Submission to House of Lords Public Services Committee

Submission by

  • National Institute for Health Research (NIHR) Health Protection Research Unit in Emerging and Zoonotic Infections
  • University of Liverpool, Institute of Infection and Global Health, and
  • University of Oxford, Nuffield Department of Primary Care Health Sciences

to

House of Lords Public Services Committee Inquiry: Lessons from Coronavirus

 

Background:

We are University researchers in emerging infections and health policy responses to them.[1] Since the beginning of the COVID-19 epidemic in the UK we have been conducting research into the dynamics of COVID-19-related policy development and healthcare worker behaviour in the UK. The research is funded by UK Research and Innovation and the National Institute for Health Research. We interview key policy players and frontline healthcare workers, who speak candidly to us on condition of anonymity.[2]

In an infectious disease outbreak, health policy makers are under tremendous pressure (Brändström and Kuipers 2003). They must respond rapidly to get ahead of the epidemic, and make high-impact decisions despite uncertainty (Boin 2009). This includes scientific uncertainty about the natural history of the coronavirus (Weible et al 2020). Our remarks here acknowledge the severity of these challenges for policy makers: they are not armchair criticisms from hindsight.

 

Our evidence on the Committee’s questions:

In this submission we focus on the relationship between local and national services. The UK response to the pandemic has been characterised – to a greater extent than in some similar countries – by large central initiatives employing private contractors. Certain services, such as testing, had to be very rapidly expanded, and – rightly or wrongly – public sector bodies in the UK had not been funded to put sufficient ‘surge’ capacity in place beforehand. We would draw attention to two linked issues: the merits of a centralised response, and the use of private contractors.

To take centralisation first, UK governments have long responded to major crises by the imposition of Whitehall control, taking over some responsibilities and powers from local institutions, as for example in the 2001 Foot and Mouth Disease outbreak. In the case of COVID-19, the Whitehall response has again been to take back a large measure of control from the NHS, NHS England, Public Health England and Local Authorities (LAs). Within the NHS, for example, NHS England moved in late January to implement an emergency plan by declaring coronavirus a serious, level 4, incident, providing for ‘National Command and Control’ of all NHS resources across England (NHS England 2017; NHS Providers 2020). This decision was communicated to the NHS in a letter of 3 March (Health Services Journal 2020). NHS England has itself been made far more accountable to the centre of government than in normal times, for example by participating in daily Whitehall briefings.

In a series of fields including epidemic modelling, ‘Lighthouse’ testing centres, and NHS Test and Trace, new organisations have been set up by the centre, often using private contractors. The results have met with mixed success, and in recent weeks the respective merits of more locally- and centrally-based responses have been much debated.

In relation to the centralisation of modelling, an interviewee told us that:

‘the reason we know anything about care homes is because of the group in Manchester who made connection with their local public health and local community. But not everyone has done that, and even if they did, that would still leave huge sections of the country uncovered.

‘... People have … not … thought it through … [Regarding the] reasonable worst case scenario ... information that is [meant to be] cascaded out so that local government can prepare for eventualities … it has been very unclear … [what the centre is meant to provide], and then it has been very unclear to [LAs] what … they are supposed to do with it.’ (anonymised interview, 22 April)

LAs continue to be kept in the dark about Whitehall’s plans for localised modelling. Many have commissioned their own, which – as in the Manchester example – is proving invaluable. This is threatened by the Government’s continuing lack of clarity about its intentions, notably in relation to the work of the Joint Biosecurity Centre, resulting in a form of planning blight (anonymised interview, 17 June).

Turning to the government’s new Lighthouse testing centres, there have been powerful advocates for an alternative strategy which would continue, as in pre-COVID times, to delegate authority to local resources and teams, harnessing (to quote Sir Paul Nurse) the nation’s ‘Dunkirk spirit’ (Nurse 2020). Labs in facilities such as the Francis Crick Institute (of which he is the Director) could meet the modelled demand for laboratory analysis. The NHS’ and PHE’s own laboratories responded well to the need for rapid analysis of tests, and greater use of these more local resources would have saved exhausted health care workers at the end of long shifts from having to drive long distances to a test centre. Where the NHS tested its own staff on site and sent specimens to a nearby lab, whether in an NHS facility or otherwise, these problems were avoided.

A GP and Clinical Director in Merseyside describes how local labs may not have been given sufficient lead-time to prepare for testing:

‘We got the email from NHS England regarding antibody testing on Friday…and then I phoned the labs, our local labs, to find out, well, what’s the plan here? And of course no one had told them about the antibody testing roll-out that was going to go on nationally, and they had had as much notice as we had in order to be ready for this’ (02 June 2020)

Worryingly, this interviewee adds:

‘The problem about the half-baked implementation is that each time you botch it, you lose a little bit of energy from people … When big changes like that happen, you would think that the coordination should be put in place prior to notification and then, otherwise what you get is an undermining of the confidence in central decision making.’

NHS staff morale and motivation, one of the key subjects of our research, is critical to successful delivery of government policy on the ground. At times, mishandling at the centre has sacrificed some of this, as in this example.

Building surge capacity onto existing institutions, instead of setting up new testing organisations, would also have avoided some of the delay and confusion which always occurs when a new organisation is rapidly built from scratch, however competent the contractors tasked with this. In reality, not all the contractors did perform well: Deloitte’s and Serco’s effectiveness at some of the testing centres (such as Chessington) has been rightly criticised, for example for the reporting of incorrect test results.

Central government sent out ‘shielding letters’ to those regarded as particularly vulnerable. A number of our contacts among health and care workers felt that this centralisation had been counter-productive, creating more work for practices and consultants because they had to check who had received the letter and identify those who were inappropriately told to shield or missed). Some highlighted the harmful effects of such errors on patients. A Merseyside Clinical Director & GP told us:

‘The shielding stuff was a bit of a farce really. Not the principles of it, I, absolutely with the principles of it, but that should have been done through practices and we could have done it – because we’ve had to sort of do it anyway. Mop up, mop up the mess and we lost two weeks, when we could have done it earlier.’ (anonymised interview, 19 May).

A Merseyside GP Partner said:

‘we just have to go through those kind of people individually [who were missed], like we did at the start of April, to say who in this group would be, you know, at risk. […] Then of course the upshot of that is that they haven’t necessarily had shielding letters and therefore they haven’t had - they’re probably the ones that really need access to online deliveries from the supermarkets or volunteers coming around.” [People with learning disabilities] (anonymised interview 29 May)

A Clinical Director in a Liverpool hospital added that patients did not know how to raise queries about a letter from a central source, whereas ‘if it’s come from someone like your practice or maybe a GP practice, then you know you know who to call’ (anonymised interview 15 May).

Public health practitioners also criticised the centralisation of NHS Test and Trace, and argued for the greater efficacy of local testing and tracing compared with a new national body (Scally et al 2020). We were told that the PHE specialists in contact tracing:

‘are constantly waiting for a steer from DHSC, Number 10, as to what the policy is, even … what symptoms constitute the case definition, that’s no longer decided by PHE alone. …

‘like many big projects, not enough attention is given to the nitty-gritty of operational details … things that make or break a big project. So … what seemed great as a strategy decided by someone with no public health background, actually there is a reason we do it this way’ (anonymised interview, 22 May).

A public health official gave a similar opinion: NHS Test and Trace has been:

‘an exercise in people above my position telling me they know better and in almost every circumstance they turned out not to. That’s what this whole pandemic has been like, and I won’t forget that.’ (Guardian 2020)

Other professionals at local level also sometimes expressed scepticism about the planning of Test and Trace activities. The Merseyside GP & Clinical Director already quoted was concerned that tests were done and not followed up: ‘there’s no point doing a test if you’re not going to contact trace and manage that test.’ They added: ‘There seems to be a complete lack of coordination between central government and the community teams.’ (anonymised interview, 19 May).

A Director of Public Health told us:

‘National government has operated on the basis that they are best placed to understand the needs of local communities,  more than local government does, and has the necessary skills and expertise to respond accordingly, seemingly forgetting all about directors of public health in local authorities and their teams, who have spent years training and working on this exact agenda.’ (17 July).

This interviewee explained that their main concerns had been:

‘Lack of sharing of modelling data national to local, to understand potential impact of pandemic - still an issue now in relation to future waves.

Lack of sharing of pillar 2 data national to local; lack of patient identifiable data.

Lack of understanding of local public health systems and how they can/could be geared up to respond; lack of understanding of Director of Public Health role locally, and value in engaging experts at an early stage.

Mixed messages,  meaning local distrust of national messages, and emphasising need for strong local communications [with the public].’

DHSC could adopt better-informed policies for both NHS services and public health if its access to in-house medical advice had not been severely reduced over the last generation (Sheard 2010). There is no substitute for properly harnessing existing professional skills, experience and local knowledge. The detective-work of infectious disease contract tracing is a particularly good illustration, and it is heartening that LA public health departments are now being allowed to engage with NHS Test and Trace more productively (anonymised interview, 5 June).

As a Clinical Director in a Liverpool hospital commented:

‘Learning that occurs at local level … is impossible to get back to up to central level really because … communication doesn’t really flow that way at the moment’ (anonymised interview, 15 May).

The use of private contractors is, then, inevitable: the point is how well it was managed in these cases. The cumulative impression left by the cases discussed here is that the government has reached for centralised private solutions without sufficient insight into the operational requirements (for instance in contract tracing), and has let corporate service providers convince it too easily that their generic capacities can smoothly be plugged into COVID-19 responses, which in fact need the detailed expert knowledge possessed only by existing professionals and the public sector bodies at local level who employ them. The UK’s COVID-19 experience has been that contracting-out can only be effective when adequate time is available: not in the very short timescales the virus allows us. The tracing app, for example, may ultimately work excellently, but we learn from the responsible Minister that it is unlikely to be ready before the winter (Daily Telegraph 2020).

There is a strong sense of disillusionment at local level about the performance of central government so far during the epidemic. Some of this feeling is the familiar one that front line staff know best about the right way to deliver services, for example the GP who told us:

‘it’s probably better for us to decide [what to do next], and the reason for that is because the politicians don’t have any real clue about how general practice works. … we can see by some of the things that come down to the CCG to organise that, you know, that a lot of the people [at the centre] just live in cloud cuckoo land.” (anonymised interview, 29 May).

However, discontent is perhaps most acute over the new issue of providing Pillar 2 testing and tracing data to local public health departments, something which DHSC appears to be belatedly taking on board, but which, at the time of writing, is still far from fully satisfactory. Leicester has been a case in point, but we are also hearing similar reports of delay from elsewhere. Question marks must remain, for the time being, over the role being played by the new (central) Joint Biosecurity Centre, and whether it is indeed the best solution to the country’s needs.

 

Conclusion

We hope this testimony from the health care front line and from the policy world speaks for itself, but the research team would be happy to contribute further to the Inquiry if the Committee wishes.

References:

Boin A. The New World of Crises and Crisis Management: Implications for Policymaking and Research. Review of Policy Research 2009; 26(4): 367–77.

Brändström A, Kuipers S. From ‘normal incidents’ to political crises: Understanding the selective politicization of policy failures (pt. 1). Government and Opposition 2003; 38(3): 279–305.

Daily Telegraph, ‘Contact-tracing app will not be ready until winter, admits health minister’ 17 June 2020

Guardian, ‘England's coronavirus tracing plan 'beset by conflict and confusion', 27 May 2020

Health Services Journal, ‘National incident over coronavirus allows NHSE to command local resources’, 3 March 2020

Horton R. COVID-19 and the NHS – “a national scandal”. Lancet 2020; 395(10229):1022.

Klein R. The new politics of the NHS: from creation to reinvention. 7th edition. (Radcliffe, London: 2013).

NHS England, NHS England Incident Response Plan (National), 2017.

NHS Providers, ‘Confronting Coronavirus in the NHS: the story so far’, April 2020, https://nhsproviders.org/confronting-coronavirus-in-the-nhs (Accessed 14 July 2020).

Nurse, P., speaking on BBC Radio 4 ‘Today’ programme (2 April 2020).

Scally G, Jacobson B, Abbasi K. The UK’s public health response to covid-19. BMJ 2020; 369: m1932.

Sheard S. Quacks and Clerks: Historical and Contemporary Perspectives on the Structure and Function of the British Medical Civil Service. Social Policy and Administration 2010; 44(2): 193–207.

Weible C M, Nohrstedt D, Cairney P, et al. COVID-19 and the policy sciences: initial reactions and perspectives. Policy Sciences 2020; https://doi.org/10.1007/s11077-020-09381-4.



[1] This work comes from the NIHR Health Protection Research Unit in Emerging and

Infections at University of Liverpool in partnership with Public Health England (PHE), in collaboration with Liverpool School of Tropical Medicine and the University of Oxford (Grant No. NIHR200907). The views expressed here are our own and not necessarily those of the NHS, the NIHR, the Department of Health and Social Care (DHSC) or PHE.  We are grateful for the support of Liverpool Health Partners, and the Centre of Excellence in Infectious Disease Research (CEIDR), Liverpool.

[2] More details of our methods are available on request.

Posted on: 20/07/2020