The Week in Public Services: 9th July 2020

This week: how well did the UK manage the first wave; local government cash; and the summer economic statement

General

There were two backdrops to Rishi Sunak’s ‘summer economic statement’ speech yesterday — the coming tide of unemployment and the increasingly large hit to the public finances. The speech focussed mainly on measures to address unemployment — but the longer-term question about the sustainability of the UKs public finances remains. John Appleby paints a — literally — beautiful picture on the second question, and what it might mean for the health service.

To strip through the complexity of the summer economic statement, you should just read Gemma Tetlow’s blog (and the Institute for Fiscal Studies’ analysis) of the summer economic statement — but you knew that already, right?

On a sidenote: the statement revealed that the NHS has apparently spent £15bn on PPE during the pandemic so far!? Someone should really be looking at how the Treasury arrived at that number, and how much the public sector has been paying for PPE, because on first glance it looks VERY big. That’s almost as much as a year’s worth of local authority spending on adult social care…

Looking into the past, a big New Statesman investigation has looked at how austerity affected public services’ ability to absorb external shocks. Forthcoming Institute for Government research will be looking at how well-prepared and how resilient public services were ahead of the pandemic…coming soon(ish).

And if detailed investigations into the past are your thing, Paul Cairney at the University of Stirling is doing a phenomenal job in summarising policy advice and inquiries during the crisis from the SAGE minutes, NERVTAG minutes, parliamentary inquiries, and much more. Worth reading.

Health and Social Care

First story this week — the Financial Times is reporting that the government is putting pressure on the NHS to deliver its health election pledges, and the Treasury and №10 are apparently increasingly frustrated with NHS England’s degree of independence from ministers. Sooooo…back to business as usual then? There were well-documented tensions between the May government and NHS England too. Despite all the bluster, I think Andy Cowper is probably right that the politics of this are likely to play out in NHS England’s favour. Perhaps this is a sign of things returning to normal.

Also in ‘normal’ news — the latest general practice patient survey statistics have been published. The survey took place between January and March 2020, before the major changes in general practice caused by the pandemic — but still tell an interesting story. There was a slight decline in people reporting a “good overall experience” of their general practice compared to 2019 — while also a slight rise in awareness and use of online services. Check out the data here — or just read Becks Fisher’s great summary. (This also led me to this interesting paper about digital appointments in general practice, and how they could affect general practitioners’ workloads).

Onto more pressing matters — one thing that’s been clear throughout this crisis is that Covid-19 imposes huge pressures on Intensive Care Units. But what about patients’ recovery needs afterwards? The BBCs reality check team have looked at the support recovering patients will need. In the drive to free up beds for Covid-19 patients “in many cases the rehabilitation assessments that would normally be done in hospital would have been done in the community, or in a care home or a non-specialist rehabilitation setting”.

In response, NHS England announced this week that it would launch an online Covid-19 rehab service. The NHS Trust membership body, NHS Providers, continue to call on the government to be ‘realistic’ about how long it will take to restore normal services again (which seems fair, as this new briefing from the Royal College of Physicians has found that almost half of physician specialities, including cardiology, gastroenterology and rheumatology, expect to be working at less than previous pre-COVID activity levels for at least one year or more).

Over at the Nuffield Trust, a good blog which I missed from March looked at the Covid-19 response in Singapore and what, if anything, the UK might learn from it. Things that really stuck out to me:

• How much the experience of SARS prompted investment in preparedness — from border surveillance systems to visitor management systems in hospitals
• But equally, how much was similar to the UKs response — “preparations have focused somewhat more on how the health care community should respond to an international infectious disease emergency, and less on how the rest of the economy, especially our small and medium enterprises, would”

Also on the Nuffield site, a new ‘staff tracker’ is providing regular updates on the government’s progress against its staff targets. A very useful resource for holding the government to account. The pandemic is only likely to make workforce problems — from retaining nurses to falling international recruitment to the psychological assistance staff will need as a result of the last few months of acutely intense and stressful work — harder.

And last but not least, a new history of ‘strategic health authorities’ in the NHS, and what they did well (and badly). Any policy wonks thinking that we’ve missed the ‘regional tier’ of the NHS during this crisis should give it a read.

Elsewhere, a Kings Business Schools report analyses health and social care staff pay, and what should change after Covid-19. The sections on what Covid-19 has shown about health and social care staff are clear and very detailed — and it helpfully details some proposals (drawing on what other countries did, and what England did in the past) on how to change working conditions.

Back to testing: 2.5 million coronavirus tests were never sent back to the government. Since the start of the pandemic, 10.5 million antigen and antibody tests have been sent through designated testing centres or through the post — but only 8 million have been returned to a lab and processed. That means that one-fifth of the total were never sent back. Ed Conway and Rowland Manthorpe have written a compelling longread on testing, which concludes that as soon as the testing target was set, quantity trumped quality. The details — from ministers phoning around to fill in excel spreadsheets and hand-written tables of testing data, allegedly from mid-May — are incredible. There would always be problems quickly expanding a new testing regime — but it raises an obvious question about whether creating a centralised system for home-testing and drive-in/walk-in centres was the right one.

The National Care Forum — the membership body for charitable care providers — have surveyed their members and found that 9% of staff and 12% of residents in their care homes are still waiting for Covid-19 testing, despite the government’s pledge to offer testing to all staff and residents in care homes for over-65s by the beginning of June. The Royal College of Pathologists have outlined their vision for “robust [testing] process and structures that will work for the future”. Maybe the government should have a read…

Unfortunately the contact-tracing system doesn’t — at least if the anecdote bears out the reality — appear to be working efficiently either. “For the past two weeks I have been able to log in, but I have sat in front of my computer with nothing to do […] I’m supposed to have a line manager but I still don’t know who it is.” Not sounding great — particularly as the test-and-trace system appears to be very leaky — not reaching that many people who test positive, or that many of their contacts. And not to mention that local authorities– even though they’ve been receiving postcode-level data since June 21st — are still not getting detailed enough data to identify exactly who has tested positive and put into place preventative measures. Aaaaaaarghhhh.

Pivoting to look across the world, Charles Tallack has compared how the first wave of Covid-19 hit the UK and other European countries. The UK has had the highest proportion of excess deaths (excess deaths as a percentage of usual deaths) of any western European country aside from Spain — and that disappears once you adjust for the difference in age structure. Germany comes off best on this metric. He clearly demonstrates that Covid-19 has had its worst impact (at least when looking just at mortality in western European countries) in the UK. The big question remains, of course, why — Faisal Islam explores hypotheses in this longread.

In social care, the big story this week is the prime minister’s ‘open-mouth-insert-foot’ comments about care homes. According to Johnson, many care homes “failed to follow proper procedures” during the Covid-19 outbreak. This has — unsurprisingly — gone down like a lead balloon. Not least because that it was the care homes which defied the government’s restrictions — not taking hospital patients and restricting visitors at an early stage, that seem to have fared best.

A big splash in the Guardian also found that the government accidentally distributed out-of-date PPE to care homes and had to tell care homes to stop using them on June 26th. Not only was this dangerous — but may also have undermined care homes’ insurance policies.

Meanwhile, the results of the ONS-led Vivaldi study — a large scale survey which looked at Covid-19 infections, and factors associated with infections, in 9,081 care homes providing care for dementia patients and the elderly in England — have been published. Care homes which made greater use of agency staff were more likely to have Covid-19 infections. Here’s my summary of the key findings.

Looking away from care homes, Frances Ryan has investigated the consequences of the removal of some local authority social care obligations during the pandemic. Despite the national focus on care homes, the situation for disabled and older people receiving care in their own homes is little better.

According to Adelina Comas-Herrera of the London School of Economics, underfunding and “low political appreciation” are to blame for why care homes have seen so many residents die during the pandemic. The main lesson though she draws though, is that “the best way to protect people living in care homes is by containing Covid-19 both inside and outside care homes, with strong contract tracing and testing capabilities and good local information systems to identify and contain clusters”.

Did other countries better control infections in care homes? Australia appears to have done so — its retention payments for care home and homecare workers, and its clear messaging made a difference, argues Sharon Blackburn. (In Australia, there has been 69 cases in residential care, resulting in 29 deaths, and 31 in homecare, resulting in three deaths).

Canada, in contrast, showed many of the same flaws in preparedness and response as the UK did — low-paid staff working in multiple homes, homes with no isolation facilities, lack of testing, lack of PPE, and sending hospital patients back to homes too soon — even though the total number of deaths in care homes (both of residents and staff) was much lower.

And in a subject close to my heart: the Health Foundation and Future Care Capital have blogged about how to improve social care data. I spend most of my time thinking about social care data from the operational side — what data would you need to measure outcomes? How would you know if you’re providing a good service? etc. The main argument of this blog — that “fixing social care data is not only a technical challenge” and requires thinking about why we collect data, who benefits from that collection, and whether it’s the people who should do — was thought-provoking. It’s always worth stepping back to consider why we want things to be different.

At the same time, maybe there is light around the corner. The question that all the public spending nerds have been waiting for is finally here: can the man who’s prized money out of the Treasury more successfully than any cabinet minister over the last decade sort out social care funding? NHS England chief executive Simon Stevens has called for “a fair and properly resourced adult social care system with a proper set of workforce supports”

Let’s see where this goes (although the cynic in me would of course note that the 2019 NHS long-term plan contained some nice-sounding words about a properly funded social care system too, not that that made much difference). Here’s your reminder of what the Johnson government has done — and not just said — about social care reform so far. A very short briefing…

Children and Young People

New research from the National Foundation for Educational Research has surveyed teachers to understand how schools provided support to vulnerable children and children of key workers while they were otherwise closed. They found that teachers in the most deprived schools were more likely to use in-school time to provide extra-curricular activities to pupils, rather than teach the same curriculum content as other pupils were learning remotely.

Back to the reopening debate: if schools are to open, how are kids going to get there safely? The Education Policy Institute have published a useful discussion of this under-noted problem. One-third of secondary school children either use public transport or take school buses to school. The EPI conclude that “there is currently no credible solution to the problem of [pupils] mixing with other year groups, and other schools, on the bus home” — even if the schools can implement school year ‘bubbles’.

In children’s social care, the government has published an interesting update on children’s services in Northamptonshire, where the council has been supported by commissioners since November 2018. The report provides a snapshot of how children’s services have been responding to Covid-19 — “data shows a 40% reduction in referrals, a slight increase in child protection caseloads (4%) […] the Council is aware and preparing for an increase in referrals when children return to school”. The reduction in health visitors, as detailed here by The Guardian, has almost certainly contributed to the reduction in referrals.

At the same time, there has been a sharp increase in child sexual abuse during the pandemic, according to National Crime Agency figures obtained by The Guardian. During each of the 13 weeks of lockdown, around 350 cases of online child sexual abuse were passed to police, a 10% increase on the same period in 2019 — which is likely in any case to have been under-reported. A lack of secure placements has meant that ‘open’ children’s residential homes are being asked to take young people who need “higher staff ratios and more restrictive measures”.

Law and Order

In policing, Phil Kay has written a timely Crest blog about how to increase diversity within policing, arguing that forces in England should follow the Northern Ireland example of time-limited positive discrimination in recruitment.

In concerning news, police forces are worried about ‘a new era of austerity’ following the higher costs they’ve had to pay to respond to Covid-19 (protective equipment, computers to work from home), and cuts to the funding they receive from local authorities (and lost income from policing major events such as football matches and festivals). Expect most public services to face a variant of this dilemma (lost income, higher costs) as we move beyond the recovery phase of the crisis.

In courts, the government has abandoned proposals to abandon jury trials, but is considering smaller juries to allow for social distancing in courts. The government is also planning to use 10 sites as ‘Nightingale courts’, open for longer hours, in order to allow for more cases to take place. Lawyers are, unsurprisingly, not thrilled about the prospect of longer hours. You can read the Courts’ service plans for the recovery, here.

Grim news in prisons. Rates of coronavirus testing look very low in some prisons in England and Wales, and there were 20 more deaths in prisons between 24 March and 27 May 2020 than the same period in 2019. Some prison charities are concerned that testing figures may be hugely under-reported because some prisoners will not report symptoms for fear of an incredibly restrictive isolation regime for those who test positive.

Meanwhile, a Prison Inspectorate report into three Category C men’s prisons found “emerging frustrations and concerns felt by both staff and prisoners about the cumulative impact of restricted regimes” — even where Covid-19 has been contained.

Local Government

In local government, the government has now officially promised to share postcode-level data with local authorities — which is good, if very late. The former deputy mayor of Leicester (the first city to go into a local lockdown) is very unimpressed with the government’s centralised approach to the crisis.

The big but under-noted story last week, however, was the raft of changes which the government announced a about local government finance, consisting of:

• A £500m unringfenced grant
• A promise to replace 75% of councils’ income from sales, fees, and taxes this year
• Removing the requirement on councils to balance their budgets in-year, extending it over three instead

Overall — the grant provides cash for a month’s worth of emergency costs*, gave an answer to local authorities about what would happen to (most of) their lost income, but gave no answer on lost tax revenues. So that’s a bit more certainty, but it’d be a stretch to call it a comprehensive package — expect further revisions, and probably more grants (depending on how the pandemic and spending pressures play out). You can read my full analysis here.

What does all this amount to? Broadly — the new funding and data-sharing is a good thing. It’s definitely better than what came before. But in many ways, it’s revealing that these are being presented as breakthroughs when they would be more like standard practice in other countries. Richard Vize despairs of the government’s “obsession with setting up new structures from scratch rather than working with what they already have”, here. See also this from David McCoy. The Local Government Association have set out their asks of government for the recovery, here.

*That is, assuming the costs of responding to Covid-19 in future months remain comparable to the costs in March, April, and May. I’ve even got a handy chart for you: