reduce government funding for childcare: “The risk that the government faces in tightening the funding environment now is that some otherwise-viable providers will go bust, and it will be costlier and more difficult to rebuild this capacity later on than it would have been to support it to stay open.”
• FFT Education DataLab have a great series of charts showing the impact of disadvantage at Key Stage 2 and Key Stage 4, broken down by English region. Their conclusion: “Geographic differences in the composition of pupil populations rather than school effectiveness largely account for regional differences in attainment.”
• An article in The Lancet summarises the evidence regarding the impact of the pandemic on children’s mental health.
• A blog post by Billy Huband-Thompson talks about combining evidence with values in education policy.

Law and Order

Quite a lot of new research on prisons this week:

• Nuffield Trust analysis of Covid-19 in prisons during the second wave shows that there have been more cases in prisons than in the general population (per 1,000 people). However, it isn’t clear whether this is actually due to more cases, or whether it reflects more testing in prisons.
• Prisons are currently in ‘stage four’ (lockdown) — this blog describes what that means.
• The Centre for Social Justice published a report on digital technology in prisons, which argues that the pandemic has exposed the fact that prisons haven’t moved into the digital age. Most prisons in England and Wales don’t have broadband, for prisoners or prison staff. This has created serious problems in the period of lockdown, when prisoners have been unable to see their family in person. Video calling has been installed during the pandemic, but prisoners are entitled to just one 30-minute call per month. The paper’s key recommendation is that “the installation of broadband technology with limited, secure access to the internet for prisoners is both overdue and necessary.”
• And some good news: an MoJ evaluation of the educational programme delivered by the Prisoners’ Education Trust shows a positive impact. Prisoners supported by the programme were more likely to find a job, and less likely to reoffend.

We have highlighted backlogs in the courts repeatedly in Week in Public Services. A new Crest Advisory report has some sensible recommendations for how to manage the backlogs. However, their modelling for the increase in backlogs over the next few years is based on some questionable assumptions, as described in this previous blog.

The Police Foundation published a new report on digital forensics, with recommendations including overcoming fragmented systems, better co-ordination and more specialist staff.

Last, but by no means least, Danny Shaw’s blog recounts his protracted legal battle with the Home Office to access unpublished evidence about the increase in serious violence. A 2017/18 document from the department’s Analysis and Insight Unit stated that reductions in police resources had contributed to the increase in serious violence, as well as an increase in drug-related violence. Police resources were not the only factor — among other reasons, the analysis shows that half the increase in knife crime, gun crime and robbery was due to recording changes. However, the government under Theresa May refused to acknowledge any link between less resources and higher crime, not even referencing it in its own Serious Violence Strategy (2018). Shaw writes: “Policy should be based on evidence. Much of the evidence in the Serious Violence Strategy was on view. But crucial parts were omitted for political reasons. When that happens, trust in policy and policy-makers is damaged, and we all suffer as a result.”

Local Government

A shorter section… Local government is playing a key role in the vaccine rollout. Recognising this, central government has made £23m available to councils to help encourage take up of vaccines, and fight misinformation.

A long post this week, so well done if you made it to the end!