The week in public services: 9th June 2020

This week: the inequalities of lockdown; contact tracing teething problems; and what we can learn from other countries

General

A two-week update this time — so a bit longer than normal (life got in the way).

First up — a new report from the Institute for Fiscal Studies: survey data they have gathered show that the lockdown has exacerbated inequality in mothers and fathers’ earnings in two-parent mixed-sex households. Why? Mothers were disproportionately likely to work in sectors that have been shut down, and are doing more childcare than fathers.

Lawrence Freedman has written another very good article for the New Statesman, using the newly-released SAGE minutes to trace when and how scientific advice to government changed. What stands out to me is:

• How a better (bigger) testing and tracing system could have slowed the spread of Covid-19 in late February and early March — public health officials might have been able to systematically test and trace people returning from holiday in Italy and Spain, for example
• SAGE advised that “special policy consideration be given to care homes and various types of retirement communities” on 10 March…but thereafter transmission and deaths in care homes didn’t much feature
• This really important point: “Sage’s scientific approach was very data-driven, which would have been fine had the data been readily available and timely”. This echoes Nick Hassey’s point that it is really risky to calibrate your response to a pandemic based on data when that data is lagging, uncertain, and often not available. Perhaps following a precautionary principle or rules-based decision-making would be better in this kind of situation — the Covid-19 inquiry should really look into this

And fancy hearing about a success story for a change? My colleague Gavin interviewed the Taiwanese digital government minister, Audrey Tang, yesterday. Strongly recommend watching this back — it’s fascinating (and novel) to watch a minister responsible for digital technology with deep knowledge of the subject matter. Back in the UK, the government finally published details of NHS data-sharing contracts after being threatened with a lawsuit by Foxglove and OpenDemocracy…

The big debate in relaxing some of the lockdown restrictions in England, though, has really been about the ‘new’ test-and-trace system. On which note:

• Dominic Harrison, the director of public health at Blackburn, considers whether England should ‘case find’ — testing all possible contacts of someone with the disease — or just contact trace — testing only those who have been in close recent contact. The former would be more demanding and disruptive but could contain the spread of the virus faster.
• At the minute, England is not case-finding. The NHS Test-and-Trace system is currently reaching just less than 40% of known contacts of people diagnosed with coronavirus, according to data leaked to Channel 4.
• One anonymous newly-hired tracer reveals his disastrous experience being trained for and attempting to operate the scheme, and why he quit

Taking all this into account, the usually mild-mannered Association of Directors of Public Health argue that “the Government is misjudging this balancing act and lifting too many restrictions, too quickly”. They are particularly critical of the test-and-trace system, which they say “is currently far from being the robust operation that is now urgently required as a safeguard to easing restrictions”. The chief of the Association, Jeanelle de Gruchy, thinks that the government’s reluctance to involve local public health directors “reflects a historic lack of understanding of the importance of public health […] society still tends to think that a healthy population is created by the NHS — and it’s not”.

It’s a fair criticism — and one where I better understood their point of view after I read this article which explains how local directors of public health are trying to prepare plans to respond to local outbreaks…but don’t have much control over many of the levers, or access to much of the data, that they need to use and see to respond to local outbreaks. They are particularly frustrated by the national government’s approach to what it calls ‘the science’. Chris Ham, the former chief executive of the Kings Fund, makes a similar argument here.

Health and Social Care

Lots of stories this week. To start, this longread from the Financial Times analyses Germany’s response to Covid-19. There are lots of different factors in Germany’s relative success, and it’s hard to pin any one down definitively, but the following seem to have helped:

• Having a functioning test-and-trace system working early
• The pandemic hit after a continuous steady rise in German spending on healthcare
• The “decentralised nature of health provision”

Of course, Germany isn’t the only country we could compare the UK to. To the libertarians shouting ‘what about those freedom-loving Swedes?’ — what indeed? This good blog from health economist Xander Koolman shows that Sweden is not really doing much better economically than its close neighbours that imposed harsher lockdowns, Denmark and Norway. Why? “The liberal Swedish approach has led to similar behaviour [social distancing and less spending] among citizens.” He makes the same point comparing neighbouring US states Minnesota (lockdown) and South Dakota (no lockdown). You can lift restrictions, but you can’t force people to spend and behave as they did pre-pandemic.

Back in the UK, this New Scientist article explores, in contrast, why the UK has had such a high number of coronavirus deaths. Slowness to act and respond emerges as the main theme.

Moving over to the NHS specifically, Anita Charlesworth has written a great summary of the varied ways Covid-19 is affecting the NHS — from the fall in A&E attendances and admissions, to problems people with long-term conditions have had accessing care during the pandemic. Well worth a read. Pairs well with Jessie Morris’ analysis of how Covid-19 has changed urgent and emergency care, which concludes that “centralising specialist intensive care services for Covid care may help to reduce the burden in some areas.” Elsewhere on the Heath Foundation site, Jen Dixon sets out four questions that Covid-19 poses the health services in the UK, including reflections on how well the UK is performing compared to other countries.

Procurement, especially of PPE, has been one of the major problems during this crisis. Ongoing PPE shortages will make it hard for hospitals to start doing routine operations as quickly as the government would like, say NHS Providers. Meanwhile, Colin Cram argues that certain bits of NHS procurement should be centralised in order to avoid Trusts competing with one another for essential goods during pandemics.

PPE problems aside, how will the NHS learn to live with coronavirus and deliver ‘normal’ care services too? That’s the subject of a new paper from Nuffield Trust chief executive Nigel Edwards, who looks at the logistical and practical problems in ‘returning to normal’. His Twitter summary is here. Worth reading in full.

Moving back in time, Samuel Horti has been digging into health select committee hearings from before and after the passage of the 2012 Health and Social Care Act, and found (£) that several former public health specialists warned the coalition government that the Lansley reforms would “fragment, weaken and ultimately destroy the specialty of public health” and “disrupt… the ability to effectively respond to an emergency or epidemic situation and undermine public trust and confidence”.

And remember the furore about whether the government should publish the results of the Exercise Cygnus flu pandemic planning exercise? Well, Scotland’s about to have its own version of that debate. The Scottish government conducted an exercise to test how prepared Scotland was for a MERS-like coronavirus in 2018. The difference? As of Wednesday this week, Scotland has published the report Exercise Iris for anyone to read, here.

Last but not least, Nuffield Trust have published an insightful interview with general practitioner Farzana Hussain. The NHS’s biggest mistakes in her view? “Number one: not learning from things that have gone wrong. Number two: wanting it all today.”

And, of course, those testing targets continue to be a problem. This time, people who don’t pass an online credit check cannot obtain a home test and are having to go to drive-in centres instead. Given that people who don’t pass the credit check might not have a car, this policy risks excluding a large number of people who need tests…

If I were being generous, it’s one way to minimise the risk of people requesting fraudulent home tests (I guess?), but this seems like quite a bad idea. I also recommend this BBC fact-check of whether the government has met nine of the targets it set itself — from testing to PPE distribution. It’s remarkable how many targets where the government can’t say if it hit them…

Over in social care, David Brindle has written a good column on care homes, which puts better than I could some concerns I’ve had in the back of my head since the crisis started. Local authorities certainly weren’t paying enough for state-funded care home placements at the start of this crisis — and care homes need additional funding now to maintain solvent and pay for essential protective equipment to contain the spread of the virus amongst residents and employees (if you need a reminder, this Wired article is great)…

…but over the medium-term, the support the government should provide is less clear. Given that some self-funders are now less likely to want to put themselves or relatives into care homes now*, the government would now have to spend even more to keep care homes afloat. Should it do that? Or should it put that money towards more support in people’s homes and community care? Are care homes fundamentally finished as a business model? With analysts forecasting low occupancy rates until 2022 or 2023 (or perhaps even 2028), it’s hard to see how small care homes will stay afloat without substantial state support.

This is, in essence, the same set of dilemmas the government faces in providing financial assistance to any particular company or sector — are they merely illiquid or totally insolvent? how should you structure the bailout to avoid creating financial windfalls? — which Giles so neatly summarised for the Institute for Government here. There are no easy answers — but the further that time goes on, the more important they’ll become.

And that’s before we get on to the questions of whether local authorities or central government should fund the bailout, and what to do about self-funded places (which is causing a particular headache in local government, who are having to work out if supporting homes with few state-funded users breaches state aid rules). Sally Warren from the Kings Fund set out how the current system works, here.

The New Economics Foundation have taken a more radical look at different ways of running social care businesses, and argue that having more “micro-enterprise” (small social business) providers would improve the quality of care provided.

ITV News reports that some care homes think they are being used as “clearing houses” where hospital patients are being held for a short time (usually 14 days) before being discharged into the community. The Nuffield Trust’s Billy Palmer has crunched the numbers and found that discharges to care homes were higher this year than in 2019 up to mid-March, after which they fell dramatically. If you want to do your own analysis, the data (published as a one-off from NHS England) is here.

The Association of Directors of Adult Social Services, clearly frustrated with the suggestion that local authorities aren’t doing enough to support care providers, have published a survey of local authorities which highlights the measures they are taking to support care providers. The Local Government Association estimate that care providers face £6.6bn in Covid-19 costs between April and September this year. That’s a truly massive number — equivalent to about one-third of spending on publicly-funded adult social care in the last ‘normal year’ of spending…over the course of just six months.

And while I don’t agree with Polly Toynbee’s proposed solution (nationalised integration) for the problems she identifies in social care here, her take on the politics between Hunt and Johnson (i.e. that Hunt’s criticisms about government protection for care homes and the government’s focus on his failure to implement the lessons from the Cygnus report can be seen as part of leadership manoeuvres) is important. It’s one that hadn’t occurred to me as it’s felt like, in many ways, the pandemic has put ‘normal politics’ on hold for a while. Neil Crowther sagely points out that the ‘integrate health and social care’ crowd don’t seem to have clocked that care home deaths have also been bad in Scotland, which has health and social care integration. In practice it seems that integration wouldn’t lead to greater focus on social care; it might still end up with acute care being prioritised within an integrated system.

In another Guardian opinion piece, John Beer argues that the Care Quality Commission was wrong to suspend inspections. “Had the CQC continued its inspections, it would have been in a position to challenge cases where PPE was being diverted away from care homes to the NHS, and to aid struggling homes in their battle to secure tests for staff and residents”, Beer argues.

And quite a big story in The Guardian that hasn’t had as much attention as I would have expected — ministers apparently rejected a Public Health England proposal from the end of April this year for a tighter lockdown of care homes which would have included using NHS facilities to quarantine and isolate residents before returning them to care homes, and the government paying care homes to pay staff more to ensure they wouldn’t rotate between Covid-infected and Covid-free homes.

Why does reducing the rotation of staff between homes matter? There is evidence that asymptomatic care workers may be inadvertently spreading the virus to vulnerable residents (see also this survey of providers from the National Care Forum). MHA, the largest care provider in England, Scotland, and Wales found that 42% of their care workers who tested positive for coronavirus did not display symptoms.

But hey, that incoming recession might at least partially mollify social care recruitment problems. CV-Library, an online jobs board, is reporting that applications for social care job postings in May this year were 19% higher than in May 2019. See also this interesting analysis from the Indeed Hiring Lab: social care job postings haven’t fallen as much as other jobs, but advertised wages haven’t budged and clicks per social care job advert have barely increased (they’ve doubled for most other kinds of job postings). Here’s a hint for the answer to that puzzle: it rhymes with ‘pow lay’.

Over in the numerical world, new data from the Office for National Statistics has shown that there were 83% more deaths from dementia than usual in April 2020. Alzheimer’s UK and other charities have suggested that a lack of social contact is causing declines in health. If you missed the BBC Panorama special about how coronavirus has particularly hit those who have dementia, you can read Lewis Goodall’s twitter summary here.

The ONS chief health analysis statto, Nick Stripe, has analysed the ‘non-covid’ excess deaths in detail though, and argues that “dementia [death] increases are so sharp it’s implausible that they are unrelated to COVID”. That they are not coded as Covid-19 deaths may simply reflect peoples’ difficulty describing symptoms. There is less evidence of a rise in deaths from illnesses related to reduction in hospital capacity (such as cancers and renal failures).

Last but not least I know I bang on about lack of data being a problem in social care (one that this pandemic has sadly exposed all too clearly) but…:

• It’s not just me! The UK Statistics Authority and Future Care Capital are sounding the alarm too (and the UKSA have provided a useful list of data that is already-collected to help understand the impact of Covid-19)
• Future Care Capital have published a “social care data finder” of all the nationally and locally-collected data on social care during this pandemic — very useful

Children and Young People

Building on the success of a ‘social workers in schools’ scheme that the What Works Centre for Children’s Social Care had funded, they are launching an expanded trial to see if its positive impacts replicate. The government has used the positive findings from the to announce £6.5m for 150 schools to place social workers in schools.

On the thorny question of when and how to re-open schools, this article explains why many other countries have opened up earlier than the UK, and how to weigh up the different risks and benefits (though it doesn’t discuss any of the practicalities). What explains the variation in timing? “Important factors include medical and public health preparedness, the ability of schools to deliver effective online teaching, and the implications for schools of the labour supply of parents.” The third factor is not one that had occurred to me as something that would vary that much between countries, but the differences are quite stark.

(FYI for more answers on the ‘economic’ lockdown questions, check out the ESRC-funded Economics Observatory, which this article was part of. The summary of how coronavirus might affect supply of and demand for healthcare is particularly good).

In a reminder of more normal times, the National Foundation for Educational Research latest report about the teacher labour market was published last Friday. TL;DR — even before the coronavirus pandemic there were substantial challenges recruiting and retaining enough teachers.

And if you’re interested in what coronavirus is doing to the teacher labour market, Jack Worth has been tweeting useful monthly updates on teacher training statistics here. Maybe worsening prospects in the rest of the labour market will help ease recruitment problems (though I doubt it will do anything for retention). The UCL Centre for Education Policy’s Asma Benhenda has written a useful briefing on what we know about how past recessions have affected teaching. My 280-character summary here.

NfER have also published a useful report on how prepared school leaders were to reopen (some) schools on 1st June. The key finding that stuck out to me was that in May, schools only had 75% of their normal teacher numbers. 29% of those teachers available to work were only able to work at home.

Last but not least, I’ve heard (lots of) contradictory claims about how much of a risk reopening schools for spreading Covid-19…so nice one to the Parliamentary Office for Science and Technology for publishing this concise overview of the evidence. TL;DR — children are much less likely to develop severe symptoms, but we don’t know if children transmit the virus less than adults.

Law and order

Interesting article from Mark Thomson about police strategies to keep crime down after lockdown, following Croydon’s ‘violence suppression unit’ and their efforts to reassert a police presence following the reduction in police beats after 2010.

Another good Rob Allen blog about what Covid 19 has shown us about prisons. “Put bluntly, since imprisonment has become a more onerous punishment than it was, its use should be reserved for more serious offences than previously; and the length of custodial sentences which are imposed should be reduced to reflect the greater pain that they inflict on those who serve them in the current conditions.”

And conditions in prisons have become pretty brutal in order to implement social distancing rules — many prisoners are locked up for upwards of 23 hours a day, with all the corresponding negative impacts on mental and physical health that one would expect from that kind of regime. There were five suicides in six days at the end of May. This Guardian article is a good summary — raises the question of whether this is the inevitable price of the measures taken to contain the spread of the virus — or whether we could have done anything differently. To hear directly about what life was like on the inside during these stricter rules, check out this podcast with newly-released prisoner David Adams.

The Ministry of Justice and the Prison and Probation service have now published their plans and criteria for easing restrictive conditions, here. There will be a conditional easing of conditions in prisons depending on the spread of the virus — but one of the biggest challenges prisons will face is when courts are back operating normally, and they may have to accommodate an influx of new prisoners.

Local government

Good overview of the English local government funding debate, including the distinction between capital and revenue funding. One for the nerds (obviously I loved it).

Nesta have reported on the results of an interesting new project that I missed last month. They’ve been interviewing councils to try to see if their response to Covid-19 has changed other ways they work. Greater use of digital technology, less management and bureaucracy is the TL;DR.

Back on the local government frontline, the Local Government Association continues to bang the drum that councils need more than one-off funding announcements from government in order to ensure their medium-term financial sustainability. This article from the chair of the London councils makes much the same point. Richard Vize has polemicized about what the government’s reluctance to involve local government in the pandemic response has meant for the UKs death rate. In the same vein, Chris Game makes a compelling argument that the government’s centralised approach to contact tracing has been counterproductive.

New polling from the New Local Government Network shows council leaders feeling much less confident in their economic future but more confident in community cohesion and trust. Full details here. Every cloud has a silver lining, I guess. They’ve also put out an interesting report with the Local Trust about how Covid-19 has changed relationships between communities and public services. TL;DR — relationships have become stronger and digital technology is bringing public services and communities closer together.

And how have councils actually changed during the pandemic? This briefing from the County Councils Network is chock full of examples of the various innovations and new services councils have set up.

*There is some polling data on this, jointly commissioned by IPPR and Policy Exchange (!), which is worth a read, here