The Week in Public Services: 5th January 2021

This week: coronavirus is out-of-control in the UK; schools U-turns; and new year’s resolutions

Happy new year! Hope you got some kind of break…before we kick off, here’s two new year’s resolutions for everyone.

Firstly — stop saying statistically significant if you mean ‘actually significant’; it’s deeply confusing for non-stattos. Try using “statistically detectable” — a much clearer phrase — instead. I am going to try to do this more this year.

Secondly — stop using ‘there is no data’ as a justification for not acting at all. True enough, there is usually not a perfect randomised controlled trial to provide you with gold-standard evidence. But that doesn’t mean there is no useful information to inform decision-making. There is normally evidence from comparable situations, at the very least. As someone who often falls into ‘we know nothing’ trap, I whole-heartedly endorse this. We don’t know everything; but we often know more than we think.

In case you’ve just woken up from a year-long snooze under a rock — and if you have, let me know how I can get in on that — Ed Yong wrote an excellent longread on what we learned in 2020, and what 2021 will bring. It’s focussed on the US but could equally well describe the UK in many places — especially the final sections on the unequal impact of the pandemic. The big King’s Fund review of 2020 is also well worth reading — the only King’s Fund piece referencing Lenin, to the best of my knowledge. Stick to the end — the final chart is one of the best ways of visualising changing waiting times in the NHS that I’ve seen.

Health and Social Care

In the course of two weeks, we have moved through the discovery of a faster-spreading new variant of Covid-19, several national press conferences, put most of the country under Tier 4 restrictions, then closed all schools. The UK ended 2020 with the highest number of coronavirus patients in hospital since the pandemic began.

The virus is spreading terrifyingly quickly. These hospitalisation numbers are going to keep rising in the short-term — let’s hope that new restrictions change the trajectory. Jeremy Hunt, the former health secretary, has concluded that the government has no choice but to close all schools, borders, and ban household mixing.

In short: there’s been a lot to digest over the last few weeks. Here’s what I found most helpful to get up to speed:

• Deepti Gurdasani’s summary of the Imperial report on the new, B117, strain of Covid-19 — the essential points being that it appears to be more transmissible than previous strains (indeed, this strain rose in prevalence even during the November lockdown), and is more prevalent in children

Sidenote: a lot of the media commentary on the need for new restrictions has focussed on this new variant which, while true, lets the government off the hook somewhat. As Alistair McLellan argued at the end of December, it was clear that admissions were rising at the start of December. Even if it wasn’t clear that a new virus was the cause of faster spread, the government could and should have acted earlier. In short — ‘the facts’ changed much earlier than the government changed its mind.

• On the data front, John Burn-Murdoch’s essential public service continues, showing just how grim and widespread the rises in cases and hospitalisations has been. This chart — how many NHS beds are occupied by patients with coronavirus — is key. The more this rises, the more the NHS will have to postpone other care — which is already looking dire

As stark as they are, the statistics can’t convey the reality of the frontline in hospitals — which this thread from Chris Hopson does. Staff absences, especially of staff in critical care wards, are as big a problem as rising hospitalisations. Shaun Lintern continues to outline the reality of the hospital frontline for the Independent. These stories are particularly striking.

Summing up: cases are rising rapidly everywhere, and to dangerously high hospital occupancy levels in London and the southeast of England.

Taking a step back, the government’s slow reaction to these warning signs reveals a bigger problem: its approach to managing this pandemic has been consistently ad-hoc, rather than based on clear rules. Without a clear set of criteria for deciding when to review its approach and/or change restrictions, the government has found it harder to weigh up competing arguments, and consistently found itself acting too late. Chris Cook suggests that a rules-based response might be other benefits too — such as making it easier to ensure compliance (‘I am following these rules in order to prevent/get out of…’ etc.)

Taking an even bigger step back, the fact that we are (again) shutting almost everything down to preserve the capacity of the NHS to treat coronavirus patients should make us reconsider whether the health service is resilient enough to weather unexpected crises. There was already a lot of ink spilled over whether the NHS (and the rest of the British state) was resilient enough last year (I am as guilty as the next wonk), but the thread above is well worth reading. I think Ian sums up the political problem perfectly: how do you sustain additional resources that look inefficient in normal times? I also liked Chris Cook’s suggestion of caps on staff working hours and/or high staffing ratios (which is logical given the real problem during the pandemic has been trained staff, rather than physical resources).

Political difficulties aside — Nick Hassey has a proposal for a ‘global insurance policy’ to guard against future pandemics here. Worth reading — many of the problems here (preparedness doesn’t pay — so it needs states to step in) are the same problems that bedevil governments trying to improve resilience.

The other big, and more positive, story is the vaccine rollout. We now have vaccines data (woo!), and over 944,000 people have had their first dose of the vaccine as of the week ending the 27th December. That’s impressive — but still low compared to Israel, which has vaccinated more than a million people — 10% of its population.

It’s an obvious point, but the speed of the rollout really, really matters. The quicker the rollout, the faster the reduction in deaths. The real question is, of course, why isn’t the rollout proceeding faster?

There are a bunch of possible answers to this — but here is what I have managed to piece together as happening:

• Resource constraints: the UK doesn’t have enough glass vials to distribute all of the Oxford-AstraZeneca vaccine it has available (all credit — Bloomberg covered the difficulties of getting all the infrastructure ready to deliver a vaccine months ago)
• Logistical problems: it’s harder to prove that there are problems in the delivery chain — and Matt Hancock has said the only constraining factor is manufacturing… — but there are more military personnel being deployed to vaccine sites, which suggest this could be a problem
• Administrative challenges: delivering a vaccine is, simply put, a massive administrative headache

This is not a problem unique to the UK, of course (Ashish Jha set out similar problems occurring in the US in this thread) . But all of this points to at least one basic communications problem — there are so many confusing numbers around, so why does the government not just get ahead of these confusing briefings, by setting out a clear delivery plan and targets? (And no, an op-ed in the Telegraph does not count).

The other major vaccine debate is about the logic of spaced vaccines. Should we prioritise giving two doses for full protection, or give as many people as possible one dose, when the supply of vaccines is limited?

The case for is that it’s the best way to use limited supplies. A single dose, even if doesn’t give full immunity, can reduce the severity of symptoms people get — which would do a lot of good given the high and increasing prevalence of coronavirus at present. Most existing vaccines generate more effective immune responses with longer intervals between doses. This is the logic that the four UK chief medical officers set out in this statement (and Jonathan Van-Tam explained at the press conference). See also these threads from Sandy Douglas and Jim McManus.

The case against is that there is ‘no evidence’ (or, rather, no randomised controlled trials specifically on) that delaying the second dose past a certain time interval would still confer immunity. In other words, there is a risk that too long a delay between vaccine doses will result in no protection at all. Ashish Jha’s thread where he explains what changed his mind from double-dose to spaced doses is very clear, and well worth reading. (Confession: your author also thinks this is the right thing to do).

Either way, changing the vaccine strategy this late in the day creates uncertainty for patients and lots of additional work for GPs to rearrange and reschedule lots of patient appointments. It’s probably the right thing to do, but the communications could have been handled more sensitively.

There’s been less news about social care over the last few weeks as stories of nearly overwhelmed hospitals have dominated the news. I hope that this is because the sector is better-prepared for a second (or third, I suppose) wave, and they have the support they need from central government and local authorities — but another wave of coronavirus in care homes (and among those who receive homecare) is undoubtedly a big risk. The latest data on deaths in care homes notified to the Care Quality Commission show a steady increase in reported deaths in care homes since the start of October. It’s essential that the government focus on preventing deaths in all settings — not just preserving hospital capacity — this time around.

Looking to the US, a good article from the New York Times analyses why nursing homes in the United States were so hard hit during the pandemic. The short answer(s)? “Long-term care continues to be understaffed, poorly regulated and vulnerable to predation by for-profit conglomerates and private-equity firms […] long-term care was designed to fail years before Covid-19.”

Children and Young People

Schools have rarely been out of the news in 2021 so far. I’m not going to recap all of it, but the government in England moved pretty spectacularly quickly from telling parents to send their children to schools (Sunday 3rd January) to…closing schools (Monday 4th January). A couple of reflections:

• I think this might be the earliest point in the year where any British government has u-turned (any takers to prove me wrong on this?)
• Trying to keep some schools open and some shut based on a mix of local authority case and hospitalisation data when cases are rising everywhere is pretty much the definition of rearranging the deckchairs on the titanic

What policymakers and politicians should learn from this debacle is that schools are neither inherently safe nor inherently dangerous. Rather, the effect of opening schools on transmission depends on the prevalence of coronavirus in the community — as this neat paper demonstrates.

Following the schools closure, the government confirmed that GCSEs and A Levels in England are cancelled this year to be replaced with…‘alternative arrangements’ — they should read this excellent blog from the UCL Centre for Education Policy for ideas (they recommend externally set and marked tests, flexibility in timing, and flexibility in content).

Taking a step back, the bigger question from this debacle is whether it is a political failure, or whether it points to wider problems at the Department for Education. Chris Cooks argues it’s the latter (his case: look at the past year of policy and implementation failures), and that it’s due to a lack of institutional memory, the department taking on direct responsibility for so many academies, and successive ministers continuing Gove’s press ‘strategy’ of waging war on teaching unions.

Axel Heitmueller raises the key question: why has there been so little progress on alternatives to face-to-face teaching? Now I think there’s a simple answer here: I’m not sure there’s that much scope for innovation and redesigning school teaching so it’s not face-to-face (though happy to be proved wrong here), and I think it’s more of a case of harm-mitigation while schools are closed. The overarching point — that the government could have put more measures in place to prepare — I entirely agree with, though. As my colleague Benoit set out last August…

In other news, Children England have helpfully put all their briefings about Covid-19 in one place, giving us a helpful picture of how the pandemic has affected children.

Law and Order

Less news, but two interesting blogs from the festive period:

• This LSE blog about why anti-social behaviour and drug offences increased during the pandemic. The authors argues that “Covid-19 and the associated lockdowns increase the incentives to commit crime by decreasing returns to legal activities. Offsetting this is the fact that fewer people leave the house, making committing some crimes — such as robbery — more difficult. Lockdown has also made policing easier, which explains a higher number of arrests in drug-related crimes.” (Full analysis here)
• This Guardian article about rising use of force against prisoners in England and Wales (your regular reminder that we have been trying to draw attention to the deteriorating conditions in prisons since 2016 at the IfG…)

Five predictions for 2021…

…are coming in two weeks’ time. Unfortunately, I can’t think beyond next week at the minute!