The Week in Public Services: 9th February 2021

This week: NHS reform; vaccine successes and worries; and how to help children catch up on education.

General

As regular readers know, in the pandemic era there is always a huge amount to cover in this blog, and this week it’s no different! So once again I’ve kept this introductory section short.

Yesterday Rachel Reeves, shadow Cabinet Office minster, delivered a speech on government procurement. In the speech, Reeves claimed that taxpayer’s money had been “irresponsibly and unforgivably wasted” and said that Labour aspires to “clean up cronyism in contracting”. Whether the accusations of ‘cronyism’ are justified or not, the government continued to use non-competitive procurement procedures months after the start of the pandemic. The government needs to make sure it gets out of ‘crisis mode’ and brings an end to abnormal procurement, according to my colleague Tom Pope’s piece this week. Reeves also talked about Labour’s proposals for insourcing: “Under Keir Starmer’s Labour government we will see the biggest wave of insourcing of public services for a generation.” The Institute for Government (IfG) addressed exactly that topic last year, looking at the circumstances in which insourcing can add value.

Health and Social Care

Covid-19

The latest update from the Health Foundation’s Test and Trace tracker reports good performance in the last week — over 80% of people tested in the community got their result in less than 24 hours. Adam Briggs has a tweet-thread on the topic. The challenge as ever remains isolation: a UCL survey recently reported that only 62% of people are isolating for the recommended 10 days when they develop Covid-19 symptoms.

On a similar theme, the government (finally) released data about the NHS Covid-19 app. The app has told 1.7 million people to self-isolate since its launch, and researchers have estimated that it may have prevented 600,000 cases. (I’m a bit sceptical of that last number, but check back next week when I imagine there will be more analysis of the data.)

Alexandra Eastaugh (Health Foundation) published research on the links between pay and wellbeing during the pandemic. Those who persistently had lower pay from March to September reported poorer mental health and wellbeing (such as feeling lonely and less happy). This is just one example of the way in which the pandemic has shone a light on the wider determinants of health.

The pandemic has helped us gain a wider perspective on public health. But David Oliver, writing in the BMJ this week, is worried that this may only be a short-term gain: “The sudden interest in prevention, wider health determinants, and wellbeing in social care… seems driven largely by immediate concerns over money, jobs, ruined industries, unhappy voters, and bad press. Once we’re through with this pandemic will we all still be so interested, outside the professional communities and advocates who always have been?”

The King’s Fund has a fascinating scrolling article on lessons for health and care systems recovering from disasters. One of the key lessons, looking at the response to other crises, is that “a focus on ‘community recovery’ — or rather ‘community-led recovery’ — is essential.”

Sky News has a piece reporting on the experience of disabled people during the pandemic, drawing on research from the charity Scope — a year of isolation for people who have been shielding has been really difficult.

Social care

In Scotland, the Independent Review of Adult Social Care published its main report. It makes 53 recommendations, among them a proposal to create a National Care Service in Scotland to oversee the sector, with accountability moving from local government to a Scottish Minister — but importantly, this doesn’t mean nationalisation. On funding, recommendations include better pay for staff, and removing charging for non-residential social care support. The report recognises that the Scottish Government will need to raise new revenue in order to pay for these reforms. Anna Dixon, chief executive of the Centre for Ageing Better and a member of the advisory group for the review, has written a blog arguing that England should also learn from the report’s recommendations. As well all know, reform is certainly needed — try reading Robert Booth’s report in the Guardian for why social care staff in England need better training and higher pay. “Whatever solutions emerge, the widening cracks in UK social care emerging under the persistent pressure of Covid have made doing nothing politically impossible.” Let’s see if that proves true.

A couple of pieces on social care data this week:

• This week the NHS reported that it had “now offered the Covid-19 vaccine to residents at every eligible care home with older residents across England.” Yesterday Matt Hancock said that “93% of residents of eligible care homes” had been given a first dose of the vaccine (in the UK, I think). Overall, this is really good news. But it leaves quite a lot of questions — which care homes are not ‘eligible’? And the data haven’t been published. But perhaps this isn’t so surprising when we don’t know how many care homes there are in England, nor how many residents. Writing for Tortoise (£), Simon Briscoe persuasively argues that the lack of data on social care in England is revealing: “The statistical system has shared successive governments’ indifference towards the sector. No one has cared enough to collect the data. Had care homes been counted and been properly understood they might have been better protected during the pandemic — and at the forefront of policy, rather than an afterthought.”
• We at the IfG agree: see our recommendations from Performance Tracker 2019, under the heading ‘The government ought to fill key gaps in performance data’.
• But… there is some good news on this topic. The Social Care Analysis team from the ONS is working on producing statistics about people who fund their own social care in England. This can help us better understand how adult social care is currently working, and also assess the pressure faced by local councils.

NHS reform

Proposed changes to the structure of the NHS in England have generated a huge amount of attention this week. So much it gets its own sub-heading.

A draft health and social care white paper, seemingly leaked, was published by Health Policy Insight on Friday. The proposals state the aim is to change legislation to “directly implement or build upon NHS England’s recommendations” in the 2019 Long Term Plan. One of the eye-catching parts is about competition in the NHS: “The Health and Social Care Act 2012 put a regime in place which put competition as the organising principle for improvement in NHS care. This has in some cases hindered integration between providers. In practice, the NHS has not operated as the market intended by the 2012 Act.” The focus is instead on integration, especially through the Integrated Care System (ICS) model. Andy Cowper has analysed the proposed reforms here. Cowper draws attention to the extra powers given to the Minister for Health and Social Care: “It unambiguously puts the Secretary of State back in charge, in a massive political land-grab.”

Authors from the Health Foundation (Hugh Alderwick et al.) have also written about structural NHS reform (written before the draft text was leaked). They say that NHS England’s “emphasis on closer collaboration between the NHS, local government, and other agencies makes sense” and that “the need for legal changes to reduce fragmentation and complexity has long been recognised.” Some changes, then, along the lines of the government’s proposals could be helpful. (This line of thinking is similar to that laid out in Fraser Battye’s Strategy Unit blog, which featured in a previous edition of Week in Public Services.) On the other hand, Alderwick et al. argue against over-optimistic expectations regarding the benefits delivered by organisational changes: “Overall, evidence suggests that previous reorganisations have delivered little measurable benefit. Other policies to support NHS improvement, such as boosting investment, expanding the workforce, and modernising services, are likely to have had a greater effect on performance.” Like Cowper, they also caution about giving the Minister more powers: “Changes to bring the NHS under closer ministerial control are likely to be rooted in short term political interests, not clear thinking about the right balance of national responsibilities.”

Here at the IfG, Nicholas Timmins has also written a piece assessing the proposed reforms. According to Timmins, the white paper would remove “the one bit of Andrew Lansley’s Health and Social Care Act 2012 that has worked, namely the statutory independence of NHS England. It reverts, instead, to a model where ministers exercise command and control over the running of the health service… The draft white paper offers no justification for this other than the frankly spurious one that the pandemic has shown the need. Before parliament even begins to think of granting such powers, it must require ministers to spell out precisely what it is that they have not been able to get the NHS to do in the absence of such powers. Nothing, right now, springs to mind. If good answers are not forthcoming, the power should be refused.”

If this feels quite negative, Donna Hall’s reaction to the overall direction of the NHS reforms is more positive. Writing about the Integrated Care System plans published at the end of 2020, she argues there are opportunities here to improve how public services serve citizens: “There have been numerous NHS reor­ganisations over the years, but this is dif­ferent as it’s the NHS looking outwards to place, partnerships and people rather than inwards.”

If you want even more on this (why wouldn’t you?):

• Richard Sloggett sets out five reasons why the government wants more powers over the NHS.
• Isabel Hardman has written about the politics of the reforms in the Spectator.
• The Health Foundation has a really useful long read on what the reforms may mean for GP practices and Primary Care Networks.
• Have a look at my colleague Graham’s tweet-thread.
• And of course come back next week, this story is going to continue to run.

Vaccines

• A milestone of 10 million vaccines in the UK was reached this week. As of 7 February, 17% of the UK population had received their first dose: Wales and England lead the way, with Northern Ireland and Scotland slightly further behind.
• There are serious concerns about the South African variant of Covid-19. A very small study suggested that the Oxford/AstraZeneca vaccine may be only 10% effective at preventing infection from the South African variant. But there are many caveats, as Tom Chivers helpfully explains: it was an extremely small study (just 42 cases of Covid-19 in total), and the vaccine should still help prevent people being hospitalised. It has, however, increased the number of people talking about yearly ‘booster’ shots, like health minister Edward Argar.
• Julian Tang makes the case for vaccinating younger people earlier in the schedule than currently. Personally I’m unconvinced (but, obviously, I’m not an expert).
• Katy Balls has written a good piece in the Spectator about the successes of the Vaccine Taskforce — also including the wonderful detail that in early discussions Matt Hancock used the example of how vaccines feature in the plot of lockdown favourite Contagion.

Children and Young People

Let’s start with research about the impact of the pandemic.

A new study from ASK Research/Nuffield Foundation examined the experiences of providers of specialist education and the families of children and young people with Education, Health and Care Plans (EHCPs), from March to August 2020. In the first lockdown, in theory all pupils with an EHCP were able to continue going to school or college, but in practice this was not possible due to other factors such as staff shortages. Section 7 of the report, ‘The effects of lockdown’, describes the challenges faced by many families who received much less support than normal. Some parents had to combine caring for children with SEND, supporting home learning, and working from home. Hopefully the situation is better in the current lockdown. Nevertheless, as the research recommends, the government needs to continue to focus on better access to remote learning, as well as targeting resources to help pupils with EHCPs, and their families, after such a disruptive year.

ImpactEd published its report ‘Lockdown Lessons’, based on interviews with over 60,000 pupils aged 6–18 across England. This is yet another study to find evidence of the impact of disadvantage during the pandemic. 45% of students eligible for Pupil Premium said they understood their school work in lockdown, compared to 57% of other pupils. 67% of students eligible for pupil premium said they were able to use a digital device to complete online work, compared to 78% of other pupils. We have covered numerous studies on this blog which have found evidence of the differential experiences of pupils during the pandemic year. In my opinion, there is a very strong case for significant funding, specifically targeted at helping disadvantaged pupils. The National Tutoring Programme is a start, but its scale (£350m) is not sufficient given the extended period of disruption.

On that note… a new paper reports the findings of a fascinating study in Italy. In March to June 2020, online tutors were assigned to pupils from disadvantaged backgrounds, for a median period of five weeks. The tutors were volunteer university students (who were given some training by educationalists). Pupils who received tutoring improved academically (0.26 SD), as well as having higher wellbeing (0.17 SD). Because tutors were volunteers, the scheme was also cheap (just €50 per student). I think there are two lessons here. First, individual tutoring appears to be effective even when delivered online. (Many previous studies have found that it is effective in-person.) Second, individual tutoring can be effective even when it is not delivered by qualified teachers. These findings have policy implications: they strongly suggest increased investment in tutoring for disadvantaged students is a good way of closing the attainment gap. We know that the attainment gap increases during school holidays. Tutoring (whether in-person or online) could help close that gap in the future, as well as targeting investment at the students who need it most.

The Public Accounts Committee published a report on the free school meals voucher scheme in the first lockdown. The report is critical of Edenred (the company the government used) for problems early in March, and is also critical of the DfE: “The Department focused on firefighting the problems with the voucher scheme and did not actively manage its contract with Edenred. The Department extended the contract twice, increasing its value fivefold, from £78 million to £425 million, but it failed to take the opportunities those extensions presented to renegotiate the terms and secure better value for money for the taxpayer.”

What is the government’s current approach to helping improve children’s education after the pandemic?

• The government has appointed Sir Kevan Collins as its ‘education recovery commissioner’. Collins is a former teacher and was chief executive of the Education Endowment Foundation for eight years until 2019. It is a clear sign that the government is thinking seriously about how to help children catch up — although no new funding was announced with Collins’ appointment. Collins is in the “all ideas on table” phase of the role.
• Talking of ideas on the table… James Forsyth reports in The Times (£) that the government is considering a number of fairly radical options, including extending the school day or shortening the summer break. Harry Quilter-Pinner has a helpful tweet-thread on these ideas. Clearly, if the government goes for one of these options, more funding will be needed: estimates of cost range from £2–7bn. I would add one more point, which is that the government should not lose sight of reducing inequality in addition to universal measures. As discussed above, schemes such as individual tutoring for disadvantaged students should be an important part of the DfE’s overall plans moving forward.
• Do you remember the ‘expert group on differential learning loss’? If not, don’t worry, because the government didn’t either. On 2 February, SchoolsWeek reported it still didn’t have any members, despite being announced back in December. Then on 8 February, the DfE confirmed it had been scrapped entirely. Its duties will instead fall to Kevan Collins.

Finally in this section, a round up of a few other items:

• A briefing paper from UCL’s Centre for Education Policy and Equalising Opportunities looks at why the timing of benefit payments, such as Universal Credit, may make a difference to food poverty. Families in poverty are likely to struggle the most at the end of a month, resulting in children eating less food. Based on evidence from the United States, this problem can be reduced if benefits are paid half-way through the month instead of at the beginning alongside wages. Studies show a small positive effect on children’s health and education. Although the benefits are relatively small, the cost to government is close to zero. Given this, the paper recommends that the government pilot and evaluate the effect of moving Universal Credit payments to the middle of the month.
• Pro Bono Economics has not one but two new reports out. First, analysis of children on waiting lists for children’s mental health services. Children who have to wait for mental health provision require higher spending from other public services — £75 million per year, 90% of which is incurred by schools. The report argues that “decisions around the resourcing and prioritisation of children’s mental health services cannot be made in isolation from decisions in other key services — the knock-on consequences have the potential to be significant.” Second, a study on school breakfast provision. According to their modelling, the benefit-cost ratio of providing free school breakfasts to Key Stage 1 pupils is 50:1, because of the long-term economic benefits which accrue from improving children’s energy, concentration, behaviour and overall readiness to learn.
• The Guardian has a report on 10 years of free schools in England.

Law and Order

News on crime in Wales tells a relatively familiar story — overall levels of reported crime fell from October 2019–2020, but certain crimes such as cyber crime and harassment and stalking rose.

Robert Neill, chair of the Justice Committee, has written to Secretary of State Robert Buckland asking for more detail on the situation in the crown courts. Jury trials are not being processed as fast as the recovery plan implies, so the backlog is likely to still be growing.

We also got some more news on the records deleted in error from the police’s national database. Kit Malthouse, the policing minister, said that 209,550 records were deleted, and that work is under way to restore them — although it may take three months.

Local Government

The Centre for Data Ethics and Innovation has published a report about local government’s use of data during the pandemic, based on a forum of local authority data specialists and follow-up interviews. They found that there was lots of innovation during the pandemic but “authorities have had more success in changing how they deploy existing datasets than in acquiring or sharing data with central government or local service providers.” This fits with the repeated theme that data sharing between central and local government has often been inadequate during the pandemic. According to the report, some interviewees also worried that “local authorities will lose their appetite for experimentation once the emergency subsides, and with it their willingness to experiment with untried data-driven interventions.”