The Challenge of Controlling COVID-19: Public Health and Social Care Policy in England During the First Wave 9781447362524

Table of contents :
The Challenge of Controlling COVID-19
Contents
Acknowledgements
Preface
Introduction
1 The approach to the early stage of the pandemic by politicians and scientists
Politicians
Scientists and politicians
2 The position of public health and the problem of ‘test and trace’
Public health
The problems with the test, trace and isolate system4
The launch of NHS Test and Trace
Partial relaunch of NHS Test and Trace
Further changes in NHS Test and Trace and structural change for PHE
3 Care homes for elderly people1
The Government’s policy response
Hospital discharge and hospital admission
Testing
The structural position of social care
Social care and health care
Privatisation
Staffing
Conclusion
References

Citation preview

RAPID RESPONSE

The Challenge of Controlling COVID-​19 Public Health and Social Care Policy in England During the First Wave Jane Lewis

First published in Great Britain in 2021 by Policy Press, an imprint of Bristol University Press University of Bristol 1–​9 Old Park Hill Bristol BS2 8BB UK t: +44 (0)117 954 5940 e: bup-​[email protected] Details of international sales and distribution partners are available at policy.bristoluniversitypress.co.uk © Bristol University Press 2020 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 978-​1-​4473-​6251-​7  ePub ISBN 978-​1-​4473-​6252-​4  ePdf The right of Jane Lewis to be identified as author of this work has been asserted by her in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved:  no part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without the prior permission of Bristol University Press. Every reasonable effort has been made to obtain permission to reproduce copyrighted material. If, however, anyone knows of an oversight, please contact the publisher. The statements and opinions contained within this publication are solely those of the author and not of the University of Bristol or Bristol University Press. The University of Bristol and Bristol University Press disclaim responsibility for any injury to persons or property resulting from any material published in this publication. Bristol University Press and Policy Press work to counter discrimination on grounds of gender, race, disability, age and sexuality.

Contents

Acknowledgements  v Preface  vii   Introduction  1 1. The approach to the early stage of the pandemic by politicians and scientists  9 Politicians  9 Scientists and politicians  11 2. The position of public health and the problem of ‘test and trace’  23 Public health  23 The problems with the test, trace and isolate system  26 3. Care homes for elderly people  45 The Government’s policy response  47 The structural position of social care  55   Conclusion  67 Notes  81 References  85

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Acknowledgements

I am grateful to Celia Davies, David Piachaud, Anne West and three anonymous reviewers for helpful suggestions.

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Preface

My text offers an analysis of the first wave1 of COVID-​19 in England.2 It is neither a diary nor journalism. Rather, it seeks to take account of as many of the key documents relating to the policy response as possible, focusing on the approach taken by the Government and the position of other key actors, particularly scientists and public health practitioners. It looks in detail at two issues of particular importance and concern: the performance of the test, trace and isolate system, and the heavy toll exacted on the residents and staff of care homes. I hope that the account and the conclusions regarding the policy problems that have been experienced may become a point of reference for those offering a comparative analysis of all the countries of the UK and beyond in the future. I look only at the first wave of the pandemic. The main part of the text was written between late July and October 2020, with some additions up to late December. It will be interesting to see the correctives offered by those taking the longer view in the future. Jane Lewis 31 December 2020

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Introduction

COVID-​191 has proved an altogether more threatening and deadly disease than the new strain of influenza that had been expected at some point and for which plans, if not adequate preparations, had been made. Better understanding of the way in which COVID-​19 behaves has rapidly emerged, but many questions have been difficult to answer: for example, why the virus is so highly transmissible, how far being infected will give immunity, and why some individuals are more vulnerable to infection and death. This makes control difficult. But public health structures and expertise are longstanding in the UK and the control of epidemics has long been recognised to come within the purview of government, requiring a coordinated response between central and local government, and between public health and clinical doctors, healthcare managers and government officials. The pandemic has laid bare socioeconomic fault lines and exposed major divisions in western societies. In the UK, it became clear early on that older people, those on low incomes and black and minority ethnic communities suffered the highest rates of sickness and death, while young people have suffered major disruption to their education and many of those of working age, especially the self-​employed, face high levels of unemployment and/​or debt. The interests of different groups as to how the virus should be controlled –​by strict rules about individual behaviour or a more laissez-​faire approach –​have often been perceived to be in conflict by commentators and politicians, many of whom also tend to take a strong position on the vexed issue of freedom versus responsibility. Attitudinal surveys of opinion and of personal behaviour show that there are also fault lines in the wider population on this issue.2 There are therefore real 1

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The Challenge of Controlling COVID-19

problems for the state in attempting to control the pandemic. Setting rules and telling people what they must and must not do (for example, get tested for the virus and self-​isolate if they test positive); how they should behave (for example, not visiting elderly relatives in a care home); and how far to enforce such behaviours are not necessarily straightforward for liberal western democracies. It is particularly difficult for the Conservative Party in the UK, which has long been committed to individual freedom and choice and would wish to avoid any charge that it is behaving as a ‘nanny state’. It is also difficult for governments to make well-​founded decisions in a timely fashion during a fast-​moving pandemic, and this has proved particularly problematic for western countries. Decisions about how to deal with a new virus like COVID-​19 –​whether to try to suppress it, eliminate it or ignore it as much as possible (which effectively means ‘letting it rip’) –​have to be made, and much depends on the nature and quality of advice that is sought and offered. Carrying on in ‘as normal’ a way as possible has been justified as the best strategy for keeping the economy open, but the infectiousness of the virus meant that this risked high death rates and healthcare systems being overwhelmed by COVID-​ 19 patients. Nevertheless, this was the route chosen by the US Federal Government and was also supported by a significant proportion of the US population, who explicitly insisted upon personal freedom and rejected government interference. To a lesser extent it also characterised the Swedish approach, which relied mainly on advising citizens on the best way to avoid contracting the virus and, unlike the US, on people’s longstanding trust in government. Some countries in East and Southeast Asia –​for example, Taiwan, Vietnam and South Korea –​as well as New Zealand opted for the very different strategy of strict measures, including testing for COVID-​19, tracing contacts (which in East Asia often used technology in ways that would likely be considered to impinge on the privacy of the individual in European countries) and quarantining, all with the aim of eliminating the virus. Most Western European countries have tried to suppress it, with more or less steady application of these same longstanding public health instruments. Governments have also had to

Introduction

3

decide how to operationalise their decisions, for example how far to decentralise and how to ensure coordination of their policy responses.3 In the UK, major policy issues have often been presented by many politicians and commentators as dichotomous choices between freedom and responsibility, and whether to prioritise health or the economy, but they are not necessarily so. It became clear in 2020 that countries adopting a rapid and decisive response to controlling the virus also ended up with the least economic disruption. At every turn, controlling the virus was essential to economic functioning, and getting people back to work after the cessations of social and economic activity in the form of ‘lockdowns’ that many European countries had to adopt continued to depend on successful control of the virus. The COVID-​19 death rate in the UK was the highest in Europe during the first wave. Patrick Vallance, the Chief Scientific Officer (CSO), told MPs on 17 March that limiting deaths to 20,000 would be a ‘good outcome’ (HoC (House of Commons) Health and Social Care Committee, 17 March 2020). By late September, the number of excess deaths4 from COVID-​ 19 reached close to 60,000 in the UK, of which at least 40 per cent were accounted for by deaths in care homes for older people5 (Bell et al, 2020). Neither the certification nor measurement of deaths from COVID-​19 is straightforward (Beaney et al, 2020; Spiegelhalter, 30 April 2020; West et al, 2020). Indeed, on 12 August a new UK-​ wide standard was announced for recording the official death toll, resulting in 5,377 deaths being cut from the official total, a reduction of 11.5 per cent. Nevertheless, by 23 June the UK had recorded about four times as many deaths as Germany. The Office for National Statistics (ONS) published its first comparative study of excess mortality in European countries at the end of July. It reported that England had experienced the longest continuous period of excess mortality of any of the countries compared between 21 February and 12 June, and the highest levels of excess mortality for the period as a whole (ONS, 2020a). By any measure of mortality –​deaths registered, deaths per 100,000 population, or excess deaths –​the UK has not performed well. Yet in 2019, the

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The Challenge of Controlling COVID-19

Global Health Security Index ranked the US first overall in terms of pandemic readiness and the UK second (Cameron et al, 2019). There have been successes in dealing with COVID-​ 19 (especially in respect of treatment by the NHS and on the part of biomedical researchers seeking drug treatments and vaccines). The most important immediate successes were the rapid reconfiguration of existing hospitals6 and the reorganisation of primary care, alongside the dedication of NHS frontline staff, which elicited displays of gratitude from the public on a weekly basis over two months in the form of handclaps for carers. The response of clinical staff and hospital managers was rapid, and was a professional triumph in the face of extreme and extraordinary pressure (notably in respect of the shortage or absence of personal protective equipment in the early months), grounded in a strong professional culture and the public ethos of the NHS, with its commitment to a universal service available free to all at the point of need. However, the failures regarding control of the pandemic are of a number and seriousness to warrant attention from a policy perspective. Control of the pandemic was a matter for public health provision in the first instance, and while the main fear early on was that the NHS would be overwhelmed –​which was avoided during the first wave –​it is widely agreed that the ongoing struggle to control the pandemic has proved to be extremely difficult. This ‘rapid response’ contribution focuses on the COVID-​19 policies adopted by the UK Government (elected in 2019 with a large majority) in respect of England. The devolved administrations of Northern Ireland, Scotland and Wales have followed the UK Government’s prescriptions in large measure, but there have been significant differences in timing, for example, of lockdowns, and public health messaging in particular. Interestingly, polling for the BBC in Scotland gave the First Minister, Nicola Sturgeon, a net approval rating of plus 61 for her handling of the pandemic, while Prime Minister Boris Johnson was given a net rating of minus 43 (Ipsos Mori, 18 November 2020). Further exploration of the differences in policy approaches between the four countries, as well as between the UK and other

Introduction

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European countries, must be left for a later stage in the analysis of the pandemic. Press commentary and the public debate have tended to focus on the short-​term causes of the major problems that have arisen, particularly the shortcomings of Government ministers. These have been significant, but in a pandemic, governments are reliant both on scientific experts for advice as to how a new virus such as COVID-​19 is behaving and what might be done about it, and on particular groups of people to operationalise its decisions. Public health practitioners have played a strong and important role in controlling epidemics in the past. However, in responding to COVID-​ 19, the Government relied as much, and often more, on the private sector to tackle crucial dimensions of what have historically been the responsibility of specialists in public health, such as tracing those who might have contracted the virus. In addition, given the vulnerability of older people to COVID-​19, more engagement with specialists in social care might also have been expected. What follows explores the Government’s approach to controlling COVID-​19, the relationship between ministers, scientists and public health doctors and officials, and also the structural issues that have underpinned two major issues: (i) the difficulties in securing effective testing for the virus, together with tracing and isolating those infected by it, that is, in establishing the major public health instrument necessary for the control of COVID-​19; (ii) the problems of controlling the virus in care homes, which experienced extremely high death rates. Both these problems demonstrate the impact of short-​ term government failures resulting from the nature of the approach taken by the Government, whether for reasons of poor advice, poor understanding, or the sheer immensity of the difficulties in operationalising the decisions taken. However, problematic patterns of decision-​ making and operational failure repeated themselves during the first wave, underpinned by systemic problems of structure and governance. As Gaskell et al (2020) have pointed out, the degree of centralisation and lack of coordination in the Government’s response to COVID-​ 19 have been striking (see also Nickson et al, 2020).

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The Challenge of Controlling COVID-19

The first chapter reviews the approach of the Government in relation to the advice provided by scientists on the steps necessary to control the pandemic in February and March, the period in which COVID-​19 cases surged, resulting in the UK finally ‘locking down’ on 23 March. Chapter 2 examines the position of public health in the healthcare system and then focuses on the setting up and operation of the test, trace and isolate (TTI) programme. Unlike the wearing of face masks, the maintaining of social distance and handwashing, which depend more on the individual (but do also require careful and effective public health messaging), the TTI system is entirely within the Government’s responsibility to organise and is crucial to controlling the pandemic. Chapter 3 focuses on policies towards and the structural problems of residential and nursing homes for elderly people. I argue that the approach of the Government to policymaking has been a very important factor in explaining the problems that have arisen, but that it is also crucial to understand the longstanding structural problems of public health and social care provision in the form of care homes, alongside the continuing preference of the Government to favour private providers and central over local government. Indeed, similarities in the systemic issues affecting the policy responses to these two very different problems are striking. It is also important to remember that the background to these problems was one of austerity over the previous decade, particularly for local government, which has operational responsibility for public health work on the ground as well as responsibility for shaping the social care market. The aim is not to attribute blame, for example, between Government ministers and scientists (see Cairney, 2020 on this), or to come to conclusions as to what should or could have been done, which would require a much closer interrogation of the scientific evidence available, as well as establishing who knew what about the pandemic when, and to whom the information was passed. Rather, I use primary, documentary sources and historical methods in order to explore the policy decisions on pandemic control that were taken and what characterised the nature of decision-​making. I present a chronological, detailed account and analysis of the

Introduction

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establishment of the TTI system and the problems experienced by care homes, from which cross-​cutting themes are identified and discussed. While chronology in and of itself explains nothing, it is a basic underpinning for the analysis of a fast-​ moving pandemic. It stretches the concept of contemporary history to attempt analysis of an issue as soon as I do here, but my attempt is closer to this than ‘high journalism’, which necessarily focuses on providing an even more immediate commentary. In short, historical analysis is usually inductive, relying on as extensive an exploration of the documentation as possible in order to arrive at explanatory variables. My analysis is thus not theoretically driven, but provides support for the importance of some of the frameworks that have been used and developed by political scientists in the course of their early inquiries into the policy response to COVID-​19, particularly the degree and nature of centralisation, the effect of fragmentation, and the difficulty of securing coordination (see especially Gaskell et al, 2020; Weible et al, 2020). I focus particularly on the period from early March to 19 June 2020, when the threat level from the virus was lowered from 4 to 3 by the new Joint Biosecurity Centre,7 with a somewhat less detailed account of what followed between July and September, when the threat level was once again raised to 4 as the infection rate rose.

1 The approach to the early stage of the pandemic by politicians and scientists Politicians

The UK Government had substantial warning about the new coronavirus and, in broad outline, what they might expect. The first death in China was announced on 11 January 2020, and the first confirmed cases appeared in Italy and the UK at the end of January. The first death occurred in England on 5 March. The World Health Organization (WHO) declared a public health emergency of international concern on 30 January and confirmed the existence of a pandemic on 12 March. By the end of January, it was clear that the virus was being transmitted from person to person, that it had a serious effect on those contracting it, and that there was the potential for it to become a pandemic. Commentators have broadly agreed that the UK Government was nevertheless slow to acknowledge the seriousness of the situation and to respond; the editor-​in-​chief of the British Medical Journal recorded the verdict of their editorial writers as: ‘Too little, too late, too flawed’ (Godlee, 21 May 2020). However, not all contributions from academics have agreed (for example, Cairney, 2020). The Government considered that it was well prepared for the pandemic. Prime Minister Johnson made this clear after he chaired his first COBRA1 meeting on 2 March –​in fact the fifth that had been held on the new coronavirus –​when he said: ‘…let me be absolutely clear that for the overwhelming majority of people who contract the virus, this will be a mild disease from which they will speedily and fully recover … Our country remains extremely well prepared, as it has been since the outbreak began in Wuhan several months ago’ (Johnson, 3 9

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The Challenge of Controlling COVID-19

March 2020). However, the opportunity to make preparations during February had been missed. It may be that preparations for Brexit on 31 January absorbed the Cabinet’s attention in January, but in February and early March, it seemed that the Government was inclined to believe, and certainly said, that the virus would be moderate in its effects. While the UK Government was not alone in the lack of urgency of its response, when compared to countries such as South Korea, Singapore, Germany and Ireland, it was desultory. No objection was raised to holding large sporting events:  rugby at Twickenham in the first week of March, when cases rose fivefold and deaths eightfold; horse racing at Cheltenham over four days from 10 March; and football involving Liverpool and Atlético Madrid on 11 March (just as the number of confirmed cases in Spain began to rise steeply). From late January to early March, non-​mandatory guidance to self-​isolate for 14 days was extended to travellers from designated high-​risk countries (China being the first), but these did not include Spain. Nor was any testing or screening carried out. Self-​isolation guidance at the borders was abandoned on 13 March and not reinstated until 8 June, when a 14-​day quarantine system was announced for arrivals from across the world, although a number of countries (the list changed over time) were exempted on 10 July. Between 13 March and 23 March, when the UK ‘locked down’, the evidence suggests that thousands of new infections were brought into the UK from Europe (HoC Home Affairs Committee, 5 August 2020, para 73). The Prime Minister continued to behave ‘normally’, shaking hands and attending the Twickenham rugby match in early March. But on 12 March the Government performed a ‘screeching u-​ turn’, when the PM’s television address admitted that this is ‘the worst public health crisis for a generation … many more families are going to lose loved ones’. This prompts further exploration of the relationship between Government actions and the advice that it was receiving; after all, it insisted from the beginning that it was following the advice of scientists. While the details as to how the Government treated advice –​for example, which scientific view was favoured when and why must await an

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official inquiry (although this will likely be politicised) –​it is possible to outline some of the issues and the advice that has since become publicly available. It is also possible to consider further the Government’s pattern of thinking about, and the key dimensions of its approach to, controlling the virus. Politicians were slow to react and much in need of advice on controlling the pandemic, but the relationship with scientists was far from easy.

Scientists and politicians

The main debate in the literature so far has centred on the failings of scientific advisers and politicians with the inevitable tendency to blame one party more than the other. But the evidence suggests that there are some difficulties with taking a clear-​ cut position on this. There was no one ‘scientific view’ on offer and as Salajan et al (2020) have pointed out, while decision makers may prioritise expert advice, they are challenged by scientific uncertainties. The UK Government did not ignore the views of scientists, but they may have had difficulty using often far from united scientific opinion to reach the policy decisions that they, and not the scientists, were responsible for taking. In addition, there may also have been limitations as to the nature of the advice that was offered by those sitting on the bodies that advised Government, probably due in part to the relatively narrow range of specialities represented. Historically, epidemics have been controlled by public health doctors and their staff at the local level, exercising the authority provided by law, and using above all the well-​ established tools of testing, tracing contacts, and quarantining/​isolating.2 The central public health body involved in the control of COVID-​ 19 was Public Health England (PHE), set up in 2013 by the Conservative/​Liberal Democrat Coalition Government as an arms-​length executive agency with operational autonomy, but responsible directly to the Department of Health and Social Care (DHSC) and the Secretary of State for Health and Social Care. PHE was created by the 2012 Health and Social Care Act following the then

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The Challenge of Controlling COVID-19

Secretary of State’s (Andrew Lansley) major reorganisation of the NHS and has operated alongside a large number of other central health organisations, most importantly NHS England (NHSE), which has much greater autonomy. However, the main source of scientific advice given to Government was SAGE (the Government’s Scientific Advisory Group for Emergencies), which changes its membership depending on the nature of the emergency. In the event of a pandemic, SAGE was intended to act in collaboration with the Chief Medical Officer (CMO), Professor Chris Whitty, a civil servant and thus statutorily independent, politically impartial and located in PHE, and the Chief Scientific Officer (CSO), Sir Patrick Vallance, who is head of profession for the scientists working in the NHS. Both the CMO and the CSO are members and chairs of SAGE. Advice to Government was filtered through the CSO and the CMO. SAGE considered a range of options and played a major role in shaping the Government’s response, but it did not make policy recommendations. Its ‘consensus statements’ did not present a single view, but rather put forward assessments as to the nature, degree and range of uncertainty. The CMO explained to the House of Commons’ Science and Technology Committee that he aimed to put forward the Group’s ‘central view’ and to convey the range of uncertainty to Government (Clark, 18 May 2020). But the way in which policy decisions emerged tended to be opaque. Indeed, on 22 May, Sir Paul Nurse, Director of the Francis Crick Institute (a biomedical research institute, established through a partnership between a UK Government funding agency, two charities and three universities) saw fit to ask who was formulating strategy, what was the relationship between SAGE, PHE and politicians, and who was bringing evidence and action together? (Nurse, 22 May 2020, BBC Radio 4 Today interview). He repeated his concern about secrecy in respect of decision-​making in an interview with The Guardian (Sample, 2 August 2020), when he was quoted as saying that ‘it sometimes seems like a “black box made up of scientists, civil servants and politicians are coming up with the decisions”’. Both ministers and scientists have rehearsed the well-​worn dictum that scientists advise and ministers decide, but the

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precise way in which decisions on action and possibly strategy (this tended to be particularly opaque) were arrived at has not been clear and may have made the passing of blame onto scientists (and civil servants) easier, not least because scientists often stood alongside politicians at the regular Downing Street Briefings on COVID-​19. However, standing side by side at briefings does not necessarily indicate a shared understanding. Furthermore, the membership of SAGE and its sub-​groups, the papers submitted to it and the minutes of its meetings remained secret until 29 May,3 by which time the role it was playing had become the subject of media speculation, with some scientists objecting to the redactions in the official record of their proceedings. What is clear from the publication of the membership of SAGE is that the Group was dominated by epidemiologists doing mathematical modelling to determine the course of the disease. Field epidemiologists, public health practitioners and social care experts were notable by their absence. But, while the mathematical modellers on SAGE were aware early on of the risks to elderly people in care homes, they did not know how care homes worked, for example in terms of their reliance on agency staff who were likely to work in several different homes and might thus pass on infection. Lord O’Donnell, Cabinet Secretary between 2005 and 2011, also suggested that given the effects of the pandemic on the economy, more social scientists should also have been members of SAGE and its sub-​groups (O’Donnell, 2020; see also Cairney, 2020), although the views of economists reach the Treasury and the Chancellor and then the Cabinet. Nevertheless, it may be that bringing together scientists and economists in a single forum would have helped to clarify the balance of risks. SAGE seems to have agreed on 4 February and again on 11 February that the Government should plan by using ‘influenza pandemic assumptions’, which could be modified as the data on the pattern of the disease became more certain. This is significant because the influenza outbreak in 2009 had been successfully handled (Hine, 2010), and planning had taken place for a further influenza pandemic. Indeed, the Government’s Coronavirus Action Plan (DHSC, 3 March 2020) echoed parts of the Influenza Pandemic Preparedness

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The Challenge of Controlling COVID-19

Strategy of 2011 (DH, 2011).4 The Coronavirus Action Plan reiterated that the UK ‘is well prepared for disease outbreaks … Our plans have been regularly tested and updated…’ (DHSC, 3 March 2020, para 3.2), which was true in that exercises had been carried out, notably the three day Exercise Cygnus in 2016.5 However, the recommendations following this Exercise, particularly regarding the supply of beds, ventilators and masks, were not followed under the conditions of austerity that prevailed after 2010. In addition, the Government’s strategy for dealing with COVID-​19 outlined by the Plan was also modelled closely on dealing with the expected influenza pandemic. Like the 2011 influenza strategy, the Coronavirus Action Plan described four phases:  containment, involving detection of cases and follow-​up of contacts; delay, involving measures to slow the spread of the virus, ‘pushing it away from the winter season’; research; and mitigation by providing the best care for the sick and supporting hospitals and communities (DHSC, 3 March 2020, para 3.9). This Plan did stress the importance of tracing and isolating contacts, but stated that there would be ‘less emphasis’ on measures such as intensive contact tracing in the mitigation phase, because ‘as the disease becomes established these measures may lose their effectiveness…’ (ibid., para 4.48). This echoed the Influenza Strategy, which also confined the importance of ‘test and trace’ to the first phase of the pandemic. Readers were also assured that stockpiles of ‘the most important medicines and protective equipment for healthcare staff … are being monitored daily’ (ibid., para 4.14), which was later shown not to have been the case. SAGE also commented on issues that were central to the control of COVID-​19 at an early stage. There are examples of advice that seem to back up what the Government chose to do or not to do and also enable us to see how uncertainty played into the decision not to act, for example regarding two of the issues outlined above –​the decisions not to stop big sporting events and not to impose quarantine regulations. In respect of the first, the Scientific Pandemic Influenza Group on Modelling, Operational sub-​Group (SPI-​M-​O) concluded on 11 February that the direct impact of stopping large

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public gatherings on the spread of the virus at the population level would be low, but that social interaction in bars and restaurants might ‘slightly accelerate’ the spread. Of course, attendance at large-​ scale sporting events was often also accompanied by visits to bars. This ‘consensus view on public gatherings’ was passed on to SAGE (Meeting 12, Minutes 3 March 2020), which added that it would be difficult to stop interaction in bars and restaurants. In the event, Government chose not to cancel large events and nor did it place any limitations on bars and restaurants. It is possible that the necessarily equivocal nature of much of the advice offered by SAGE lulled ministers into a lack of urgency. Or there may have been a lack of capacity on the part of Government to ask the further questions that would have been necessary prior to making difficult policy decisions. Yet again, the Government may have been straightforwardly reluctant to interfere with the everyday lives of citizens. On quarantine, SAGE considered this early on, before the Prime Minister became actively involved in plans for controlling the virus. On 3 February, SAGE estimated (as it admitted on the basis of ‘limited data’) that if the UK reduced imported infections by 50 per cent this would ‘maybe delay the onset of any epidemic in the UK by about 5 days’. Infections would have to be reduced by 95 per cent to buy a month of time and ‘only a month of additional preparation time for the NHS would be meaningful’. But buying that amount of time would require ‘draconian and coordinated measures, because direct flights from China are not the only route for infected individuals to enter the UK’ (Meeting 3, Minutes 3 February 2020). On 23 March, SAGE minutes recorded the conclusion that closing the UK borders ‘would have a negligible effect on spread’ of the virus, because by then the number of cases arriving was insignificant compared to the domestic infection rate (Meeting 18, Minutes 23 March 2020). However, in response to a Home Office request for advice on what to do about border restrictions at the end of April (Home Office, 2020), SAGE stated firmly that determining ‘a tolerable level of risk from imported cases … is a policy question’, thus excluding it from consideration (Meeting 29, Minutes 28 April 2020).

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The Challenge of Controlling COVID-19

SAGE’s advice was only as good as the quality of its data, and as Professor Neil Ferguson admitted later, this was poor in the early part of the pandemic:  in particular, it was not known how far COVID-​19 was ‘seeded’ from many of the people arriving from Italy and Spain (Ferguson, 10 June 2020). As the House of Commons Home Affairs Select Committee (5 August 2020, p 3) commented:  ‘The UK’s approach [to border control] was highly unusual’ compared to other countries, but the advice from scientists at this stage did not support firm action. However, the Home Affairs Select Committee reported that it asked to see the advice underpinning the Government’s decision to impose quarantining for an expanding number of countries up to 12 March and then for abandoning all such measures, but, receiving no answer, suggested that it was reasonable to conclude that such advice did not exist. The Home Office News Team (5 August 2020) denied that this was the case. SAGE became more explicitly careful about offering advice on policy as a result of its findings as time went on. But politicians wanted it to be thought that they were acting on scientific advice. Thus, when he introduced the Coronavirus Action Plan the Prime Minister said: ‘the plan does not set out what the government will do, it sets out the steps we could take at the right time on the basis of the scientific advice’ (Johnson, 3 March 2020). However, the tensions between political imperatives and scientific understandings (there was never only one) became sharper over time. SAGE’s main focus was modelling the course of the pandemic and the findings on this seem to have had a major influence on politicians in mid-​March, especially in respect of changing the Government’s belief in a pandemic with moderate effects, to the possibility that it could result in high mortality. There is also evidence to suggest that some toyed with the possibility of achieving herd immunity by allowing a large proportion of the population to become infected, even if this was not a position taken by the vast majority of people in the Group. Building on the experience of controlling influenza may have played a part in any such thinking. On 13 March, the CSO had told an interviewer on BBC Radio 4’s Today programme that the Government’s strategy had in

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part been ‘to build up some herd immunity’. However, the next day the Secretary of State, Matt Hancock, denied that herd immunity was ever considered as a practical possibility (Hancock, 14 March 2020). In fact, a policy to allow the virus to spread among younger people while attempting to shield the vulnerable6 was not only likely to fail, but also to result in the NHS becoming ‘overwhelmed’ and, as Professor Devi Sridhar (24 December 2020) has commented, neglected to take account of possible mutations in the virus. In addition, as Mark Carney (2020), former Governor of the Bank of England and the BBC’s Reith lecturer has remarked, ‘the pathway to herd immunity runs directly through the inequalities in our society’. For as Marmot et al (2020) have documented, inequalities have increased both in terms of extent and depth. People in low-​wage, precarious employment, people in poverty, people in overcrowded accommodation and black and minority ethnic people have all suffered disproportionately high death rates (see also Bambra et al, 2020; Tinson and Clair, 2020). One of the main problems with the confidence engendered by building on the way in which the 2009 influenza outbreak had been tackled was the extent to which the COVID-​19 virus behaved in a very different way. What turned out to have been important at the beginning of the pandemic was the speed of transmission; however, the number of tests carried out was too small to be a useful tool in analysing its spread. SAGE signalled the need for an early warning surveillance system in mid-​February (Meeting 8, Minutes 18 February 2020), but the Office for National Statistics (ONS) was not asked by the Government to provide this until mid-​April. Data problems may also have affected the early advice SAGE gave on crucial issues such as closing borders. In the event, the ‘containment’ phase of the pandemic proved relatively short. The main catalyst for the Government’s startling u-​turn on 12 March, which signalled a move to the ‘delay’ phase and with it lockdown, seems to have been the findings by the modelling group at Imperial College under the direction of Professor Neil Ferguson which were submitted to SAGE in early March, warning that up to 250,000 people might die without drastic action and that

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The Challenge of Controlling COVID-19

with no action the death toll could be twice that (Imperial College Response Team, 16 March 2020). However, the 27 February Minutes of SAGE (Meeting 11) show that the Group had already warned that the UK could face an 80 per cent infection rate and a 1 per cent mortality rate (and, importantly, also warned that only a proportion of those infected would manifest symptoms), although the CMO seemed to suggest at the Downing Street Briefing of 3 March that moving to lockdown too early would risk ‘fatigue’ on the part of the public. It is impossible to know at this point whether the Government, the PM included, ignored SAGE’s warnings in late February and during the first two weeks of March, whether SAGE chose not to draw attention to them, or whether the views of SAGE were accurately relayed to ministers. On 16 March, SAGE advised that additional interventions, such as school closures were needed, because the number of cases was thought to be doubling every five to six days (Meeting 16, Minutes 16 March 2020). It was finally decided that doing little or nothing would exact too heavy a price in terms of mortality and, given the extensive spread of the virus in the UK, the only option was complete ‘lockdown’. This was announced a week later on 23 March in the hope of stopping the NHS from being overwhelmed. This was a risk that had been intensified by the way in which austerity had affected hospitals after 2010; for example, occupancy rates for intensive care beds were already running at or just above recognised safe levels before the pandemic started. The UK was the last country to enter lockdown in Europe; Italy also locked down late on 10 March, but nevertheless had fewer confirmed cases when it did so. As a comparative Imperial College-​led study has shown, the timing of lockdown in relation to when initial infections occurred affected the peak number of people infected, which drives both the number of COVID-​19 deaths and the pressure on the healthcare system, which in turn limits the capacity of the NHS to treat other diseases (Kontis et al, 2020). Peak infection actually occurred in England before lockdown. The delay in locking down, even as little as the week between SAGE’s recommendation for additional measures and the Government announcement on 23 March, resulted in an increased number of deaths

The approach of politicians and scientists

19

and had an adverse effect on the efforts to suppress the virus (Colbourne, 2020), which had become particularly widespread geographically in England compared to other Western European countries (Spiegelhalter, 2 August 2020). The reasons for the delay were possibly related to the Government’s lack of urgency and over-​ confidence, but its relationship with its scientific advisory body was also difficult. The modelling done by SAGE required good data (and sound assumptions). Its recommendations regarding the effectiveness of possible measures to control the virus demanded high standards of evidence –​higher than were often available –​and its conclusions were thus often equivocal. Above all, the Government was looking for policy solutions which the mathematical modellers who dominated SAGE did not have, and in any case regarded as strictly political territory, while public health practitioners, who might have made a valuable contribution –​particularly on operational issues at the local level –​were not consulted. Nor was there any forum in which a balance sheet of the possible impacts on the population in terms of health, but also economic performance, could be drawn up. The Government stressed throughout that it had ‘followed the science’ (although by the end of April, as tensions grew, the phrase was changed to being ‘guided by the science’ [Torjesen, 17 July 2020]), alongside an insistence that decisions had been taken at ‘the right time’. By May, tensions between SAGE and the politicians were being referred to openly. Jeremy Hunt, Chair of the Select Committee on Health and Social Care (and Conservative Secretary of State for Health from 2012 until 2018), blamed the Group for lack of attention to what had happened in other countries, describing their efforts in terms that echoed those of Richard Horton (2020, p 41), editor of The Lancet, as ‘one of the biggest failures of scientific advice to Ministers in our lifetimes’ (HoC Debates, 11 May 2020, vol 676, col 59), albeit that Horton blamed scientists for colluding with Government rather than misleading it. On 19 May, Therese Coffey, Secretary of State for Work and Pensions, told Sky News that ‘if the science was wrong, advice at the time was wrong, I am not surprised people think we made the

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The Challenge of Controlling COVID-19

wrong decisions’. This prompted Venki Ramakrishnan, then President of the Royal Society, to comment that: …it is not possible for scientists to give frank advice if they feel that they will be made the scapegoats for difficult policy decisions … Governments not only have to contend with the uncertainty of the science but a host of other practical considerations, including feasibility. In all this they want certainty from scientists –​and feel or claim that they are “following the science” –​but wishing something does not make it so (Ramakrishan, 24 May 2020).

A very clear break between scientists and politicians was to come in late September, when SAGE recommended a two-​ week ‘circuit breaker’, that is, a short lockdown, alongside a package of further interventions (Meeting 58, Minutes 21 September 2020), but the Government decided not to go this far and instead confined its actions to tightening existing regulations, for example, by ordering the shutdown of bars and restaurants at 10pm. *** The Government may have had unrealistic expectations of SAGE. The dominant voice among the experts on SAGE belonged to those modelling the virus, with the Group also playing an important role in reporting on whether a particular approach to disease prevention met their high standards of evidence. They relayed their findings via the CMO and the CSO to the Government. They did not make recommendations based on observations, for instance on what was happening in other countries, and they did not engage with operational issues, such as how to set up a test and trace system and make it work. As Nickson et al (2020) have suggested, ministers need to be clearer about SAGE’s remit, the role of science advice and its limitations. In addition, in the early stages of the pandemic, the data available to influential members of SAGE was inadequate and the problem this posed was compounded by the Government’s tendency throughout the first wave of the virus to postpone taking decisive action. It may also be that the Government should have widened its group of advisers,

The approach of politicians and scientists

21

most obviously to include public health practitioners, and that their means of engaging with scientific advisers and public health and social care leaders required modification, although as the next two chapters show, ministers showed little appetite for consulting with people working on the ground. A Government facing a new disease that was spreading extremely quickly wanted solutions, but SAGE’s advice often spelled out the uncertainties, denying ministers the certainties they desired (for instance on whether to cancel large public sporting events and close borders). This was not the fault of the scientists whose views were sought via SAGE. Nor can the Government necessarily be blamed for hoping for and wanting more, although as the President of the Royal Society intimated, it showed inadequate understanding of the nature of scientific advice. Inevitably, given the rapid spread and high number of cases requiring hospital treatment by mid-​March, attention became more firmly fixed on treatment and in particular on the danger that the NHS would be ‘overwhelmed’ than on the need for further urgent development of measures to control the pandemic by developing the role of public health.

2 The position of public health and the problem of ‘test and trace’ Public health

David Nabarro, a World Health Organization (WHO) Special Envoy responding to COVID-​19 and Professor of Global Health at Imperial College, has remarked that when dealing with a lethal and unknown virus the traditional public health methods of test, trace and quarantine/​isolate are likely to be the main or only tools available (Nabarro, 4 August 2020, BBC Radio 4 Today interview). Public health practitioners have historically adhered to the ‘precautionary principle’ (Greenhalgh et al, 9 April 2020), which enables the adoption of precautionary measures when scientific evidence is uncertain, and the stakes are high. In the absence of either effective treatment for a disease or the ready means to prevent it, the principle also suggests the need to combine as many methods of control for which there is an evidence-​ base, even if the beneficial effect is judged to be relatively mild. However, SAGE set a high evidence bar for a positive recommendation (for example, on the wearing of face masks, Meeting 27, Minutes 21 April 2020) before it would make a positive recommendation.1 Some economists are unconvinced about the precautionary principle, believing that it results in extreme caution and, in the case of COVID-​19, lockdowns which are economically damaging and have adverse health impacts of their own (for example, Le Grand, 2 July 2020, BBC Radio 4 World at One interview). Above all, an effective test, trace and isolate (TTI) system was essential to enable first an understanding of the spread of the virus via testing and, second, control of the virus via tracing the contacts of those testing positive and requiring 23

24

The Challenge of Controlling COVID-19

them also to self-​ isolate. However, the position of public health centrally and locally was weak. While SAGE recognised the importance of testing to provide data, it made it clear that it would not consider what it termed ‘operational’ questions (Meeting 19, Minutes 26 March 2020 and Meeting 21, Minutes 31 March 2020), and regarded the business of setting testing priorities, organising the work of test and trace, and communicating the results as the responsibility of the Chief Medical Officer (CMO) (just as it regarded border restrictions to be the responsibility of the Home Office) (see Chapter 1). SAGE did not discuss testing and contact tracing in more detail until mid-​April, when the Group emphasised the need to carry out community testing (Meeting 26, Minutes 16 April 2020 and Meeting 32, Minutes 1 May 2020). Initially, Public Health England (PHE) had only three representatives among the 50-​strong core group of SAGE (Vize, 21 May 2020). As for leadership on public health practice, the CMO had served as Professor of Public and International Health at the London School of Hygiene and Tropical Medicine; the Chief Scientific Officer (CSO) had served as a university professor at University College London before taking charge of research and development at the multinational pharmaceutical company GlaxoSmithKline; and the Chief Executive (CE) of PHE, Duncan Selbie, had occupied three senior management posts in the NHS and said when he was appointed that his knowledge of public health could be fitted onto a ‘postage stamp’ (Das, 2013). In addition, there was no forum where ministers and civil servants could consult public health practitioners on key operational matters. While the Department of Health and Social Care (DHSC) had the overarching responsibility for leading on pandemic readiness (DHSC, 4 April 2020), the control of infectious disease, for example tuberculosis, meningitis and sexually transmitted diseases, as well as pandemics has historically been located with public health practitioners operating mainly at the local level, which gave rise to some of the earliest comprehensive state interventions, for example, in respect of vaccination. However, the voice of public health weakened after the Second World War, as a result of major NHS reorganisations made more at the behest of administrative

Public health and the problem of ‘test and trace’

25

considerations than professional strength (Lewis, 1986; Webster, 1998). A Labour Government set up a central agency –​the Health Protection Agency (HPA) –​in 2003, which took over work on infectious disease from the health authorities (Vize, 21 May 2020), but Labour also retained a Public Health Observatory and infectious disease control teams. Communicable disease control consultants in the Health Authorities were supported by the independent HPA. So while public health was fragmented, it was still linked up to communicable disease control and the NHS. When the HPA became PHE and was set up as an executive agency of the DHSC in 2013, its stated mission was to ‘protect and improve the nation’s health and to address inequalities’. In practice, PHE focused more on health promotion campaigns addressing obesity, smoking and health inequalities than on infectious disease and emergency preparedness. In any case, something like maintenance of the pandemic stockpile, for example, was the responsibility of DHSC. PHE controlled 21 regional teams and, by 2020, 8 laboratories (the 50 that had been operated by the HPA in 2003 had been merged by successive governments in order to make efficiency savings). Another 122 laboratories were controlled by the NHS (Roderick et al, 26 June 2020). The capacity of PHE to meet the need for testing was thus limited. It was a relatively small agency, with 5,500 staff at the beginning of the pandemic and a budget of £287m, with £90m allocated for infectious disease. In addition, no formal provision for coordination between the central agencies was created by the 2012 health reforms. At the local level, these same reforms returned the operation of public health to the administration of local authorities, but from 2010, local public health departments fell victim to the cuts in public spending. The Institute for Fiscal Studies (IFS) has reported that cuts to local government resulted in a 17 per cent fall in local councils’ spending on public services after 2009–​10, making local government increasingly reliant on local taxes, which provide less money in poorer areas (Harris et al, 2019). During the 2009 H1N1 swine flu outbreak, environmental health officers, youth services, community and neighbourhood teams had been deployed, but their numbers

26

The Challenge of Controlling COVID-19

were much reduced by 2020. The Local Directors of Public Health (DsPH)2 created by the 2012 Health and Social Care Act were not nearly as powerful as their distant forerunners –​the local Medical Officers of Health –​had been prior to the abolition of these posts in the NHS reorganisation of 1974. A King’s Fund assessment of the English local government public health reforms published in January 2020 was positive about the move back to local government for the public health services but warned that the funding for the local departments was insufficient (Buck, 2020).3 In Liverpool, the Director of Public Health’s budget fell by 25 per cent between 2013 and 2020. By 2020, both local and central public health bodies were substantially weakened. Non-​ringfenced support amounting to £1,600m was made available to local authorities in March 2020, rising to £3,688m by July (National Audit Office (NAO), September 2020), including a £600m fund for infection control in care homes, and £300m for testing. However, in the case of Nottingham, for example, while the city received £19.8m, it lost £19m in revenue as a result of the lockdown. Indeed, the House of Commons (HoC) Public Accounts Committee (2020a) report on the Government response to COVID-​19 said that local authorities lacked both the clarity and financial support they needed.

The problems with the test, trace and isolate system4

Without an efficient and effective means of testing very large numbers of people, tracing their close contacts and isolating both those testing positive and their contacts, the Government faced losing control of the pandemic as both scientists and the authorities entered what Grey et al (2020) have called ‘the fog’. SAGE had little to say on the practical operation of such a key public health programme and the voice of public health practitioners was weak. A full ‘test and trace’ system –​NHS Test and Trace –​was not announced until the beginning of April and proved to be very far from a panacea. It is also significant that ‘isolate’ was not part of the ‘branding’. Throughout the first surge of the pandemic, only those with a narrow range of symptoms were officially eligible

Public health and the problem of ‘test and trace’

27

for a test, and priority setting within this group was poor. Testing was not always reliable or timely, and the further actions needed to find the contacts of a person testing positive were inadequate: the proportion of contacts traced was small and the time it took to find them was all too often longer than the one to two days that is generally believed to be necessary to achieve useful results. No screening or monitoring of the people told to isolate by NHS Test and Trace, or of people entering the UK after 8 June (when a 14-​day isolation period was imposed), took place, and no data were available on whether the people required to isolate managed to do so. Government policy in respect of the key ‘test and trace’ system was characterised by over-​centralisation and heavy reliance on outsourcing and marked by lack of capacity, lack of strategy and planning, and lack of coordination. One of the most surprising features of policy to control the virus was the abandoning of the basic public health tool of testing for its presence, together with tracing contacts in the community on 12 March. At that point, the criteria for testing were narrowed to only the most severe hospital cases and all contact tracing was stopped, just as the Government made its ‘screeching u-​turn’ and acknowledged the seriousness of the threat. Testing was not extended to frontline NHS workers until the end of March and regular testing for them was still not fully established as late as September. These decisions were at variance with the WHO’s (16 March 2020) injunction to ‘test, test, test’ in order to understand the spread of infection (alongside contact tracing and isolating contacts to break the chain of transmission), and with practice in neighbouring countries. For example, Germany was carrying out over 110,000 tests a day by the beginning of April –​when this number was only being set as a target by the UK Government –​and had recruited large numbers of tracers locally in early March. Indeed, in mid-​March in the UK, the CSO reported that there was capacity to carry out only 4000 tests per day (HoC Health and Social Care Committee, 17 March 2020, Q 78). Professor Neil Ferguson, a member of SAGE, told the HoC Science and Technology Committee (25 March 2020) that testing had not been included in his initial modelling because PHE was saying that there was no capacity to aim for

28

The Challenge of Controlling COVID-19

a strategy of widespread testing (see the two papers issued by PHE: 12 February 2020a and b). The Prime Minister’s statement on 3 March after chairing his first COBRA meeting was optimistic: ‘Let’s not forget –​ we already have a fantastic NHS, fantastic testing systems and fantastic surveillance of the spread of disease’. However, the Government’s Coronavirus Action Plan issued on the same day anticipated that testing and tracing would have less of a part to play if community transmission became established, as would have been the case in an influenza pandemic but not in respect of COVID-​19. SAGE called for clear prioritisation of the testing of patients and health workers because there was a ‘shortage of key reagents, platforms and equipment’ (Meeting 18, Minutes 23 March 2020). In addition, neither PHE nor NHS England (NHSE) had sufficient laboratory capacity to process large numbers of tests. Indeed, there has been considerable discussion as to why more effort was not made to use other existing university and private laboratories (for example, Clark, 18 May 2020), although little mention was made of the existing and potential capacity of local public health departments to do contact tracing. Possibly the apparent difficulties in scaling up the test and trace programme resulted in the Government putting more faith than was warranted in the development of an app –​viewed by SAGE as only a ‘useful supplement’ (Meeting 23, Minutes 7 April 2020) –​early on in the pandemic. In short, lack of capacity to test and trace, which had been the responsibility of PHE and the DHSC early on, likely drove strategy at the beginning of the pandemic, rather than vice versa and community testing for the virus was not recommenced until late May. As Nickson et al (2020) have commented, there is little evidence of a testing strategy in terms of how a test and trace system should work, who would be eligible for tests as capacity grew, and how much capacity would have to grow. The Government’s neglect of funding for pandemic preparedness and its lack of urgency about the threat was also crucial to explaining the faltering start of the test and trace programme. There is little evidence of any close attention to the problem of securing self-​isolation on the part of or for those testing positive and their close contacts.

Public health and the problem of ‘test and trace’

29

The launch of NHS Test and Trace

At the beginning of April, the Government announced a new five-​pillar plan for developing the testing system (DHSC, 4 April 2020), the most important parts being pillars 1 and 2. The first pillar made provision for NHS staff and patients to be tested by PHE and the NHS. The second pillar covered community testing and tracing and was to be run by NHS Test and Trace, an outsourced service set up by NHSE, whose head, the executive chair, reported to the Prime Minister and Cabinet Secretary rather than the DHSC. The NHS Test and Trace branding was not added until the end of May. The initial focus was on providing a number of ‘drive-​through’ testing centres (not necessarily convenient for key workers at the end of a shift and not available to anyone without access to a car), with walk-​in centres coming later. Multiple companies were involved in provision: for example, operational delivery was handled by Deloitte,5 with Mitie and G4S involved in running test centres, Serco with contact traicing and Amazon with logistics (the military also administered 6 million tests between April and July). Home testing kits were provided by Randox.6 It is noteworthy that no role was given to GPs and primary care and little to DsPH and their staff in the test and trace system. Three new large ‘Lighthouse laboratories’ were also created through public/​private partnerships to process test samples. The Secretary of State for Health and Social Care, Matt Hancock (2 April 2020), expressed pride in building a TTI system ‘from scratch’, and suggested that the absence of a large private sector diagnostic industry –​as existed in Germany –​made the setting up of the Lighthouse laboratories necessary (Hancock, 18 August 2020). In fact, many of the private German laboratories were associated with universities and other medical facilities rather than big business (Morris, 11 April 2020). Nor does this explain why the contribution that many existing, smaller laboratories could have made was ignored. Sir Paul Nurse publicly challenged the position taken by Hancock, saying that he had offered to test health workers on 15 April, but had received no reply until he announced that he had started to test NHS staff anyway. He also said that

30

The Challenge of Controlling COVID-19

the large, Lighthouse laboratories, set up from scratch, were bound to take some time to become successfully operational, and that there were many existing smaller laboratories which could have been mobilised (Vize, 11 June 2020; Clark, 18 May 2020, p 9). Later on, he told The Guardian that he felt the Government was unable to admit that it was unprepared (Sample, 2 August 2020). Undoubtedly, the Government was in a hurry to build a test and trace system that could expand to cover a large proportion of the population and, in the absence of public health capacity, looked to the private sector as being most likely to be able to respond. But this does not necessarily explain or justify the exclusive focus on outsourcing. As an Interim Report by the National Audit Office pointed out, the Government’s own internal review of 15 other countries noted that while some had used private sector outsourcing to increase testing capacity, none had done so to increase tracing capacity. The DHSC had considered but ruled out the possibility of recruiting the call handlers it needed to carry out contact tracing from civil service staff and central government call centres, but had not considered whether it could make use of local authority capacity (Comptroller and Auditor General, 2020a). Yet operational public health expertise was greatest at the local level, where the work of tracing in particular needed to be done. Indeed, major problems followed from the heavy reliance on the new, centralised, outsourced NHS Test and Trace system. A Treasury document (HMT, 2020) showed that £10bn had been allocated to developing the system, which Professor Sir Chris Ham, former CE of the King’s Fund, called an ‘astonishing’ sum (9 July 2020, Twitter). The National Audit Office reported later in December that the 2020–​21 budget for NHS Test and Trace was £22bn (Comptroller and Auditor General, 2020a). Very large sums have gone to private providers, which has been all the more controversial given that the emergency powers provided under the provisions of the 2020 Coronavirus Act allow contracts to be awarded without going out to tender.7 The Government decided not to incorporate PHE’s regional capacity or local public health teams in the first instance, and local government received very

Public health and the problem of ‘test and trace’

31

little money for test and trace work compared to the private providers. In contrast, Germany (and Wales and Scotland) put considerably more emphasis on the contributions of public health experts and teams. In addition, the Government was slow to ensure adequate leadership of the test and trace system. Lord Bethell was named in early April as the minister in charge, but Baroness Dido Harding (a Conservative peer; wife of John Penrose, Conservative MP and serving as the UK Anti-​Corruption Champion; formerly the CE of the communications company TalkTalk; and chair of NHS Improvement from 2017), was not appointed until early May to head the operation. Clinical advice for both testing and tracing was provided by Professor John Newton, the Director of Health Improvement at PHE. The test and trace team was then expanded in mid-​ May with the addition of Tom Riordan, the CE of Leeds City Council, leading on tracing and Sarah-​Jane Marsh, the CE of Birmingham Women’s and Children’s Hospital, leading on testing until she was replaced in the autumn by Mike Coupe, former CE of Sainsbury’s. Riordan, who was rare in both his ability to present a view from local government and in pressing the need for local and central government to work together, may have influenced subsequent changes in the tracing programme at the beginning of August. However, even at the beginning of June, local government still had little idea as to how their role in controlling COVID-​19 would develop, for example in regard to getting the powers they needed to deal with a local outbreak. A leaked document showed only one public health expert on the executive committee of NHS Test and Trace (West, D, 15 September 2020). Lack of capacity remained a major issue for the Government and alongside it the slow delivery of test results. Government strategy was dominated by setting targets for the number of tests carried out (rather than persons tested), first for 100,000 tests a day by the end of April and then for 200,000 a day by the end of May. This was in and of itself a little surprising in that during the early 2010s a Conservative Secretary of State for Health had roundly condemned the Labour Government’s penchant for setting targets. Difficult issues such as ensuring a quick turnaround for test results and adequate sharing of

32

The Challenge of Controlling COVID-19

these data with health professionals (particularly at the local level) and local government remained. The Secretary of State declared that both targets were met on schedule, but considerable doubts have been raised about these claims. One or two hundred thousand tests did not mean that 100,000–​200,000 people were tested. Some of the tests were re-​tests on the same person, some were for research rather than diagnostic purposes, and the numbers may also have included antibody tests. In the case of the home testing kits, these were counted when they were sent out, but many were not returned. At the end of April, it is likely that the number of people tested was in fact substantially below 100,000 a day, while it was acknowledged that the subsequent claim to have reached 200,000 tests per day referred to capacity rather than actual tests achieved (DHSC, 31 May 2020). In mid-​August, the Government announced that it was moving to a measure of ‘all tests processed’ rather than a count of ‘all tests made available’. As a result, the test total fell by 1,308,071 (about 10 per cent) for the period 14 May to 12 August, largely due to errors made in reporting pillar 2 testing and in particular counting the number of home tests posted out rather than those returned (DHSC, 21 August 2020). Sir David Norgrove, the Chair of the UK Statistics Authority, wrote to the Secretary of State in mid-​May to urge the Government to update the testing strategy and to show how targets were being defined, measured and reported, noting that the main aim seemed to be to claim the largest possible number of tests (Norgrove, 11 May 2020). Tests were confined to people with symptoms, which were defined more narrowly –​in terms of cough and fever only until mid-​May, when loss of taste and smell was added –​ than by the WHO and other countries. It is noteworthy that testing was not extended to staff and symptomatic residents in care homes until mid-​April (DHSC, 15 April 2020a) and remained patchy thereafter. From mid-​ May, anyone aged five and over with symptoms could ask for a test, although again access fluctuated for a variety of reasons including test availability and laboratory capacity. Issues such as ensuring regular, repeated tests for priority groups and deciding what to do about the asymptomatic were not raised publicly.

Public health and the problem of ‘test and trace’

33

Indeed, big strategic issues such as the desirability and ways of achieving mass testing, whether and who to prioritise for testing, how to control local outbreaks,8 and re-​ assessing the centralised approach to contact tracing attracted less attention than the pursuit of increased numbers of tests and ‘magic bullets’, such as an app, or the promise of a new kind of ‘game-​changing’ test. There were also major problems with the logistics for the system and hence with coordination. COVID-​ 19 became a notifiable disease on 5 March, requiring that local public health officials be told what was happening in their areas. But it was reported at the end of April that patients’ NHS numbers and swab dates were not always being recorded accurately (Wise, 27 April 2020), which made this difficult and had implications for interpreting the pattern of the pandemic as well as for contact tracing. In answer to a written question asked by Labour MP Stella Creasy on whether the contract with Deloitte for COVID-​19 testing required the company to report positive cases to PHE, Nadine Dorries, a Minister of Health, replied that it did not (HoC, Hansard, 11 June 2020, Written Answers). In a second written answer on 19 August, Dorries said that Deloitte made the digital information available to the National Pathology Exchange, which passed it to PHE. GPs were left out of the loop entirely and did not know which of their patients had tested positive (Salisbury, 12 May and 2 June 2020). Local public health officials needed information on a daily basis, but initially the flow of data from the national to the local level was limited to a weekly feed from PHE in respect of the pillar 1 tests. Full details of pillar 2 test results (most crucially –​for controlling local outbreaks –​postcode data) were not made available to DsPH until the end of June, when data privacy issues had been resolved. As Dr. Greg Fell, the DPH for Sheffield, commented in evidence to the HoC Housing, Communities and Local Government Committee (15 June 2020), local authorities needed data on postcode, workplace and ethnicity: ‘…this is not nice-​to-​ know data; this is necessary for the public health response in an emergency’. His point was echoed by Peter Soulsby, the Mayor of Leicester, after the city experienced a spike in cases and a second lockdown (Soulsby, 7 July 2020).

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The Challenge of Controlling COVID-19

The lack of consideration of and attention to the needs of public health teams, primary care doctors, administrators and councillors at the local level resulted in particularly striking problems for contact tracing, which is essential for breaking the chain of transmission. At the end of April, Richard Gleave, Deputy Chief Executive of PHE, wrote to the local DsPH to tell them about the development of contact tracing (Gleave, 24 April 2020). Three tiers of contact tracer were to be established: a small number of people (75) comprised tier 1, located at PHE regional centres and dealing with complex outbreaks in settings such as schools, prisons, health centres and care homes; 3000 NHS health professionals comprised tier 2, triaging confirmed cases to either tier 1 or 3; and 18,000 ‘call handlers’ comprised tier 3. The main problems arose in respect of the work of tier 3. The call handlers were paid at or just above the minimum wage and were recruited and trained by private agencies online. Job advertisements tended to stress the need for empathy, a caring nature and a positive attitude. Call handlers were intended to contact those who had been in close contact with an infected person, but seem also to have been asked to collect information from index cases –​people who had tested positive for the virus –​which can be more difficult and complicated work. Call handlers worked under the direction of Serco (which subcontracted parts of the work to other companies), often relying on a script, as is the norm in call centres, and working to targets set by their employers. Anecdotal evidence from media outlets suggests that many call handlers were allocated rather few calls (for example, BBC One, Panorama, 28 September 2020); indeed, the data show that no more than an average of 2.5 close contacts per person testing positive were reached. The reasons could be many, including poor training for tracers, language problems, and reluctance on the part of the person providing the contacts to give names when the result would be an instruction to self-​ isolate for 14 days and possible loss of income. Haroon et al (14 August 2020) suggested that providing accommodation for those unable to isolate safely at home should also be considered, as per other countries including Italy, Finland and Lithuania. At the end of September, employed and self-​ employed people unable to work from home, in receipt of

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35

benefits and required to isolate, could be considered for a payment of £500, but also a fine of £1,000 (rising to £10,000 for repeat offenders) if they did not do so. The relatively small amount of data available on self-​isolation in the UK suggests that adherence to the rules has been as low as 11 per cent for close contacts and 18 per cent for those testing positive (Smith et al, 2020). The WHO guidance (10 May 2020) on contact tracing stressed the importance of recruiting tracers ‘from their own community, with understanding of context and culture’, which suggested that call handlers working from a considerable distance in call centres and not able to follow up by knocking on doors were less likely to be successful. The longstanding approach to contact tracing taken by local public health departments involved painstaking work by well-​ trained local people, but as the CMO told the HoC Science and Technology Committee in mid-​ May, the work was ‘unbelievably labour intensive if done manually’ (Clark, 18 May 2020, p 13). Thus, it was perhaps unsurprising that the Government preferred to hope for the development of an app, described initially as essential for contact tracing (for example by Gleave [4 April 2020] in his letter to DsPH at the end of April. The app was developed by NHSX, a joint unit bringing together teams from the DHSC, NHS England and NHS Improvement to drive digital transformation. However, after an unsuccessful trial on the Isle of Wight in May, when the app was found not to work on iPhones, its development was passed on to NHS Test and Trace and downgraded to a supporting role –​the ‘cherry on the cake rather than the cake itself’, as Dido Harding put it to the HoC Health and Social Care Committee (3 June 2020, Q 541). Its emergence was severely delayed. Trials of a redesigned app did not begin again until mid-​August with the launch taking place on 24 September. In the meantime, Northern Ireland announced that it was adopting the Irish Republic’s app on 31 July. The Prime Minister had promised in the House of Commons (HoC Debates, PMQs, 20 May 2020, col 568) that the system of contact tracing would be ‘world beating’ by 1 June. How to secure self-​isolation still seemed to be largely absent from the policy agenda.

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The Challenge of Controlling COVID-19

Partial relaunch of NHS Test and Trace

Dido Harding revealed to the HoC Health and Social Care Select Committee (3 June 2020, Q522) that she could not tell them how many test results were returned within 24 hours, and admitted that full-​ scale tracing would not be operational until the end of June. In fact, over the period from the end of May to the beginning of September, only 41 per cent of those tested in the community (under pillar 2) got their results within 24 hours (Comptroller and Auditor General, 2020a). This was despite the fact that the system was partially relaunched at the end of May, with a relatively small amount of new funding (£300m) allocated to local authorities to develop outbreak control plans, and the promise of closer working between PHE and the new Joint Biosecurity Centre (see Introduction, endnote 7). However, the problems arising from the amount of time taken to issue results from mobile testing centres as well as home tests persisted through the summer and into the autumn. The ‘test and trace’ statistics published for the two weeks from 28 May to 10 June (NHS Test and Trace, 2020a) showed that 14,045 people had tested positive, but that the turnaround for results often took two to three days (see also Vize, 11 June 2020). Office of National Statistics data for the same period suggested that the testing system had found about a quarter of new symptomatic cases,9 67 per cent of these were reached and asked for their contacts in week 1, and 73 per cent in week 2. The proportions of contacts who went on to isolate (fully or partially), or to become symptomatic and test positive themselves remained unknown (Mahase, 15 June 2020). As late as the week of 16–​22 July the test and trace statistics showed that only 50 per cent of people tested under pillar 2 got their results within 24 hours, with home tests experiencing the longest delays (NHS Test and Trace, 2020b). Yet when the Prime Minister had appeared in front of the HoC Liaison Committee (27 May 2020, Q 49) and was asked by Jeremy Hunt to ensure a 24-​hour turnaround on test results, he had assured the Committee that this would be done ‘as soon as possible’.

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Furthermore, call handlers working centrally continued to contact very few people and while Government ministers insisted that 80 per cent of close contacts were reached, this percentage actually referred only to those for whom contact details were provided. The National Audit Office reported that only 66 per cent of close contacts were reached between the end of May and early November (Comptroller and Auditor General, 2020a), while a University College London (UCL) report issued on 4 August stated that the centralised test and trace system was only reaching 50 per cent of close contacts (Colbourne et al, 2020). This report also laid out detailed costings for the development of a local test and trace system. Local teams would have the advantage of being able to search council tax records and school rolls for alternative means of contacting individuals and/​or visiting them. At the beginning of May, SAGE said that 80 per cent of contacts should be traced within 48 hours (Meeting 32, Minutes 1 May 2020) and modelling suggested that any delay in isolating contacts beyond 48–​72 hours would make it very difficult to break the chain of transmission. Indeed, it was widely recognised that effective testing and tracing was an essential accompaniment to the easing of lockdown restrictions. But the data from NHS Test and Trace continued to show that the centralised, outsourced service was experiencing problems and that planning to achieve even the limited strategy of increasing the testing of more symptomatic people and ensuring timely delivery of the results to the people who needed them was unclear. Coordination, particularly between central and local government, remained poor. At the end of May, reports emerged about a group of Sheffield volunteer tracers working under the leadership of a retired GP, who had found that two-​ thirds of the close contacts were not prepared to cooperate and that many of these were health or social care workers. These people were probably low paid and may well have been unable to forego two weeks’ pay while isolating (Mahase, 29 May 2020). The Independent SAGE group (9 June 2020), which had been set up by a former CSO, Sir David King, argued strongly for a Find, Test, Trace, Isolate and Support system (my ital.).10 Workers meeting the eligibility criteria

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were able to receive statutory sick pay11 (amounting to £95.85 per week) while isolating, and at the beginning of autumn people on low incomes and in receipt of benefits who were isolating were told that they ‘could be eligible’ for a single payment of £500. Independent SAGE also called for local authorities to be given more legal authority to respond to local outbreaks. Increasingly, northern local authorities experimented with setting up their own tracing teams, and as more northern towns and cities experienced local spikes in the number of cases, the DsPH continued to be reported in the press as saying that centralised tracing was reaching only half of those who had been in close contact with a person testing positive, far fewer than the local tracers (Halliday, 19 July 2020). As the former CE of the King’s Fund, Chris Ham, observed, tracers must be led by local people:  ‘they’re part detectives, part anthropologists:  they work with leaders in faith groups, in community organisations and public services to understand why there are more cases in a particular area’ (Ham, 12 August 2020, Twitter). Further changes in NHS Test and Trace and structural change for PHE

On 10 August, a DHSC press release announced a further change in focus for the test and trace programme: local and national teams would ‘work as one’ (DHSC, 10 August 2020). The number of call handlers working centrally would be reduced from 18,000 to 12,000 with an unspecified number being deployed to work with particular local authorities, after the outsourced contracts fell due for review in late August. This was made possible by the introduction of flexibility clauses allowing changes in staffing levels in the revised contracts (Comptroller and Auditor General, 2020a). Dido Harding, the Executive Chair of NHS Test and Trace, announced rather surprisingly that ‘we have always been clear that NHS Test and Trace must be local by default’ and that the change followed the ‘successful trials in a number of local areas’ (these trials were in fact initiated locally, not nationally). However, no local public health directors were included on the leadership team. Nor was any mention made of further

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changes in the contracts with private companies. While this move was significant in giving some public recognition to the importance of the local level in contact tracing, neither the extent nor the precise nature of the change was made clear. Certainly, no new funding was announced for local authorities and there was little evidence of any consultation with local public health leaders or councillors. The number of new cases had to rise quickly again, to the point of doubling every two weeks in the second week of October, before the Government consulted local leaders. Possibly as or more significant was the announcement by Matt Hancock, the Secretary of State for Health and Social Care, in a speech given on 18 August at the think tank Policy Exchange, that PHE was to be merged into a new body, the National Institute for Health Protection (NIHP) to be led by Dido Harding, notwithstanding that NHS Test and Trace had not performed well. Who would take responsibility for PHE’s health promotion work –​on obesity and smoking, as well as its drug and alcohol services, vaccinations and sexual health services –​was not announced, despite the crucial connections between preventable risk factors, inequality and COVID-​19.12 The Secretary of State for Health and Social Care stated that ‘…one of the lessons from the crisis was the need for an institution whose only job is to prepare for and respond to external threats like pandemics’ (Hancock, 18 August 2020). The new NIHP was charged with preventing future outbreaks of infectious disease. The management consultancy company, McKinsey and Co. was paid £563,400 for work to decide the ‘vision, purpose, and narrative’ of PHE’s replacement (Iacobucci, 21 August 2020). Michael Brodie, Chief Executive Officer of the NHS Business Services Authority (and prior to that Finance and Commercial Director at PHE), was appointed as interim CE of PHE during the transition period. Objections to the perceived scapegoating of PHE in advance of the public inquiry that commentators assume will take place at some point were immediate from Professor Sir Simon Wessely, President of the Royal Society of Medicine and Chris Hopson, CE of NHS Providers (McKee, 17 August 2020). Professor Jeremy Farrar’s (Director of the Wellcome

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Foundation) comments were also trenchant, referring to arbitrary sackings, the passing of blame, and an ill-​thought-​ through and short-​term reactive reorganisation in the context of under-​investment in public health for years (Courea and Lay, 19 August 2020). The Government remained committed to the centralised and outsourced delivery of its most important public health programme. By the beginning of August, there were also calls for a strategy of mass testing –​to include as many people, symptomatic and asymptomatic, as often as possible and ultimately building to a health passport for every individual as a means of keeping the economy open. The UCL report issued on 4 August argued the case for developing a strategy for population-​ wide testing, contract tracing and isolation (Colbourne et al, 2020). A paper emanating from former Labour Prime Minister Tony Blair’s Institute for Global Change on 20 August also called for mass testing and was endorsed by two prominent Conservatives, William Hague and Jeremy Hunt (Wain and Sleat, 2020). Others have urged repeated testing of particular groups, for example, Independent SAGE (21 August 2020) wanted the repeated testing of students and staff in universities. At the beginning of September, the Government endorsed the mass testing of 10 million people a day (referred to as Operation Moonshot) using quick turnaround lateral flow tests –​which remain controversial in terms of effectiveness –​at a reported cost of £100bn (equal to 77 per cent of the NHS annual revenue budget) (Gill and Gray, 16 November 2020). Mass testing was seen as a way of unlocking the economy and ending the need for social distancing. Iacobucci (16 September 2020) reported that Deloitte would manage and oversee the plans. The problems of capacity and logistics, how to deal with a possibly large number of false negatives, and how to ensure priority for particular groups of key workers and people was not mentioned. At the end of September there was still no assured regular testing of NHS staff, and care home staff and residents continued to experience difficulty in accessing tests. Despite the very large amount of public money spent on it, the capacity of the outsourced test and trace system to keep

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up with demand remained fragile, with major hold-​ups in the processing of data from the beginning of September. *** The importance of an efficient and effective TTI system remains crucial for identifying the spread of infection and enabling targeted measures of control on the one hand, and facilitating a successful re-​opening of the economy on the other. Even after vaccination becomes widely available, outbreaks of COVID-​19 will likely persist and require a fully operational TTI system. In England, from the inception of the TTI system, testing and contact tracing were decoupled, and responsibility for the work done was highly centralised and outsourced. This resulted in poor coordination between the central and local levels; the logistics for getting data to where it was needed, particularly to the local public health departments (GPs were ignored completely), were problematic. In particular, community testing under pillar 2 has continued to experience major difficulties. The only measure of success imposed by central Government were successive targets for the number of tests carried out, but the quality of work done, particularly in terms of the time taken for the results to be issued and the problems with disseminating the results, continued to disappoint. Contact tracing did not succeeded in reaching the required percentage of the close contacts identified by people testing positive in a timely manner (indeed, by September the percentage of test results returned in 24 hours and the percentage of close contacts traced had both actually fallen significantly), while securing the self-​isolation of those testing positive and of close contacts had not been achieved. Time and again during the first wave of the pandemic, the Government announced a particular policy initiative –​for example, regular testing for NHS and care home staff –​only to have patchy success and to announce the policy again. Policy statements were effectively repeated and are not necessarily a good guide to what was happening on the ground. Stopping test and trace in the early part of the pandemic was very unfortunate. Community testing was abandoned in mid-​ March and those seeking to monitor and control the spread of the disease found themselves ‘flying blind’. Preparations

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seem to have been heavily influenced by the experience in controlling influenza, which meant that scientists and public health practitioners were ready to abandon community testing once community transmission was established. East Asian countries in particular relied more on their (more relevant) experience in controlling SARS. Public health at the central level, which might have been expected to take more of a lead in controlling the pandemic, and the local public departments, which might have been expected to lead in the work of contact tracing in particular, but which had suffered major cuts under the austerity programme of the 2010s, were insufficiently funded to meet the challenges. The Government had to develop a major test and trace response quickly. It chose to do this from the centre relying mostly on private providers who had no experience of carrying out such work. While it is unlikely that local public health departments could have been mobilised quickly enough to meet the need, it is difficult to explain why they were virtually ignored until an overture was made in early August, by which point a number of them had shown how much better placed they were to carry out contact tracing. In addition, leadership of the test and trace system tended to pass over public health practitioners. However, it is of course entirely possible that if given more responsibility for ‘test and trace’, local authorities might also seek to involve private sector call centres alongside their own public health staff. PHE was a relatively weak organisation with an insufficient regional presence, but the reasons for the problems experienced by the test and trace system were many, and as Iacobucci (18 August 2020) remarked, it is far from clear what exactly the abolition of PHE was supposed to solve. In addition, the Government seemed uninclined to pay attention to the principles of public health practice, which, in the case of tracing for example, must have appeared laborious in comparison to the attraction of an app or call handlers working remotely. At the time of writing, it seems as though lack of appreciation for the importance of the public health approach persists. The Secretary of State likened the new NIHP to the German institution leading on the control of COVID-​19, the Robert Koch Institute (Hancock, 18 August

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2020), but it is unlikely that accountants and business people would be put in charge of the Koch Institute. ‘Test and trace’ has proved to be a sorry tale, with the Government eager to claim success, particularly for the number of tests carried out, and ‘breakthroughs’, for example, in the form of the tracing app and new, faster tests, which have tended to be subject to delay and to deliver less than promised. The decision to pass the responsibility for building and delivering a test and trace system for the community –​involving the work itself (in terms of quality and timeliness), the processing of results in the laboratory and their dissemination to the local level –​to a number of private sector providers has proved particularly problematic. NHS molecular virology laboratories might have played a bigger role in supervising the work of the Lighthouse Laboratories, just as local public health officials could have played a major part in tracing. Government policymaking in respect of ‘test and trace’ has resulted in vastly more tests being carried out; indeed, the setting of targets in respect of the number of tests has superseded the development of a viable strategy for operating the system effectively, particularly in terms of setting firm priorities for who should be tested and how often. There has not been a steady increase in testing or in the timely return of results, while the percentage of close contacts traced has been low, and the percentage identified as needing to isolate but in fact not so doing has been high. Testing is crucial for understanding the course of the pandemic, but control of the pandemic depends on testing being accompanied by effective contact tracing and isolation. Indeed, it is possible to argue, as Independent SAGE has done, that isolation is the most important dimension of the system and can only succeed if people are supported through it. However, the Government focused mainly on expanding testing and moving towards mass testing, as per the Moonshot programme. The tracing and isolation elements of the TTI system have been particularly problematic. Both require considerable planning and partnership working with local communities, local authorities and local public health departments. By the end of the summer, testing once again faced great difficulty in meeting demand –​it seems that NHS Test and

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Trace had not anticipated the increased demand that would follow the return to schools and colleges (Nickson et al, 2020) –​which meant that COVID-​19 hotspots were difficult to identify, raising the spectre of a further total lockdown.13 The focus on capacity was not accompanied by a similar attention to a testing strategy and a plan to achieve it, or to the issue of coordination, while the injunction to those testing positive and their contacts to isolate remains well-​nigh impossible for the low paid and precariously employed who are often also living in overcrowded accommodation.

3 Care homes for elderly people1 The majority of people in residential and nursing homes for older people are over 80 years old and particularly vulnerable to the ravages of COVID-​19. Almost half –​46 per cent –​of all excess deaths in England and Wales from the beginning of the pandemic to early August took place in care homes. In addition, the excess death rate for recipients of domiciliary care was similar to that for care home residents (Glynn, 13 July 2020). The UK was not alone in experiencing a high death rate among care home residents:  Spain, Belgium, Canada and the US were all hit particularly badly in this regard, together with Sweden, albeit that a higher proportion of over 65s live in care homes there (Grabowski, 2020). Care homes in England recorded a 79 per cent increase in excess deaths from the week ending 13 March to the week ending 26 June (the figure for Wales was 66 per cent, for Scotland 62 per cent and for Northern Ireland 46 per cent). In England, 44 per cent of homes reported at least one case of suspected or confirmed COVID-​19; the highest figure for UK countries was 65 per cent for Scotland (Bell et al, 2020). Unsurprisingly, nursing homes registered more cases and more deaths than residential homes. But other factors due to structural changes in provision, such as higher death rates in larger homes, beg additional explanation (as the total number of care homes has fallen, the number of large homes –​with 45 beds or more –​has increased. In England, some 400,000 people were resident in 15,517 care homes of very different sizes, operated by some 5000 providers (SAGE, 12 May 2020). The total adult social care workforce employed in all residential services was 680,000, with a further 715,000 employed in domiciliary care (Skills for Care, 2020). Social care in England was the earliest 45

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public service to be subject to reform designed to promote market competition in Western Europe (Pavolini and Ranci, 2008). The result has been a hugely fragmented social care system, something acknowledged by Helen Whately (2020), the Minister for Social Care, together with the problems this posed regarding ‘a lack of comprehensive data about who is receiving social care and, in essence, what is going on at the frontline’. Indeed, until 29 April the daily data on death rates reported in the Downing Street Press Briefings underestimated the true number of deaths because data from care homes were not included. Nor did the Department of Health and Social Care (DHSC) know how many people were getting care in each area. Social care has also been separated from the NHS (notwithstanding that the ‘Department of Health’ had ‘Social Care’ added onto its title in 2018), and is largely under the control of private and voluntary providers.2 Local government has remained responsible for ‘shaping’ the social care market, ensuring that it remains ‘vibrant and stable’ and for stepping in ‘around provider failure’, although the Care Quality Commission (CQC) has responsibilities for the last of these in respect of large, regulated providers (DH, 2017). In addition, local government has the responsibility of assessing need and applying the eligibility criteria that determine whether an older person qualifies for state-​funded care. Independent sector (for-​profit and not-​for-​profit) providers of care homes receive public funding for those deemed eligible on a per person-​cared-​for basis; however, 40 per cent of residents are now self-​payers.3 As Oung and Curry (2020) have pointed out, there are no guarantees regarding the level of fees paid by local authorities to independent providers in respect of those qualifying for state-​funded care, which plays an important part in accounting for frequent entry and exit of providers from the social care market and for the substantial number of mergers and acquisitions. The CQC’s report on the ‘state of care’ for 2019–​ 20 said that the pandemic had highlighted the ‘unstructured relationship’ between the Government and the social care sector (CQC, 2020a, p 5). Witnesses appearing before the HoC Health and Social Care and the Science and Technology

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Committees (13 October 2020, Qs 37 and 44) went further, claiming that there was a lack of understanding of social care by the Government and a tendency to regard social care as the ‘poor relation’ of the NHS. Nevertheless, the Secretary of State, Matt Hancock (15 May 2020), claimed that ‘right from the start, we’ve tried to throw a protective ring around our care homes’. The first part of what follows assesses the extent to which government policy in respect of social care can be characterised in this way. I then focus more specifically first on what happened regarding the issue of hospital discharge to care homes, which was linked to issues regarding both the duty of local authorities to provide care and support and the access residents had to hospital treatment, and second, on testing care home staff and residents for the virus. It is difficult to conclude from a more detailed examination of these issues, let alone the high death rate, that care homes were effectively ‘protected’. The final section looks at the way in which longstanding systemic problems of social care have become more visible during the pandemic, in particular its relationship with the NHS, the dominance of independent providers and the associated problems of staffing.

The Government’s policy response

A new virus might have been expected to enter care homes via new residents or residents discharged from hospitals, via staff and visitors. However, surprisingly, in guidance issued by Public Health England (PHE) in late February (and withdrawn in mid-​March), it was stated that that it is ‘very unlikely that anyone receiving care in a care home or the community will become infected’ (PHE, 25 February 2020). This was because it was mistakenly believed that no community transmission was taking place. Subsequent Government responses in respect of care homes followed the pattern of response to the spread of the pandemic more generally in being too little, too late. The Chief Medical Officer (CMO) said at the 3 March Downing Street Briefing on the Coronavirus Action Plan that specific advice for care homes would be issued later. This did not follow until mid-​April. Visits to care homes were not stopped

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until 2 April, although some homes took the decision to bar visitors sooner, which was not in and of itself an easy decision to make given the negative effects it would probably have on the welfare of residents. On 15 April, a leaked letter from the Association of Directors of Adult Social Services (ADASS) to Ministers was revealed by BBC News (Kuenssberg 16 April 2020) and the Local Government Chronicle (Hill, 15 April 2020). It expressed concern about the ‘significant imbalance between listening, hearing and understanding NHS England as opposed to social care’ and also raised the issue of lack of personal protective equipment (PPE) for care home staff, which was as, or even more, acute than for hospitals. While the Influenza Pandemic Preparedness Strategy of 2011 (DH, 2011, para 6.4) had recognised that there ‘…may also be particular challenges in maintaining social care services’, the Coronavirus Action Plan (DHSC, 3 March 2020, para 4.48) said only that ‘there could well be an increase in deaths arising from the outbreak, particularly amongst vulnerable and elderly groups’. Government initiatives in March were focused firmly on the NHS. The Action Plan for Social Care (DHSC, 15 April 2020a) was published more than a month after the Coronavirus Action Plan, something that the HoC Public Accounts Committee (2020a, p 12) noted, but were told that the plan brought together and enhanced guidance that had already been issued to social care providers, the intimation being that providers should in any case have been familiar with the contents. The Plan promised an expanded test and trace system and more support for care staff, but acknowledged that coordination across some 5000 mainly private care home providers was difficult. It presented four pillars:  infection control, support for the workforce (but absent consideration of the possibility that staff movement would likely spread the virus), support for residents’ independence and response to individual needs, and support for local authorities and providers. But it is hard to disagree with Alderwick, Dunn and Dixon (15 May 2020) who commented that ‘no action plan could undo decades of political neglect’. The PPE Plan issued at the same time talked of ‘emergency drops’ to primary and social care providers and the appointment of

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seven (private) wholesalers to supply social care (DHSC, 15 April 2020b).4 However, difficulties continued for health and social care (Comptroller and Auditor General, 2020b), with ARCO (2020), a leading provider of PPE, commenting on the Government’s ‘slow start’ and lack of understanding and inexperience in purchasing PPE. The story of Government policy towards care homes during the early part of the pandemic is one of efforts to ‘catch up’ with the crisis and to mitigate the disastrous rate of transmission of COVID-​19 in care homes between February and May. Several problems were particularly striking during this period:  (i) the issue of discharges of hospital patients to care homes and their right to an assessment for care and support by their local authority, alongside the right of care home residents with the virus to be admitted to hospitals, and (ii) the allied issue of testing for the virus. These problems demonstrated the lack of a ‘protective ring’ around homes. Furthermore, even if protection had been successful in terms of keeping the virus out of care homes, there would still have been insufficient attention to the welfare of residents, especially those with dementia, for whom the isolation that accompanied lockdown and the lack of visitors was hard to understand or bear. Hospital discharge and hospital admission

The discharge of elderly patients from hospitals into care homes became a major cause of concern in March. Yet the PHE National Infection Service (24 February 2020) had issued a document which considered the possibility of a COVID-​19 outbreak in a hospital and stated that there should be no discharges to care homes. This document was passed to SAGE. However, on 17 March NHS England (NHSE), together with NHS Improvement (NHSI), wrote to the Chief Executives (CEs) of all NHS Trusts, Foundation Trusts, Clinical Commissioning Groups, GP Practices, Primary Care Networks and Providers of Community Health Services, with a copy to the CEs of local authorities and Directors of Adult Social Care, setting out the important actions needed to redirect staff and resources to meet the COVID surge.5

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The letter highlighted the need to free up 30,000 hospital beds by postponing elective surgery, buying extra capacity in independent hospitals, and urgently discharging all hospital inpatients medically fit to leave. It noted that in the case of those needing social care, Parliament was ensuring that local authority eligibility assessments would not be allowed to delay discharge. At the same time, routine inspections by the Care Quality Commission of health and social care settings were suspended, which was understandable, but which rendered care homes invisible to official scrutiny (Tarrant and Hayes, 20 May 2020).6 Supplies of PPE were said to be adequate and testing would be established for symptomatic NHS staff; neither was promised for social care workers until 15 April. To facilitate discharge, from 20 March all post-​ discharge community support was funded by the NHS. In addition, the Coronavirus Act passed on 25 March provided for ‘easements’ to the ‘duty’ of local authorities to meet care and support needs under the 2014 Care Act. The ‘duty’ was replaced by the ‘power’ to meet needs in order to allow local authorities to prioritise more easily. By the end of April, seven local authorities were using easements, although by early July none reported doing so. Nevertheless, there was concern that social care provision by the state had been reduced (CQC, 2020b; DHSC, 1 April 2020; see also Foster, 2020). On 2 April, the DHSC, PHE, the CQC and NHSE (2020) issued official guidance on the admission and care of residents during a COVID-​19 outbreak in a care home, and said that while they wanted to protect staff and residents they also needed ‘care homes to continue to make their full capacity available to support the national effort … Helping to move patients who no longer require acute care into the most appropriate setting will help to save thousands of lives’ (p 3). The document stated that ‘negative tests are not required prior to transfers/​admissions into the care home’ (p 4) but any resident testing positive ‘must’ be isolated (not necessarily easy given the generally high occupancy rates in care homes). Justifying the policy, the Prime Minister told the House of Commons (HoC) Liaison Committee (27 May 2020, Q 44) that each discharge from hospital was made by a clinician. Homes were also supposed to be able to say ‘no’ to discharges

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if they had no appropriate facilities, but the pressure to accept these people was obviously high. The document stated that the supply of PPE would be ‘ensured’, but staff coming into contact with a Covid patient while not wearing PPE ‘can remain at work’ (p 7). The priority was quite clearly to stop the NHS being overwhelmed. The HoC Public Accounts Committee (2020b) report in July said that 25,000 elderly people were discharged without making sure that all were tested, ‘…a decision that remained in force even after it became clear people could transfer the virus without even having symptoms’ (p 3), which they referred to as a ‘reckless and negligent policy’ (p 11). A report published by HealthWatch and the British Red Cross (2020) in early October, which used the stories of 590 people discharged from hospital during the first wave, 50 of whom went to care homes, found that 33 per cent were discharged at night and that 64 per cent of these felt unprepared. Almost a third (30 per cent) of those who were tested for COVID-​19 did not get their results before they left. Discharge of these patients, combined with the lack of adequate testing and PPE, made the policy particularly dangerous. As Professor David Oliver, a Geriatric Consultant at the Royal Berkshire Hospital, told the HoC Health and Social Care and Science and Technology Committees (13 October, 2020, Q 42): ‘Let’s face it, if we had a norovirus outbreak, a clostridium outbreak or a ‘flu outbreak on a hospital ward that we can test for, we would not decant all of those people into care homes’. Nevertheless, the NHS continued to depend on the smooth discharge of as many older people requiring social care as possible and as quickly as possible, which might mean care homes accepting COVID-​19 patients. But it proved difficult to ensure suitable accommodation in a fragmented, largely privatised system, which in addition faced the high cost of insurance cover. In the case of care home residents requiring hospital admission during the early months of the first wave, reports circulated that blanket ‘do not attempt resuscitation’ (DNACPR) notices were being applied to groups of care home residents by GPs. However, Professor David Oliver (18 June 2020) has pointed out that the exclusion of very elderly people from intensive care units has also been viewed

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as a humane policy to ensure that care home residents when sick or dying could stay in the home rather than being taken to busy, alienating hospitals, and that what is important is whether these notices were discussed or not, rather than the notices in and of themselves. In late November, the CQC confirmed that at the beginning of the pandemic a combination of unprecedented pressure on care providers and the resulting confusion may have led to decisions concerning ‘do not resuscitate’ notices being incorrectly conflated with other clinical assessments around critical care (CQC, 2020c). William Laing of LaingBuisson7 also drew attention to the extent to which medical support was lacking for care homes at the peak of the pandemic, with the late arrival of ambulances and GP house calls becoming telephone calls. He suggested that in the absence of any expectation of active medical support, care home residents were encouraged to consider what instructions they should give in the case of serious illness from whatever cause, with many opting for ‘do not resuscitate’ notices (Laing, 14 May 2020). A report by Healthcare Business International comparing data on deaths, hospitalisation and ICU admissions across Europe has gone further in claiming that ‘rationing killed the elderly’, and that this was especially the case in England, Sweden and the Netherlands (Lewis, R, 26 November 2020). Testing

Recognition of the plight of care homes vis-​à-​vis the level of COVID-​ 19 infections and deaths was slow. Professor Neil Ferguson (10 June 2020) told the HoC Science and Technology Select Committee that SAGE had anticipated the risk posed to care homes, but that they could only be protected through extensive testing which was not available (see Chapter 2). Care workers and residents were not given the same priority status as NHS workers and patients during the first wave of infection. In the document on ‘scaling up testing’ published on 4 April, care workers were put into pillar 2 with other critical key workers, pillar 1 being reserved for those with a medical need and, where possible, key NHS workers.

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Care homes were reliant on the home testing kits supplied by Randox. It proved difficult to get these analysed in a timely manner in the early months, and in any case the test kits were withdrawn in mid-​July because of quality issues (Roderick et al, 26 June 2020). The reality was that Government guidance issued on 2 April advised that negative tests were not required prior to transfers or admissions to care homes and until mid-​ April, Government policy was to test no more than five symptomatic residents in any one care home. From 28 April, all social care workers were eligible for tests, but the DHSC capped the number of tests available daily at 30,000, to be shared between residents and staff. The lack of testing capacity remained a huge problem for care homes (Comptroller and Auditor General, 2020a). SAGE noted the issue of prioritising testing, including for care homes, and later in April advised that a leader for the work in care homes was needed (Meeting 28, Minutes 23 April 2020). On 12 May, SAGE’s care homes working group advised that ‘the large scale implementation of testing in care homes is central to preventing and managing outbreaks’ (SAGE Working Care Homes Group, 12 May 2020, p 6) and also stated that they had ‘medium confidence’ in recommending the need to include homes that had not reported cases. The European Centre for Disease Prevention and Control’s Public Health Emergency Team went further, advocating daily surveillance routines in homes to measure fever, respiratory rate and oxygen saturation, as well as regular testing –​weekly in the case of staff (Kostas et al, 4 June 2020). However, the ongoing story of testing in general and in care homes in particular was one of regular claims by the Government that testing was being expanded for the symptomatic and asymptomatic, and reports of continued confusion and failure. In early June, weekly testing for staff and monthly testing for residents was announced, with the Government’s Recovery Strategy stating that the ‘number one priority for adult social care’ was infection control and that widespread, swift testing was being provided (Cabinet Office, 24 July 2020, section 5.2). However, the problems with the Randox test kits in July meant that the goal for testing was not achieved (Briggs et al, 2020). Martin Green,

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the CE of Care England (which represents independent providers), bemoaned the unfulfilled pledge to test residents and staff at the end of August (Tapper, 29 August 2020; see also Rough, 2020). The HoC Health and Social Care and Science and Technology Committees (13 October 2020) received evidence in October from Teresa Steed, a care home manager, who said that while regular testing was by then being made available, turnaround times remained slow (Q 25). The CE of the National Care Forum (which speaks for non-​profit providers), Vic Rayner, reported that only 24 per cent of tests carried out in care homes were returned within 48 hours (Booth, 18 November 2020). When Professor Jane Cummings, the Adult Social Care Testing Director at the DHSC, appeared before the HoC Health and Social Care and Science and Technology Committees (13 October 2020, Qs 98 and 101), she was unable to provide the latest figure for the percentage of care homes carrying out regular testing, but said that the last figure she had was that 68 per cent of homes were testing residents, and over 50 per cent, but under 90 per cent were testing staff. The long-​lasting difficulties in ensuring a regular and efficient testing regime for care homes illustrate the ‘unstructured relationship’ between Government and the social care referred to by the CQC. It is also important to note that the ongoing distress on the part of care home residents and their relatives about the prohibition on visiting could only be addressed by an efficient system of testing. While unlimited visiting would in all probability have increased the death rate in care homes (Oliver, 13 October 2020), there were many reports of elderly residents, especially those with dementia, giving up the ‘will to live’ in the absence of human contact (Henwood and Hudson, 10 August 2020). The Government appointed a Social Care Sector COVID-​19 Support Taskforce on 15 June, chaired by David Pearson, a former President of ADASS, and reporting to the Minister for Social Care. It was given responsibility for the delivery of the Government’s Social Care Action Plan issued in mid-​April, and the provision of extra public money for infection control announced in the Care Home Support Package in May. Pearson’s credentials as a social care leader

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were welcome and the final report of the Support Taskforce issued in October produced 52 recommendations, including the need to address staff shortage and staff movement between homes, and to produce a Ten Year Plan, as had been done for the NHS in 2019 (Social Care Sector COVID-​19 Support Taskforce, 18 September 2020). However, the Minister of State, Helen Whately (13 October 2020), failed to commit to such a plan when she appeared before the HoC Health and Social Care and Science and Technology Committees. Neither the Taskforce nor the Government acknowledged the huge issues raised by the structural position of social care as the next section shows.

The structural position of social care

As has become clear, during the first wave of the pandemic social care did not command either the attention of Government or the respect of the public to the same extent as healthcare and the NHS. The lack of priority accorded to the position of residents and staff in nursing and residential homes played a large part in accounting for the high death rate. When politicians and the apparatus of central government began to pay more attention to the problems being experienced by care homes in mid-​April, the focus was inevitably on short-​term issues, such as dangers posed by staff moving between homes. However, as Ros Altman (6 June 2020), a Conservative life peer, has noted, these were in large part the function of much deeper, long-​term structural issues, particularly the differences between the organisation of the NHS and social care, the main reason for these being the extent to which social care has been privatised, with accompanying fragmentation and problems for staffing and care quality. Social care and health care

Very different principles have underpinned the provision of social care and health care, and continue to do so. Primary and secondary health care have remained free at the point of delivery and the vast majority of providers are public, despite

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increased willingness on the part of Government (especially since the 2012 NHS reforms) to outsource healthcare provision. However, social care has always been means-​tested and since 1990, provision has come to be mainly in the hands of independent providers, mostly for-​profit, but with some charitable, not-​for-​profit providers; 83 per cent of beds are in for-​profit establishments, 13 per cent are in homes run by the voluntary sector and only 3 per cent are publicly provided. Indeed, the different types of ownership of homes (and their different sizes) mean that their interests are not necessarily the same.8 Social care is a major service and the NHS depends increasingly –​as the population ages –​on its successful and efficient operation (so that the discharge of often frail and vulnerable people from hospital can proceed smoothly), but it is fragmented and, to a large extent, outside Government control. The NHS/​social care boundary has always proved difficult to navigate (Brigden and Lewis, 2000) and the nature of its development over the past three decades has made it even more difficult to achieve meaningful ‘integration’ between the two services, despite the emphasis placed on the need for this by NHSE since 2014, and further signalled by the creation of the Department of Health and Social Care in 2018. The determination of central government to step back from responsibility for delivering social care services was plain in the 1990 NHS and Community Care Act, which conceptualised the need for social care reform in relation to the problems of social security on the one hand and of the NHS on the other. During the 1980s, a change in social security legislation opened up a loophole for residents in private residential and nursing homes to claim benefits and use them to pay for care, which served to tilt the balance of care firmly towards institutional provision and resulted in a huge increase in privately provided long-​term care homes for elderly people (Lewis and Glennerster, 1996). Regarding the NHS, the sharp increase in the number of over 85 year olds, which nearly doubled between 1981 and the end of the 1990s, meant that the Government was more inclined to draw a tighter ring around the NHS as an acute care

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service and resulted in the NHS shedding its long-​term care responsibilities. Local authorities were given the responsibility of assessing need and means testing for social care, using an asset threshold above which the applicant is deemed ineligible for publicly funded care (set currently at £23,250). Attention to what social care per se should look like was absent. It became a residual as the Government aimed to solve the public policy problems of social security and the growing need for NHS long-​term care by pushing the responsibility for provision into the independent –​now mainly private –​ sector and setting limits on the public funds available for it. While it was clear from the first that NHSE led the NHS response to COVID-​19, the administrative lead for social care was unclear. The DHSC was responsible for overall policy, but it admitted to the HoC Public Accounts Committee (2020b, p 10) that there was ‘considerable ambiguity’ as to how social care was managed between local and central government, and providers. Politically, the secondary status of social care seemed to be confirmed: the Secretary of State for Health and Social Care, Matt Hancock, spoke mainly for the NHS, leaving social care for the most part to the Minister for Social Care, Helen Whately. She acknowledged the lack of basic data returns from care homes. Privately owned and run care homes were used to being left alone, albeit that the CQC was responsible for registering them and for undertaking periodic inspections which rated them ‘outstanding’, ‘good’, ‘needs improvement’ or ‘inadequate’, operating an essentially risk-​ based approach to ensuring quality, and measuring performance against essential minimum standards. There has been no regulation of the qualifications needed by staff, for example, which might be considered crucial for securing better-​ quality care. The vast majority of both residential homes (80 per cent) and nursing homes (72 per cent) were rated ‘good’ by the CQC in March 2020, while only 4 per cent of residential homes and 2 per cent of nursing homes were judged ‘inadequate’. NHSE and NHSI (2020) had recognised that care homes had become increasingly remote from primary care services when they drew up and brought forward the implementation of a Framework for Enhanced Health in Care Homes, which provided for every care home to

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be assigned to a primary care network. This may go some way to ameliorate the position that care homes found themselves in during the height of the first wave of the pandemic, when medical support was reported to have been difficult for many homes to obtain. However, COVID-​ 19 also necessitated extensive guidance from PHE and NHSE on procedures, for example on staffing, infection control and visitors. But official guidance was issued later than for the NHS, and care homes were not always well placed to follow it. Privatisation

When the 1990 NHS and Community Care Act was passed, it was predicted that the application of market principles would result in greater choice, flexibility, responsiveness, quality and cost effectiveness (Audit Commission, 1992). However, applying the test as to whether someone was likely to be helped to bed at a time of their choosing by a domiciliary carer, Lewis and Glennerster (1996) concluded that little had changed in respect of the first four of these criteria, but that the privatisation of provision did save money. Indeed, by 2010, the average unit cost of the usually more specialised local authority home care was twice that of independent providers (UKHCA, 2012). COVID-​ 19 has thrown the problems of quality and staffing that are common in privately owned care homes into stark relief. When private provision of social care started to grow in the late twentieth century, care homes tended to be small, but while 80 per cent of homes continue to be owned by small providers, large providers, which also tend to run the care homes with the largest number of beds, have grown considerably in importance, such that the biggest five companies (HC-​ One Ltd, Four Seasons, Barchester Healthcare, Care UK and BUPA Group) –​three of which are funded by private equity firms –​control almost one-​fi fth of care home beds (Blakeley and Quilter-​ Pinner, 2019). The number of beds per home ranges from 1 to 215. This matters because the structure of private sector provision, particularly the way in which large homes operate, seems to have implications for the way they are staffed and the quality

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of the care that is provided. As Blakeley and Quilter-​Pinner put it, there are potential linkages between size, ownership and quality. A 2009 systematic review and meta-​ analysis of the evidence concluded that on average, not-​ for-​ profit nursing homes delivered higher-​ quality care than did for-​ profit nursing homes (Comondore et al, 2009). While 89 per cent of both small nursing and residential homes were rated ‘good’ by the CQC in 2017, only 65 per cent of large nursing homes and 72 per cent of large residential homes achieved this. Nevertheless, in a study of 59 homes where there were concerns about quality, the CQC (2020d) reported that it was ‘assured’ or ‘somewhat assured’ about the management of infection prevention and control for COVID-​19. The Centre for Health and the Public Interest’s study of 830 care home companies found that the profits of the 18 largest providers were double those of the small and medium-​sized companies (Kotecha, 2019). The care home business became attractive to large firms given the projections of population ageing, a steady income stream from local authorities and private payers, and the possibility of asset-​ stripping by mortgaging the buildings, or selling them and leasing them back. Most recently, private equity firms have entered the care home market and by using these techniques have been able to load up care homes with debt while extracting as much as possible from them. This makes them appear profitable and thus easy to sell on; the Four Seasons chain of homes changed hands four times in 13 years (Blakeley and Quilter-​ Pinner, 2019; Kotecha, 2019). This pattern of ownership and operation is not confined to the UK; it is very common in the US and is also found in other Western European countries. For example, in July 2020 the website of the international law firm Clifford Chance (22 July 2020) reported that it was advising ORPEA on the sale and leaseback of eight German nursing homes (22 July 2020). Competition, whether in health or social care provision, has been strongly argued to bear down on price. However, because many care homes are burdened with debt, in order to make ‘sufficient’ profits they must cut running costs, which includes tolerating low staffing ratios, poor staff training, frequent use of agency staff and low pay (Dromey and

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Hochlaf, 2020), as well as by making sure that bed occupancy remains as high as possible. In the COVID-​19 pandemic, the high death rate in care homes lowered bed occupancy rates, which fell from 87 to 79 per cent in nursing homes and from 87 to 82 per cent in homes without nursing (Skills for Care, 2020). Local authorities have responsibility for shaping the market to ensure supply, but care home provision has become much more unstable as a result of COVID-​19. The CQC has responsibility for monitoring the financial health of large care homes and ensuring supply via their Market Oversight Scheme, introduced under the 2014 Care Act in the wake of the collapse of a large provider, Southern Cross. The main demand from care home providers has been for a greater investment of public funds. Indeed, the policy debate on social care has focused on funding, which is not surprising given the precarious financial position of many providers, exacerbated by falling occupancy rates and the costs of implementing Covid-​safe measures, particularly the need to secure PPE and to limit the movement of staff between homes. The problem is often presented as one of insufficient financial support by local authorities in respect of the contracts they have with private providers for the care of those deemed eligible for publicly funded care. Certainly, local authority payments for those eligible for support do not meet the real costs of care. Jeremy Hunt, the Chair of the HoC Health and Social Care Committee, has reminded audiences on more than one occasion that while in 2018 he was successful in getting an extra 3.4 per cent per year settlement for the NHS over a five-​year period (which was nevertheless lower than the long-​term average),9 he was refused any comparable settlement for social care before being moved to the post of Foreign Secretary (Hunt, 19 May 2020, BBC Radio 4 PM interview; Hunt, 23 May 2020, BBC Radio 4 Political Thinking interview; Hunt, 13 July 2020). Under the policy of austerity, local authority spending on public services was reduced by 17 per cent, notwithstanding the continued increase in demand and, in the case of care for older people, a rise in the numbers of people over 80 years old. Government provided an extra £3.2bn to local authorities to help with pressures on local services due to COVID-​19, including –​but

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not exclusively –​social care. Only the infection control fund, amounting initially to £600m, with a further £546m added in late September, was ringfenced for adult social care, with 75 per cent going to care homes and about 13 per cent to home care provision (HoC Public Accounts Committee, 2020b and HoC Health and Social Care and Science and Technology Committees, 13 October 2020, Q 46). The comparison with the £22bn budgeted for 2020–​21 for the test and trace system, run by private providers, is striking. The whole issue of finance is vastly complicated by the fact that the Government has sought to exit from the direct provision of care and has a longstanding lack of desire to assume financial (or administrative) responsibility for it in the long term. However, guaranteeing the debts of private equity companies involved in care home provision is potentially politically difficult. Jeremy Hunt has rejected the idea of making social care a public service, insisting only that all care home residents should have a care plan, integrated with NHS provision (Hunt, 19 May 2020, BBC Radio 4 PM interview). However, the latter is not so easy when the two services are funded and operated so differently. Furthermore, during the first wave of the pandemic, care homes competed against one another in the scramble for PPE and staff. Given the privatised and fragmented nature of care home provision, staff cannot be redeployed in an emergency as in the NHS and it is also difficult to ensure a common approach to infection control. Staffing

As Fixsen et al (2005, p 46) have observed:  ‘in human services, practitioners are the intervention’ (their emphasis), and in care work what is at stake is the ‘care relationship’. The introduction of market principles have resulted in a ‘time and task’ approach, which has meant time-​limited visits for people needing help with bathing, feeding and toileting at home, and reliance on large numbers of agency workers in care homes (Lewis and West, 2014). In both residential and domiciliary care, continuity of care has become difficult to achieve and what in ‘normal’ times is a problem of achieving ‘good care’ adds to the health risk in a pandemic. Social

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care work has always been defined as unskilled –​even as the proportion of residents in care homes with demanding medical conditions such as dementia rose –​and has been held in low regard compared to health care. The contribution of social care workers was slow to be recognised during the pandemic compared to NHS workers, despite Office for National Statistics (ONS) figures for 9 March to 25 May showing that the death rate of social care workers was higher than that of health workers (ONS, 2020b). Care homes face a high risk of infection, which means that staffing levels need to be adequate (not least to cope with higher levels of staff absence); staff need more training in infection control, especially as the availability of nursing care is limited, even in nursing homes; and the movement of staff needs to be reduced with provision for ‘zoning and cohorting’ staff and residents within homes (for example, isolating residents with COVID-​19 and arranging for staff to work with a particular group of residents on a particular floor) (ADASS, 2020). However, progress towards the National Minimum Standards introduced in the early 2000s in regard to matters such as the ratio of staff with a level 2 (lower secondary level) qualification to untrained staff proved difficult to reach and was abandoned in 2010. Reliance on agency workers, minimal staffing levels and minimally paid care assistants has persisted and been exacerbated by staff absence due to sickness. Furthermore, ONS data have shown that care homes using agency staff regularly are likely to have more COVID-​19 infections, while those in which staff receive sick pay are likely to have fewer infections (Tinsley, 3 July 2020). The report of Skills for Care (an independent body, receiving DHSC funding) for 2019–​20 found that between March and August 2020 the vacancy rate for staff was 7 per cent, the staff turnover rate was 30.4 per cent (but higher for the least well-​paid care workers and for the 24 per cent on zero hours contracts, the majority of whom work in domiciliary care). Just under a quarter of care workers received the national minimum wage and 73 per cent were paid less than the real living wage (£9.30 per hour, £10.75 in London) (Gardiner, 2020; see also Dromey and Hochlaf,

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2018). Nor does experience seem to have much effect on pay:  five years’ experience results in a rise of 1 per cent an hour. Lord Sutherland, who acted as the Chair of the Royal Commission on Long-​ Term Care for the Elderly (1999), was cited by the HoC Health Select Committee in 2010 as saying that care home workers must be either ‘“altruistic or desperate”’ to do the job (HoC, 2010, para 148, note 183). And as the Sheffield team of volunteer contact tracers working under the leadership of a retired GP found in May (see above, Chapter 2), low-​paid health and social care workers were often unwilling to give their details to tracers, not least because they feared being told to isolate, which meant losing what were low, and for many zero hours workers, also precarious, wages. These workers were often not entitled to statutory sick pay while isolating. Government policy needed to recognise that the impediments to staff taking precautions to limit infection went beyond the availability of PPE and deep cleaning, something the final report of the Social Care Sector COVID-​19 Support Taskforce (October 2020) recognised, at least in part. The CQC’s report on the State of Care for 2019–​20 said that the workforce needed clear career progression, skills training and ‘appropriate’ professionalisation (CQC, 2020a), but stopped well short of raising the issues of registration for all care workers and national training standards. However, neither steps of this kind nor the fundamental issue of paying better wages are easy to impose on a privatised service. Small providers face genuine difficulties in funding training and paying better wages, while the business model of the largest providers has been built on squeezing costs, which are dominated by the costs of staff. Nevertheless, staff are, in Fixsen et al’s (2005) words, the essence of the intervention. The Government response was confined to a ‘care badge’ initiative in mid-​April, designed to recognise the ‘heroic frontline responsibilities’ of care workers, but it is noteworthy that the Action Plan for Adult Social Care (DHSC, 15 April 2020a, p 15) issued at the same time said that the Government was making it easier for employers to ‘access rapid online induction training for new staff’, with no mention of the importance of further training. The commitment of the Government to doing enough to

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secure genuine improvement in the terms and conditions of staff and the quality of care has not been clearly demonstrated. Indeed, on a trip to the North of England on 6 July, the Prime Minister sought to lay the blame for the spread of the virus on care home staff for not following ‘procedures’ (BBC News, 7 July 2020; see also Oliver, 15 July 2020). *** The problems of care homes, particularly the vexed issue of wages for, and conditions of, care work, are intimately linked to the issue of funding for what has become mainly private provision. This has attracted considerable analysis and comment over a 20-​year period, since the Royal Commission on Long-​Term Care (1999) reported (see also Jarrett, 2017), but seems to be an intractable problem, for anything that changes the balance between private and public provision is far from straightforward. Various Parliamentary committees, independent reviews, think tanks and experts have suggested a variety of funding reforms, some of the main ones being: (i) free personal care (House of Lords (HoL) Economic Affairs Committee, 4 July 2019), which does not address the issue of catastrophic costs incurred by some residents and risks creating new boundaries, for example between meal preparation and help to eat; (ii) providing a cap on the lifetime contributions that individuals make to their social care costs and raising the means-​tested threshold above which people are liable for their full care costs (Dilnot, 2011);10 (iii) a system relying mainly on public funding via general taxation, mandatory social insurance, redirected public expenditure or hypothecated taxation (Murray, R, 2018); and (iv) the idea of the state providing a level of basic care and allowing top-​ups (Elsden and Morton, 2020).11 Even though it has been put ‘on hold’ for some years, Dilnot’s proposal, which is politically attractive not least because it would save individuals from having to sell their homes to pay for care, may well still be the most likely to be implemented. With the cap set at its original 2011 level, this option has been estimated to cost around £3.1bn by 2023–​34 (HoC Health and Social Care Committee, 22 October 2020, para 102). It is difficult to see how to avoid substantial social care reform. As the Competition and Markets Authority (2017, p

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3) stated in its study of the care homes market: ‘The current model of service provision cannot be sustained without additional public funding’, suggesting that homes taking local authority funded residents will be particularly likely to prove unsustainable given the low rates local authorities pay. Self-​ payers are charged fees that are much higher than those paid by local authorities (41 per cent higher in 2017), effectively cross-​subsidising the costs of care for those deemed eligible for state funding, something that is likely to come under increasing pressure in the future. COVID-​19 has made an already existing crisis worse. Poor levels of staffing, poor pay, and too often poor quality as well as acute fragmentation due to the nature of independent provision make decisions about long-​term funding and investment, together with workforce planning, extremely difficult. Furthermore, passing more public money to care homes as they are currently constituted, even for PPE, is not unproblematic when so much money ‘leaks’ out of the care homes themselves and into the hands of large corporate owners. However, the vexed question of the care experienced by residents was painfully highlighted by the first wave of the COVID-​19 pandemic.

Conclusion

The lockdown in late March 2020 rendered the first wave of COVID-​19 manageable:  the NHS was hugely stretched, but not overwhelmed, and after late April the number of deaths fell. The Government did not have to face the kind of horror experienced in Northern Italy slightly earlier, with pictures from Bergamo of very ill patients in hospital corridors and full morgues. But exercising control over the pandemic has proved elusive in western liberal democracies and England has suffered badly in terms of high numbers of hospitalisations, high morbidity, high death rates and severe economic disruption. This Rapid Response has explored the relationship between politicians and scientists and some of the dilemmas this has entailed. It then highlighted and documented what is so far known about two key areas in the effort to control COVID-​19: first, the position of public health and the need to establish an effective test and trace and isolate (TTI) system, historically central to any response by the public health authorities, and second, social care, in the form of care homes for older people, where residents and staff both suffered very high rates of infections and deaths. While success has been claimed for policies to control the virus, particularly for the TTI system, the claims are difficult to justify. Attributing responsibility for the problems and assessing what should or could have been done is primarily a matter for a future public inquiry. But I have sought to understand more about difficulties that were experienced by, on the one hand, exploring in more detail the nature of the Government’s approach to them and why its response took the form it did, and on the other hand, the extent to which pre-​existing structural problems in both public health and social care were important. I conclude that both these 67

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dimensions were crucial, but also that in no small measure the underlying structural issues were themselves a function of previous Government approaches to policymaking in the fields of public health and social care. The Government started poorly; it is hard to disagree with the judgement of the BMJ editorial writers that its response was ‘too little, too late, too flawed’ (see above, Chapter 1). It is not altogether clear why the Government paid so little attention to the developing pandemic in late February and early March but when it could no longer hold on to its conviction (or hope) that the virus would not amount to much, it had to act in a hurry. By then, it was too late to stop the wide geographical spread. In deciding to enter lockdown, it followed other western countries, which also tended to lack the capacity exhibited by some East Asian countries to control the disease using existing, high-​quality (but often intrusive) TTI systems. Furthermore, the Government had to take action when often little effective preparation had been made. The lack of preparedness is in and of itself a major issue. Complacency followed the successful control of H1N1 influenza and proved particularly significant given that under conditions of austerity it was accompanied by the failure to maintain preparations even for another influenza pandemic, let alone a different kind of virus (most notably perhaps in allowing the personal protective equipment (PPE) stockpile to erode). But the overwhelming impression of the Government’s approach is that it was reactive, rapidly becoming stuck in a cycle of rather late lockdowns and varying amounts of restrictions, followed by as rapid an escape from them as possible. There was little by way of clearly articulated strategic or operational planning, while the work of implementing and delivering policies that were crucial to controlling the virus, such as TTI, was often handed over to the private sector without the assurance of expert oversight. The Government appeared to swing back and forth between optimism and pessimism about the course of the virus, putting the brakes on all economic and social activity on 23 March, then relaxing its approach considerably in the summer, and strongly encouraging people to resume their ‘normal’ activities, by ‘eating out to help out’ (to support

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the hospitality industry) and returning to work, only to re-​introduce stricter rules on 22 September and a second lockdown on 5 November. In contrast, the state of Victoria in Australia used lockdowns and a detailed plan underpinned by modelling successfully to tackle community transmission after a major second surge of the virus (Baker et al, 22 December 2020). In addition, post-​lockdown, guidance and/​or rules governing the behaviour of citizens changed with bewildering regularity. Lack of a steady course, a clear strategy and a plan for action (all replicated in other policy areas, such as education) risked damaging public trust and confidence. Furthermore, it seems that little planning took place through the summer months, when the threat alert had been lowered to 3 but the Government appeared to be focused on the problem of how to determine secondary school students’ A level grades (a problem that was commonly agreed to be of its own making), civil service reform and, as in January, Brexit. This was reminiscent of the Government’s period of relative inaction between late January and early March and happened despite the publication of an Academy of Medical Sciences1 (2020) report in July –​commissioned by the Government Office for Science –​which put forward a ‘reasonable worst-​ case scenario’ of a peak in hospital admissions and deaths in early 2021. In addition, in neither period was the time used to ensure an efficient and effective TTI system, which was necessary for the control of community infection, including in care homes. Throughout the first wave of the pandemic, Government messaging to the public about COVID-​19 was confusing and it appeared to lack steadiness of purpose. This is important because the decisions taken on how to control the virus were in the end political. It may be that the repeated pattern of (in)action arose from (i) the Government’s preference for allowing as much freedom as possible for as long as possible in line with its strong libertarian instincts, and that its delay in taking important decisions was due as much or more to a reluctance to countenance state intervention as to an unwillingness to follow, or to reject, scientific advice, or (ii) the belief that there was a dichotomous choice to make between the economy and the public’s health. While fears about the

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effect of strong restrictions on the economy were all too real, prompt action to suppress the virus would likely have had a more beneficial effect on the economy than the long-​drawn-​ out ‘stop/​go’ approach adopted by the Government. As it was, the Government and the Prime Minister in particular tended to over-​promise and under-​deliver. At the beginning, the virus was in large measure an unknown quantity. Any Government would have found the task of controlling it challenging and would have needed a considerable amount of good advice. From the very early stages, ministers insisted that they were ‘following the science’, relying on the advisory committee on emergencies, SAGE. The minutes of SAGE’s meetings show considerable equivocation and their conclusions on the issues discussed were usually offered using low, medium and high confidence levels. Thus, in early March, the Government did not act to ban large gatherings of people at sporting events, or to shut bars early, on which matters SAGE equivocated (see above, Chapter 1), nor did it act on SAGE’s comment regarding the need for testing for the virus in care homes including homes that had not reported having COVID-​19 cases, a matter in which it had ‘medium confidence’ (see above, Chapter 3). SAGE did not often speak with a single voice and had a high evidence threshold for making recommendations on such issues, which made it cautious. In addition, the Government lacked an authoritative forum to provide expert professional advice to ministers and civil servants on the “nuts and bolts” of how to implement, organise and deliver some of the programmes that were crucial to successful control of the virus, notably the TTI system (or indeed the commissioning and distribution of PPE). The voices of public health practitioners and social care experts, for example, were largely absent. SAGE was dominated by mathematical modellers, who focused on the nature of the spread of the virus. It is difficult to know exactly what the Government knew and when, but it appears that the pattern of the ministerial response was to react at the last moment:  when the numbers of infections and deaths had risen and the warnings of the mathematical modellers about what would happen in a matter of days and weeks became too strong to ignore. Thus, in mid-​ March

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the Government finally heeded the warning that the death rate would be very high if it did nothing, and high if did not take strong action, which resulted in the decision to enter lockdown. Community transmission was such by mid-​ March that drastic action was unavoidable if the NHS was not to be overwhelmed. This pattern of Government delay in responding to the scientists’ warning about a surge of infections and the need for stronger rules to govern the behaviour of the public was repeated most notably in late September, when the Government did not accept SAGE’s call for a short ‘circuit breaking’ lockdown, imposing instead somewhat stricter rules, but had then to order a one-​month lockdown on 5 November. Ministers seemed to want a firm steer from scientists but the evidence suggests that they were no more inclined to respond quickly to SAGE’s warnings about the course of the pandemic and the need for action at the end of 2020 than earlier in the year. At the end of the day, policy decisions were political and deeply challenging. Indeed, the ongoing relationship between ministers and SAGE became increasingly difficult, as concerns about the effect of restrictions and the cost of imposing them became ever larger, and as the ongoing repeated need for heavy restrictions came into conflict with the Government’s own instinctive preference for freedom and, perhaps, willingness to delay for –​as they saw it –​the protection of the economy. The claim made by Priti Patel, the Home Secretary, on BBC Radio 4 Today (22 December 2020) that the Government had been ‘consistently ahead of the curve in its response to the virus’ rang hollow. While fast action was always going to be crucial for staying ahead of the curve, the Government usually delayed until action became imperative. In many ways, the ideas of the Conservative Party and its approach to government over a generation made effective control of the virus more difficult. The UK had become ever more centralised under Conservative Party Governments since the 1980s, which also wanted to divest themselves of the need to govern public services by introducing market principles and encouraging outsourcing and privatisation (Letwin and Redwood, 1985; Letwin, 1988). Jeremy Hunt wrote in 2005 that he wanted to break down barriers between private and

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public provision, ‘in effect denationalising the provision of health care in Britain’ (Hunt, 2005, p 78), and in 2012 the Health and Social Care Act entrenched market principles in the NHS, the idea being that the service would become more effective and efficient and run itself without political interference. Even after 2014, when more emphasis was placed by NHS England on the need for greater integration of services in face of acute fragmentation (not least between health and social care), the wisdom of outsourcing to the private sector was not questioned. Care homes, which had already been ‘hived off’ from the NHS early on by legislation passed in 1991, increasingly came under the control of private owners and were largely removed from the day-​to-​day concerns of governments. But public health’s functions at the population level were not as easy to fit into a privatisation or outsourcing framework. Furthermore, a significant section of the Conservative Party saw much of the work of public health, particularly in respect of some of the health promotion programmes, as part of a ‘nanny state’ and at odds with libertarian principles. While responsibilities for public health were returned to local government by the 2012 legislation, public health work tended not to attract the attention of central Government and was increasingly underfunded. In the case of the two major areas of consideration in this text, public health and care homes, both were central to the ongoing work of controlling the spread of the virus, the former because of its historical expertise in infection control, and the latter because of the vulnerability of the residents, but both were poorly placed to confront the pandemic. Public health had experienced a slow but relentless decline in influence, provision and investment for half a century. Furthermore, public health at the local level had suffered as a result of the large cuts imposed on local government between 2010 and 2020 under austerity.2 When it came to establishing an effective TTI system, the Government tended to reach repeatedly for private sector providers and to ignore local public health departments. Nor was the advice of public health experts at the local level –​where a TTI system should be fully operational –​sought. Certainly, public health did not have the means to provide the kind of TTI system that needed

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to be at the centre of an effective response to controlling the virus and to unlocking the economy safely. But while public health was in no fit state to undertake the large-​scale effort needed, there was no reason to bypass it completely by outsourcing the work to private firms via a new entity, NHS Test and Trace, which reported directly to the Prime Minister and Cabinet Secretary, thus also bypassing the Department of Health and Social Care (DHSC). The decision to outsource proved particularly damaging for tracing and securing the isolation of those testing positive and their contacts, for which public health practitioners had well-​ developed expertise. Nevertheless, even as the TTI system continued to experience major problems, contracts were renewed with the private sector providers in August and it was also decided to demolish public health’s central body, Public Health England (PHE), in what many commentators regarded as a ‘blame game’. Thus, public health, which might have been expected to play a leading part in the control of the virus, was (further) marginalised. The performance of the private providers called upon to plug the major gaps in public health’s capacity to respond to the COVID-​19 crisis was poor throughout the first wave of the virus. Those working in local public health departments and in primary care were not only passed over in terms of the contribution they might have made, but also in respect of the information that the new test and trace system produced. Large contracts for the provision of test kits, the carrying out of testing, the processing of tests, the work of contact tracing, and the delivery of the complicated logistics demanded by setting up a TTI system from scratch were awarded to multiple private providers with little or no experience of public health practice and seemingly with little by way of penalty clauses. As Davies (2013) has noted, the shift from regulation by administrative to legal contract that was embedded in the 2012 health and social care reforms made the involvement of the private sector increasingly a technical rather than a political matter. Yet as the National Audit Office has reported, there has long been concern about the capacity of NHS bodies to draw up and manage contracts with private providers (Comptroller and Auditor General, 2016), something

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that was clearly evident in the problems experienced with contracting for PPE, as well as for ‘test and trace’ services during the pandemic. Deloitte was heavily involved with both and there is some evidence already from questions asked in Parliament that the contracts with this company may have been poorly drawn up (see above, Chapter 2), adversely affecting the efforts of locally based public health and primary care to operate effectively. Certainly, there seems to have been little strong oversight or coordination of NHS Test and Trace, which did not report to the DHSC. Indeed, the full range of causes of the problems that have continued to characterise the service have remained opaque, for example, in respect of the precise cause of the hold-​up in processing test samples by the laboratories (in September). The Government could also have invested more in existing locally integrated systems, especially in local public health departments for the work of contact tracing, and in smaller existing laboratories for the processing of tests. Why it chose not to do these things is not yet clear, but the strong preference for introducing market principles into public services is longstanding, and with it the strong conviction that private providers will be more efficient. A huge amount of public money has been and continues to be spent on outsourcing. As a second surge of the virus was acknowledged by the Government to have begun in the third week of September, COVID-​19 continued to demand considerable attention to the detail of operational matters, particularly the performance of the TTI system, which deteriorated further in terms of the basic requirements of turnaround times for tests, and the percentage of contacts traced. But the Government showed little appetite or aptitude for improving the situation and has tended to claim that all is going well. The work of TTI has been the bedrock of local public health practice in the past but the painstaking work needed to do it well at the local level seemed to meet with some impatience, with ministers preferring to put their faith in more glamorous options, such as the app or mass testing. In the current pandemic, public health principles and practice have tended to be sidelined with little apparent regard by Government for the advice that public health experts might have been able to give,

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particularly in respect of the mix of measures that might have been implemented as well as the operational issues involved in setting up an effective TTI system. Most recently, PHE, the central public health body, has effectively been blamed for the failures and will be merged into the new National Institute for Health Protection (NIHP). In fact, major social investment at the central and local levels is a prerequisite for a well-​functioning public health system to be able to provide expert advice and practice, without which it is both difficult to see either how a good TTI system can be built to meet future emergencies or to see how health promotion policies to address the health inequalities that underpin the higher COVID-​19 death rates among the poorly paid and poorly housed are to be developed and coordinated. In the case of care homes, the fact that they had become increasingly privately owned after the introduction of early market-​oriented reforms of health and social care in 1991 meant that they were largely outside Government control, for example in the way in which staffing was organised. But the extent to which they were dependent on public money paid in respect of those deemed eligible for state support, alongside their fragmentation as largely privately owned entities, made them increasingly vulnerable during the COVID-​19 crisis in terms of the health of staff and residents, and the viability of the homes themselves. Government oversight of care homes was limited because they have long been independently owned. The regulatory body, the CQC, had rather limited tools to address the quality of care and the way it was delivered. Indeed, there was considerable ambiguity in how social care was managed. It took until June for the Government to set up a new Social Care Taskforce to make detailed recommendations (published in mid-​September) on essential issues such as staffing and infection control. A well-​ run, stable care home sector is crucial, even in ‘normal times’, for the smooth running of the NHS, but during the first wave of the pandemic the healthcare service was necessarily focused firmly on its own extremely difficult situation and tended to treat care homes as an ancillary service, for example in respect of the hospital

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discharge policy and the diminution in primary care support. The pursuit of a better structured ‘integrated’ health and social care system, firmly on the policy agenda since the mid-​ 2010s, appeared to have made little progress. In addition, funding for care homes was a more complicated problem than for public health, particularly for those homes taking significant numbers of residents paid for (at increasingly low rates) by the local authorities and for large homes whose owners expected high rates of return. The level of staffing and staff qualifications had long been a concern and were difficult to address given that this sector of provision was run independently of the state. This raised particular issues for the enforcement of new infection control regulations. Indeed, the pandemic exacerbated already existing problems and made the instability of the sector worse. It is difficult to see how more equitable funding structures, better paid and trained staff, and more integration between health and social care can be achieved without the larger involvement of the state in these issues. It has long been assumed that social care provision will be in the main independent and mainly for-​ profit. But removing the provision of long-​term care from the NHS and Government control has effectively created new problems. Social care has been “out of sight and out of mind” and social care work has remained lower status than healthcare work, even as the numbers of people over 80 years old have continued to increase. It has proved difficult to provide any oversight beyond basic regulation. But integration with the NHS is difficult because care homes are privately owned, and also because it is difficult to achieve without making social care more firmly the handmaiden of the NHS. During the first wave of the pandemic, Government intervention in respect of social care came later than it did for the NHS. Social care has long-​term structural issues but there appears to be no desire to attempt the difficult work of removing either care homes or their staff from private control. Care home reform is in any case impossible during the pandemic, but it is on the Government’s agenda (as it has been for most governments during the last 20 years). However, as matters stand, care homes continue to lack full access to testing and face staffing

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problems going into the second wave of the pandemic, while increasing instability due to falling occupancy rates and profit margins may result in more closures. Political ideas seem to have played an important part in determining the Government’s approach to the emergency. Government policy has been key to controlling the pandemic, but there has been a lack of appetite among some in the Conservative Party to authorise control over people’s day-​ to-​day lives, especially when difficult health and economic trade-​offs are involved, with the result that policymaking has developed a stop-​start approach. In addition, in the case of public health, the predilection for private sector provision resulted in contracts with providers who had little or no experience in the field of public health, while in the case of care homes, independent ownership restricted the amount of data readily available about the sector and made it more difficult to ensure that necessary actions were taken. Yet, ministers have commented favourably on the extent to which it has been easier to organise the healthcare response to the pandemic in the UK than in some other countries, because the NHS covers the whole population and, for example, staff and, if necessary, patients can be moved around within the service. This can happen because, despite growing amounts of outsourcing, the NHS remains a public service. Public health is also likely to be an entirely public service in western countries. However, in the UK it had been substantially weakened before COVID-​19 struck. Indeed, the future of public health in the UK is uncertain. The future leadership for the health promotion side of its work is unclear, while the policy direction of the new body that will replace PHE –​the NIHP –​is, as yet, unknown. The NIHP may or may not continue the practice of outsourcing aspects of virus control, for example. Like care homes, public health needs considerable investment. In the case of care homes, private ownership makes it difficult to secure better terms and conditions for staff or to plan effectively for the future of residential and nursing home care. It is difficult to see how privatisation could easily be partially or wholly reversed; the legal and financial problems would be great. But to some extent, problems arising from the terms and conditions for

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staff, and the nature of care in terms of quality and matters such as infection control (which is central to controlling a pandemic), could be addressed by a more rigorous system of state regulation governing staff qualifications and training and pay in particular. As yet, there seems to be little sign of the Government presenting its actions to the public in an accountable and consistent way. Ministers have tried to claim their headline initiatives as ‘world-​ beating’ or ‘game-​changing’ and then have had to retreat. In mid-​July, the Prime Minister said that he sincerely hoped that there would be a ‘return to normality… possibly in time for Christmas’ (Johnson, 17 July 2020), but was very soon gainsaid by spikes in the numbers of infections in northern towns. As matters stood towards the end of 2020, the UK had experienced the highest number of deaths and the greatest disruption to its economy of any European country. The experience of more successful countries (thus far) suggests that minimising community transmission earlier might have avoided a heavy and long lockdown and allowed a faster and stronger economic recovery from the first surge. Facing a second wave of the COVID-​19 virus (at the time of writing), the UK finds that it faces a number of potentially difficult choices, including how far to shield the most vulnerable and/​ or implement local or national lockdown measures, as well as divided opinion between key actors, scientists included (Wise, 21 September 2020). The failure to act swiftly and decisively to suppress the new coronavirus in February/​March was particularly problematic because it allowed the virus to become embedded over a wide geographical area. The action that followed resulted in what was felt by many Conservative politicians in particular to be a choice in favour of ‘health’ over the ‘economy’, something that many East Asian countries in particular have shown to be a false dichotomy. There was a lack of consistency and steadiness at the centre, and a lack of coordination between both central agencies and the central and local levels. Government accrued power centrally to control the pandemic (via the Coronavirus Act) but the huge public spending that resulted, most notably on the outsourced ‘test and trace’ system, failed to fulfil its

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promise. The first wave of COVID-​19 is often a story of Government missteps, but also of underlying system failure, nowhere more than in the cases of public health work, which was most subject to austerity cuts and a chronic lack of investment, and of care homes, which have often tended to be treated by the Government as secondary to the fate of the NHS, and have been squeezed by large private providers facing a fall in income. The verdict on how the Government handled the pandemic on a day-​to-​day basis will be subject to democratic politics. But there will in all probability be more pandemics in the future and there are also medium-​term problems of governance to be considered, for example a review of the ways in which the Government seeks and receives expert advice and from what kind of experts, including a better understanding on the part of ministers as to the nature of scientific advice, which has to become more sophisticated than merely ‘following it’. In respect of the policy response, others have already argued for the need for greater consultation, more communication with the local level and more coordination (see especially Gaskell et al, 2020; Nickson et al, 2020), which the effort to establish the ‘test and trace’ system demonstrates well. But the most difficult issues are systemic and relate to previous decisions of primarily Conservative Governments regarding the role of the state and the preference for outsourcing, manifested in the case of the TTI system and (longstanding) privatisation in the case of care homes, which has involved the Government largely stepping back from responsibility for the sector. The successful development of vaccines, announced in late 2020, has tended to be hailed as the way out of the pandemic, which in large measure it is, but COVID-​19 is unlikely to go away. Vaccines make it possible to live with the virus but can also be seen as the latest in quite a long line of ‘magic bullets’. An effective TTI/​quarantine system, as well as –​in all probability –​effective messaging on the need for individual behavioural change (for example, regarding the wearing of face masks) will still be needed to control the future outbreaks that may occur, as will protection of vulnerable people in care homes. A mix of instruments is likely to continue to be necessary to avoid the harmful cycle of lockdowns and (usually

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too early) releases. It will not be possible for the Government to abnegate responsibility for addressing issues like these and a firm strategy is required to deal with them. Albert Camus’s line from his novel, The Plague, has been deservedly much quoted: ‘They fancied themselves free, and no one will ever be free so long as there are pestilences’. There is little point in libertarian freedoms if you end up dead. As I finish the final checks on this manuscript, we are told that a death rate of 100,000 for the UK is already ‘baked in’.

Notes Preface 1. By late autumn it was clear that it had become appropriate to refer to a ‘first wave’ of the virus, as the rate of infection began to climb again. It should be remembered that ‘surges’ varied in strength between countries and areas of the UK during the first wave. 2. Control of coronavirus is a devolved responsibility in the UK, but many responses to the virus were common to all UK countries. However, there were also important differences in the approaches taken by the different Governments.

Introduction 1. The term COVID-​19 refers to the coronavirus disease. The term SARS-​Cov-​2 refers to the virus:  severe acute respiratory syndrome coronavirus 2. I refer to COVID-​19 and to ‘the virus’. 2. For example, in July a YouGov poll showed that a large proportion of people refusing to wear face coverings would not change their behaviour until they became mandatory (Smith, 15 July 2020). 3. Weible et al (2020) have emphasised the importance of both strategic and operational responses to COVID-​19. 4. Excess deaths are defined as the number of deaths in a particular period compared to the number for the same period in the previous year or, preferably, to the average for the same period over the previous five years. 5. These include residential and nursing homes, which fall within the designation ‘adult social care’ and are more often referred to in other European countries as ‘long-​term care’. 6. Many would also count the rapid erection of large ‘Nightingale’ hospitals as a major success; five opened in April 2020 with the capacity to treat about 10,000 COVID-​19 patients. However, these hospitals were not used during the first wave of the virus and there was in any case a shortage of nursing staff in particular. 7. This body was set up to synthesise data and provide joined-​up advice to Government on managing the disease (Vize, 2 July 2020).

81

82 Notes 1  The approach to the early stage of the pandemic by politicians and scientists 1. COBR or COBRA is the Civil Contingencies Committee that meets in the inter-​departmental Cabinet Office Briefing Rooms. 2. The WHO defines quarantine as separating people and limiting the movement of people who have or may have been exposed to the disease to see if they become ill. Isolation separates people who are ill from others. However, the UK does not always clearly differentiate between these two terms. In the main, quarantine is used in respect of those coming into the UK (Goh, 15 August 2020). 3. Since this date, SAGE minutes and papers have been available online. 4. This had laid out four phases:  detection, which was to follow the WHO declaring a Public Health Emergency of International Concern and involving the collection of intelligence from affected countries, surveillance and the development of diagnostics; assessment of clinical and epidemiological information, case finding and self-​ isolation; treatment; and escalation to manage the surge in cases. 5. This report was not published until later in 2020 by the DHSC (5 November 2020). However, it was leaked to The Guardian (7 May 2020) and was published in full, with redactions. 6. Such a policy was given concrete form and wider publicity in October (Kulldorff et al, 4 October 2020).

2  The position of public health and the problem of ‘test and trace’ 1. In any case, at this stage in the pandemic, the acute shortage of many forms of PPE, face masks included, would have been a deciding factor for Government. 2. The DsPH were located in the upper tier of two-​tier local authorities, but much of the work of public health, including contact tracing, is done at the lower level in local communities, making good communication essential. 3. The report did not review the responsibility of the local DsPH for emergency preparedness. 4. There is relatively little reference to the issue of isolating positive cases in this text because data are lacking and Government policy has paid little attention to it. Rough (2020) and Briggs et al (2020) provide good initial guides to the development of test and trace in the UK. 5. Open Democracy reported that Deloitte had received £8m in government contracts to support the coronavirus response (Geoghegan et al, 2020). 6. On 18 July these kits had to be withdrawn because of quality issues, which caused particular difficulty for care home staff and residents.

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7. The National Audit office has concluded that some key decisions lacked transparent and adequate documentation as to why particular suppliers were chosen, or how conflicts of interest were identified and managed. By 31 July, over 8,600 contracts worth £18bn related to the pandemic response had been awarded without a competitive tender process, sometimes with ‘high-​priority lane access’ given to potential suppliers who were brought to the attention of ministers (Comptroller and Auditor General, 2020c). UK procurement policy during the pandemic has been subject to legal challenges (Dyer, 29 October 2020) and has attracted widespread attention outside the UK, for example, in the form of a long piece of investigative journalism published in The New York Times (Bradley et al, 17 December 2020). 8. In the event of clusters of cases, ‘backwards contact tracing’ may be used, but in England even tracing the ‘onward’ contacts of the index case has proved difficult. 9. In fact, at least 20 per cent and as many as 50 per cent or possibly more, of the total number of new cases may be asymptomatic. 10. Independent SAGE held its first meeting on 4 May and from the first aimed for complete transparency in terms of membership and minutes of its meetings. Andy Burnham, Mayor of Manchester, also complained about lack of support for those required to isolate in an interview (Pidd 19 August 2020). 11. To qualify for sick pay, a worker must earn an average of £120 a week. 12. See Marmot et al (2020) and Murray C J L (2020) (for the collaboration responsible for the Global Burden of Disease study, funded by the Gates Foundation), and the commentary by Horton (2020) on these. 13. A second month-​long lockdown began on 5 November 2020.

3  Care homes for elderly people1 1. Daly (2020) has provided a useful early account of what happened to care homes. 2. The direct provision of local authority residential care beds fell by almost 90 per cent between 1980 and 2018. 3. In England, the possession of savings and assets over £23,250 means that the person seeking a place in a care home must pay for it. 4. In a letter sent by the Minister for Social Care, Helen Whatley, to CEs of local authorities, Directors of Adult Social Services, Directors of Public Health, Care Home Providers and CCGs’ Accountable Officers on 14 May 2020, care homes were told that in the event of a shortage they should contact their usual PPE supplier in the first instance, and if this failed a list of 11 private providers was also given (Annex C). Hall et al (2020) have traced the way in which procurement was divided into 11 different ‘category towers’, managed by different contractors, who in turn choose approved

84 Notes suppliers. Companies will tend to bid low to become an approved supplier. Subsequently, it may become difficult to ensure quality and quantity. 5. The letter was signed by Simon Stevens, NHSE Chief Executive and Amanda Pritchard, NHSE Chief Operating Officer. 6. However, when inspections were resumed in early autumn, inspectors were exempted from weekly testing for the virus. 7. LaingBuisson is a company supplying analysis and data on market structures, policy and strategy across health care, social care and education. 8. Furthermore, there are a large number of associations representing different types of provider. These include, for example, Care England for independent providers and the National Care Forum for not-​for-​profit providers. Care England represents small, medium and large providers and the National Care Association small and medium providers. The Care Providers Alliance brings together the ten main for-​profit and not-​for-​profit providers of adult social care. 9. Budgets rose only 1.4 per cent each year on average (adjusting for inflation) between 2009–​10 and 2018–​19 (The Kings Fund, 2020). 10. Dilnot’s proposal is already embodied in phase 2 of the 2014 Care Act, but has not been implemented. The proposal would address the catastrophic costs that can be incurred by self-​payers, but not necessarily the underfunding of the sector. 11. I am indebted to Fran Bennett (2020) for sight of her useful summary of these proposals for the Social Care Group of the Women’s Budget Group. See also, Bottery et al (2018).

Conclusion 1. An independent body established in 1998 and funded by government, charities and business. 2. A House of Lords Public Services Committee paper (HoL Public Services Committee, 13 November 2020) highlighted the problems arising from years of underfunding of local services.

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86 Notes Bottery, S, Varrow, M, Thorlby, R and Wellings, D (2018) A Fork in the Road: Next Steps for Social Care Funding Reform, London: The Health Foundation and the King’s Fund. Bradley, J, Gebrekidan, S and McCann, A (17 December 2020) ‘Waste, negligence and cronyism: inside Britain’s pandemic spending’, The New York Times, https://​www.nytimes.com/​interactive/​2020/​12/​ 17/​world/​europe/​britain-​covid-​contracts.html Brigden, P and Lewis, J (2000) Elderly People and the Boundary between Health and Social Care 1946–​1991:  Whose Responsibility? London: The Nuffield Trust. Briggs, A, Jenkins, D and Fraser, C (2020) NHS Test and Trace: The Journey So Far, London: The Health Foundation. Buck, D (2020) The English Local Government Public Health Reforms: An Independent Assessment, London: King’s Fund. Cabinet Office (24 July 2020) Our Plan to Rebuild: The UK Government’s COVID-​19 Recovery Strategy, London: The Stationery Office. Cairney, P (2020) ‘The UK Government’s COVID-​19 policy:  assessing evidence-​informed policy analysis in real time’, British Politics, 1 November, https://​doi.org/​10.1057/​s41293-​020-​00150-​8. Cameron, E E, Nuzzo, J B, and Bell, J A (2019) Global Health Security Index, Baltimore, MD: National Threat Initiative, Washington DC and Johns Hopkins Bloomberg School of Public Health. Carney, M (2020) The Reith Lectures 2020:  How We Get What We Value, Lecture 3 ‘From Covid crisis to renaissance’, 16 December, BBC Radio 4. Clark, G (Chair of the House of Commons Science and Technology Committee) (18 May 2020), letter to Boris Johnson, Prime Minister. Clifford Chance News (2020) ‘Clifford Chance advises ORPEA on the sale and lease-​back of eight German nursing home properties’, 22 July, https://​www.cliffordchance.com/​news/​news/​2020/​07/​ clifford-​chance-​advises-​orpea-​on-​the-​sale-​and-​lease-​back-​of-​eigh. html Colbourne, T (2020) ‘Unlocking UK COVID-​19 policy’, Lancet Public Health, 10.1016/​S2468-​2667(20)30135-​3. Colbourne, T, Waites, W, Manhelm, D, Foster, D, Sturmiolo, S and Sculpher, M, et al (2020) Modelling the Health and Economic Impacts of Population-​wide Testing, Contact Tracing and Isolation Strategies for COVID-​19 in the UK, London: UCL Preprint, 4 August. Comondore, V R, Devereaux, P J, Zhou, Q, Stone, S B, Busse, J W and Ravindran, N C, et al (4 August 2009) ‘Quality of care in for-​ profit and not-​for-​profit nursing homes: systematic review and meta-​ analysis’, BMJ 2009;339:b2732. Competition and Markets Authority (2017) Care Homes Market Study. Final Report, London: Competition and Markets Authority. Comptroller and Auditor General, NAO (National Audit Office) (2016) Investigation into the Collapse of the Uniting Care Partnership Contract in Cambridgeshire and Peterborough, HC 512, London: The Stationery Office. Comptroller and Auditor General, NAO (2020a) The Government’s Approach to Test and Trace in England. Interim Report, HC 1070, London: The Stationery Office.

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Comptroller and Auditor General, NAO (2020b) The Supply of Personal Protective Equipment (PPE) during the COVID-​19 Pandemic, HC 961, London: The Stationery Office. Comptroller and Auditor General, NAO (2020c) Investigation into Government Procurement during the COVID-​19 Pandemic, HC 959, London: The Stationery Office. Courea, E and Lay, K (19 August 2020) ‘Sir Jeremy Farrar condemns Matt Hancock’s decision to scrap Public Health England’, The Times, https://​www.thetimes.co.uk/​article/​fight-​against-​obesity-​and-​ smoking-​at-​risk-​in-​public-​health-​shake-​up-​ministers-​are-​warned- ​ fgzwsw9bk CQC (Care Quality Commission) (2020a) The State of Health Care and Adult Social Care in England 2019–​2020, HC 799, London:  The Stationery Office. CQC (2020b) The Care Act and the ‘Easements’ to it, London: CQC. CQC (2020c) Review of Do Not Attempt Cardiopulmonary Resuscitation Decisions during the COVID-​ 19 Pandemic, Interim Report, London: CQC. CQC (2020d) COVID-​19 Insight. Issue 4 Infection Prevention and Control, London: DHSC. Daly, M (2020) ‘COVID-​19 and care homes in England:  what happened and why?’, Social Policy and Administration 54 (7): 985–​98. https://​doi.org/​10/​1111/​spol.12645. Das, P (2013) ‘Profile: Duncan Selbie: the new face of public health in England’, The Lancet 381, 6 April: 1175. Davies, A C L (2013) ‘This time, it’s for real:  the Health and Social Care Act 2012’, Modern Law Review 76 (3): 664–​88. DH (Department of Health) (2011) Influenza Pandemic Preparedness Strategy, London: DH. DH (Department of Health) (2017) Guidance:  Adult Social Care Market Shaping, London: DHSC. DHSC (Department of Health and Social Care) (3 March 2020) Coronavirus: Action Plan, London: DHSC. DHSC (1 April 2020) Care Act Easements:  Guidance for Local Authorities, London: DHSC. DHSC (4 April 2020) Coronavirus (COVID-​19): Scaling up our Testing Programmes, London: DHSC. DHSC (15 April 2020a) Our Action Plan for Adult Social Care, London: DHSC. DHSC (15 April 2020b) PPE Plan, London: DHSC. DHSC (31 May 2020) UK Reaches 200K Coronavirus Testing Capacity Target a Day Early, London: DHSC, Press Release. DHSC (10 August 2020) NHS Test and Trace Service to Strengthen Regional Contact Tracing, London: DHSC, Press Release. DHSC (21 August 2020) Guidance. COVID-​ 19 Testing Data: Methodology Note, London: DHSC. DHSC (5 November 2020) Exercise Cygnus Report, London: DHSC. DHSC, PHE, CQC and NHS (2 April 2020) Guidance on Admission and Care of Residents during COVID-​19 Incident in a Care Home, London: DHSC.

88 Notes Dilnot, A (2011) Fairer Care Funding. Report of the Commission on Funding of Care and Support, London: The Stationery Office. Dromey, J and Hochlaf, D (2018) Fair Care: A Workforce Strategy for Social Care, London: Institute for Public Policy Research. Dyer, C (29 October 2020) ‘COVID-​19:  leaked documents suggest that VIPs and government contacts won PPE deals after special treatment’, BMJ 2020;371:m4180. Elsdon, J and Morton, A (2020) Fixing Social Care: The Fundamental Choices, London: Centre for Policy Studies. Ferguson, N (10 June 2020) Oral Evidence to House of Commons Science and Technology Committee, HC 136, Q 868. Fixsen, D L, Naoom, S F, Blase, K A, Friedman, R M and Wallance, F (2005) Implementation Research:  A Synthesis of the Literature, Tampa, FL: University of South Florida. Foster, D (2020) Coronavirus:  Local Authorities’ Adult Social Care Duties (the Care Act Easements), London:  House of Commons Library, Briefing Paper no. 8889. Gardiner, L (2020) Three-​Quarters of Care Workers in England were Paid Less than the Real Living Wage on the Eve of the Pandemic, London: Living Wage Foundation. Gaskell, G, Stoker, W, Jennings, W and Devine, D (2020) ‘COVID-​19 and the blunders of our governments: long-​run system failings aggravated by political choices’, Political Quarterly 91 (3): 523–​33. Geoghegan, P, Corderoy, J, Evans, R, Scott, R and Pegg, D (2020) Revealed:  Sloppy Whitehall Departments Spent 56 million on COVID-​19 Consultancy. Report, 20 August, London:  Open Democracy. Gill, M and Gray, M (16 November 2020) ‘Mass testing for COVID-​19 in the UK:  an unevaluated, underdesigned, and costly mess’, BMJ 2020;371:m4436. Gleave, R (24 April 2020) Letter to Directors of Public Health. Glynn, J (13 July 2020) ‘COVID-​19: excess all-​cause mortality in domiciliary care’, BMJ 2020;370:m2751. Godlee, F (21 May 2020) ‘COVID-​ 19:  a wake-​ up call’, BMJ 2020;369:m2021. Goh, S (15 August 2020) ‘What’s in a name? Isolating the term “quarantine” from other contamination’, BMJ 2020;370:m3240. Grabowski, D (20 October 2020) ‘COVID-​19 and nursing homes’, LSE Health Policy Seminar, London. Greenhalgh, T, Schmid, M B, Czpionka, E, Bassler, D and Gruer, L (9 April 2020) ‘Face masks for the public during the COVID-​19 crisis’, BMJ 2020;369;m1435. Grey, S, MacAskill, A, McNeill, R., Stecklow, S and Wilkes, T (29 June 2020) ‘Special report:  into the fog –​how Britain lost track of the coronavirus’, Reuters, https://​www.reuters.com/​investigates/​ special-​report/​health-​coronavirus-​britain-​tracing/​. Hall, D, Lister, J, Hobbs, C, Robinson, P and Jarvis, C (2020) Privatised and Unprepared:  The NHS Supply Chain, London:  University of Greenwich and We Own It. Halliday, J (19 July 2020) ‘Test and trace failures risk exponential case growth in England, official warns’, The Guardian.

Notes

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Hancock, M (14 March 2020) ‘We must do everything in our power to protect lives’, The Telegraph, https://​www.telegraph.co.uk/​politics/​2020/​03/​14/​must-​do-​everything-​power-​protect-​lives/​. Hancock, M (2 April 2020) ‘Statement on coronavirus’, Speech. Hancock, M (15 May 2020) Downing Street Briefing. Hancock, M (18 August 2020) ‘The future of public health’, Speech given at Policy Exchange, London. Haroon, S, Chandan, J S, Middleton, J and Cheng, K K (14 August 2020) ‘COVID-​19: breaking the chain of household transmission’. BMJ 2020;370:m3181. Harris, T, Hodge, L and Phillips, D (2019) English Local Government Funding:  Trends and Challenges in 2019 and Beyond, London: Institute for Fiscal Studies Briefing. HealthWatch and the British Red Cross (2020) 590 People’s Stories of Leaving Hospital during COVID-​19, London: HealthWatch and the British Red Cross. Henwood, M and Hudson, B (10 August 2020) Care Home Visits: Another Area of Confusion Surrounding the UK’s COVID-​19 Response, London: LSE, British Policy and Politics Blog. Hill, J (15 April 2020) ‘Exclusive:  social services directors attack Whitehall’, Local Government Chronicle, https://​www.lgcplus. com/​ p olitics/​ c oronavirus/​ e xclusive-​ s ocial-​ s ervices- ​ d irectors-​ attack-​whitehall-​covid-​19-​response-​15-​04-​2020/​. HMT (Her Majesty’s Treasury) (2020) A Plan for Jobs, London: The Stationery Office. Hine, D (2010) The 2009 Influenza Pandemic: An Independent Review of the UK Response to the 2009 Influenza Pandemic, London: Cabinet Office. HoC (House of Commons) Health and Social Care Committee (2010) HC22-​I, Third Report on Social Care, London:  The Stationery Office. HoC Health and Social Care Committee (17 March 2020) HC 36, Evidence of the CMO, Q 54; Evidence of the CSO, Qs 73 and 78. HoC Health and Social Care Committee (3 June 2020) HC 36, Evidence of Dido Harding, Qs 522 and 541. HoC Health and Social Care Committee (22 October 2020) HC 206, Social Care: Funding and Workforce. HoC Home Affairs Committee (5 August 2020) HC 563, Reports on Preparedness for COVID-​19: Management of the Borders. HoC Housing, Communities and Local Government Committee (15 June 2020) HC302, Evidence of Dr Greg Fell, Q 134; Dr Clare Gardiner, Director General of the Joint Biosecurity Centre, Q 173. HoC Liaison Committee (27 May 2020) Evidence of Boris Johnson. HoC Public Accounts Committee (2020a) HC 4040, Whole of Government Response to COVID-​19. HoC Public Accounts Committee (2020b) HC 405, Readying the NHS and Social Care for the COVID-​19 Peak. HoC Science and Technology Committee (25 March 2020) HC 136, Evidence of Professor Neil Ferguson, Q 20. HoC Health and Social Care Committee and Science and Technology Committee (13 October 2020) HC 877, Evidence of Teresa Steed,

90 Notes care home manager (Qs 25 and 37); Dr David Oliver, Geriatric Consultant at the Royal Berkshire Hospital (Qs 42 and 44); Jane Townson, CE UK Homecare Association (Qs 37 and 46), Professor Jane Cummings (Qs 98 and 101). HoL (House of Lords) Economic Affairs Committee (4 July 2019) HL Paper 392, Social Care Funding: Time to End a National Scandal. HoL Public Services Committee (13 November 2020) HL Paper 167, A Critical Juncture for Public Services: Lessons from COVID-​19. Home Office (2020) Measures at the Border, Paper submitted to SAGE, 28 April. Horton, R (2020) The COVID-​19 Catastrophe, Cambridge: Polity  Press. Hunt, J (2005) ‘Health’. In D Carswell et al (23 Conservative Party authors) Direct Democracy, London: by the authors. Hunt, J (13 July 2020) ‘We Tories must keep our word on social care’, The Guardian, https://​www.theguardian.com/​commentisfree/​ 2020/​jul/​13/​tories-​social-​care-​crisis-​health-​secretary-​jeremy-​hunt. Iacobucci, G (18 August 2020) ‘Public Health England is axed in favour of new health protection agency’, BMJ 2020;370:m3257. Iacobucci, G (21 August 2020) ‘Sixty seconds on … management consultants’, BMJ 2020;370;m3310. Iacobucci, G (16 September 2020) ‘Operation Moonshot: leaked documents prompt questions over cost, evidence and reliance on the private sector’, BMJ 2020;370:m3580. Imperial College Response Team (16 March 2020) Impact of Non-​ Pharmaceutical Interventions (NPIs) to Reduce COVID-​19 Mortality and Healthcare Demand, Report 9, London: Imperial College. Independent SAGE (9 June 2020) Towards an Integrated Find, Test, Trace, Isolate, Support Response to the Pandemic, Report 4. Independent SAGE (21 August 2020) Consultation Statement on Universities in the Context of SARS-​CoV-​2. Ipsos Mori (18 November 2020) COVID-​19 Polling for BBC Scotland. Jarrett, T (2017) Social Care: Government Reviews and Policy Proposals for Paying for Care since 1997 (England), London:  House of Commons Library, Briefing Paper 8000, 23 October. Johnson, B (3 March 2020) Prime Minister’s statement on the Coronavirus Action Plan. Johnson, B (12 March 2020) Prime Minister’s statement on coronavirus. Johnson, B (17 July 2020) Downing Street Briefing. The King’s Fund (2020) The NHS Budget and How It Has Changed, London: The King’s Fund. Kontis, V, Bennett, J E, Rashid, T, Parks, R M, Pearson-​Stuttard, J, Guillot, M, et al (2020) ‘Magnitude, demographics and dynamics of the effect of the first wave of the COVID-​19 pandemic on all-​cause mortality in 21 industrialized countries’, Nature Medicine 26: 1919–​ 28. doi.org/​10.1038/​s41591-​020-​1112-​0. Kostas, D, Fonteneau, L, Georges, S, Daniau, C, Bernard-​Stoecklin, S, Domegan, L, et al (4 June 2020) ‘High impact of COVID-​19 in long-​term facilities, suggestions for monitoring in the EU/​EEA, May 2020’, Eurosurveillance 25 (22): pii = 2000956. Kotecha, V (2019) Plugging the Leaks in the UK Care Home Industry, London: Centre for Health and the Public Interest.

Notes

91

Kuenssberg, L (16 April 2020) ‘Coronavirus:  social care concerns revealed in leaked letter’, BBC News, https://​www.bbc.co.uk/​ news/​uk-​politics-​52304918. Kulldorff, M, Gupta, S and Barracharya, J (4 October 2020) The Great Barrington Declaration, Sponsored by the American Institute for Economic Research. Laing, W (14 May 2020) ‘Deaths in care homes could reach 26,000 in England by end of May, predicts Laing’. Address delivered by D Pamben, LaingBuisson News, https://​www.laingbuissonnews.com/​ care- ​ m arkets-​ c ontent/​ n ews/​ c are-​ h ome-​ d eaths-​ f rom-​ c ovid-​ 1 9-​ could-​reach-​26000-​in-​england-​by-​end-​of-​may-​says-​laing/​. Letwin, O (1988) Privatising the World:  A Study of International Privatisation in Theory and Practice, London: Cassell. Letwin, O and Redwood, J (1985) Britain’s Biggest Enterprise:  Ideas for Radical Reform of the NHS, London: Centre for Policy Studies. Lewis, J (1986) What Price Community Medicine?, Brighton: Wheatsheaf. Lewis, J and Glennerster, H (1996) Implementing the New Community Care, Buckingham: Open University Press. Lewis, J and West, A (2014) ‘Re-​shaping social care services for older people in England: policy development and the problem of achieving “good care”’, Journal of Social Policy 43 (1): 1–​18. Lewis, R (26 November 2020) Special Report: How Rationing Care in the Pandemic is Killing the Elderly, London: HBI 365. Mahase, E (29 May 2020) ‘COVID-​19: two thirds of people contacted through tracing did not fully cooperate, pilot scheme finds’, BMJ 2020;369:m2169. Mahase, E (15 June 2020) ‘COVID-​ 19:  NHS Test and Trace releases first figures, with experts calling for improvements’, BMJ 2020;369:m2404. Marmot, M, Allen, J, Goldblatt, P, Herd, E and Morrison, J (2020) Build Back Fairer: The COVID-​19 Marmot Review. The Pandemic, Socioeconomic and Health Inequalities in England, London: Institute of Health Equity. McKee, S (17 August 2020) ‘The end of Public Health England?’, Pharma Times, http://​www.pharmatimes.com/​news/​the_​end_​of_​ public_​health_​england_​1346934. Morris, C (11 April 2020) ‘Coronavirus: what can the UK learn from Germany on testing?’, BBC News, https://​www.bbc.co.uk/​news/​ health-​52234061. Murray, C J L (2020) ‘Global burden of 369 diseases and injuries in 204 countries and territories, 1990–​ 2019:  a systematic analysis for the global burden of disease study 2019’, Lancet 396, 17 October: 1204–​22. Murray, R (2018) Hypothecated Funding for Health and Social Care –​ How Might It Work? London: The King’s Fund. NAO (National Audit Office) (September 2020) COVID-​19 Cost Tracker, London: NAO. NHS Test and Trace (2020a) Experimental Statistics: Weekly NHS Test and Trace Bulletin, England: 28 May –​10 June, London: DHSC. NHS Test and Trace (2020b) Experimental Statistics: Weekly NHS Test and Trace Bulletin, England: 16–​22 July, London: DHSC.

92 Notes NHSE and NHSI (NHS England and NHS Improvement) (2020) The Framework for Enhanced Health in Care Homes, London:  NHSE and NHSI. Nickson, S, Thomas A and Mullens-​ Burgess, E (2020) Decision Making in a Crisis:  First Responses to the Coronavirus Pandemic, London: Institute for Government. Norgrove, Sir David (11 May 2020) Letter to Matt Hancock. O’Donnell, G (2020) The Covid Tragedy:  Following the Science or the Sciences?, IFS Annual Lecture, 24 September. Oliver, D (18 June 2020) ‘Let’s be open and honest about COVID-​19 deaths in care homes’, BMJ 2020;369:m2334. Oliver, D (15 July 2020) ‘Was the Prime Minister justified in blaming care homes for poor COVID-​19 practice?’, BMJ 2020;370:m2741. Oliver, D (13 October 2020) Evidence to HoC Health and Social Care and Science and Technology Committees, HC 877, Q 49. ONS (Office for National Statistics) (2020a) Comparison of All-​Cause Mortality between European Countries and Regions:  January–​June, London: ONS. ONS (2020b) Covid-​Related Deaths by Occupation England and Wales: Deaths Registered between 9 March and 25 May, London: ONS. Oung, C and Curry, N (2020) Responding to COVID-​ 19:  The Complexities of the Social Care Provider Market, London:  Nuffield Trust Comment. Pavolini, E and Ranci, C (2008) ‘Restructuring the welfare state: reforms in long-​ term care in Western European countries’, Journal of European Social Policy 18 (3): 246–​59. PHE (Public Health England) (12 February 2020a) Recommendations on Continuing Use of Case-​Identification/​Contact-​Tracing/​Case and Contact Isolation, London: PHE. PHE (12 February 2020b) When to Stop Contact Tracing: Developing Triggers from PHE Systems, London: PHE National Infection Service ICC and Modelling Cell. PHE (25 February 2020) Guidance for Social or Community Care and Residential Settings on COVID-​19, London: PHE. PHE National Infection Service (24 February 2020) If There is Evidence of a Cluster of COVID-​19 Cases in the UK, What Will the PHE Proposal Be?, London: PHE. Pidd, H. (18 August 2020) ‘Burnham on Covid’, The Guardian, https:// ​ w ww.theguardian.com/​ p olitics/​ 2 020/​ a ug/​ 1 8/​ a ndy-​ burnham-​were-​a-​clear-​voice-​telling-​the-​machine-​what-​its-​doing-​ wrong-​covid-​19-​manchester. Ramakrishan, V (24 May 2020) ‘Scientists must not be made scapegoats for policy failures’, The Observer, https://​www.theguardian.com/​ world/​2020/​may/​24/​everyone-​wants-​to-​follow-​the-​science-​but-​ we-​cant-​waste-​time-​on-​blame. Roderick, P, Macfarlane, A and Pollock, A (26 June 2020) ‘Getting back on track: control of COVID-​19 outbreaks in the community’, BMJ 2020;369:m2484. Rough, E (2020) Coronavirus: Testing for COVID-​19, London: House of Commons Library, Briefing Paper, 5 August.

Notes

93

Royal Commission Report on Long-​Term Care for the Elderly (1999) With Respect to Old Age: Long-​Term Care –​Rights and Responsibilities, London: The Stationery Office. SAGE (Working Care Homes Group) (12 May 2020) SAGE Paper on Care Homes. Salajan, S, Tsolova, M, Ciotte, J and Suk, E (2020) ‘To what extent does evidence support decision-​ making during infectious disease outbreaks? A scoping literature review’, Evidence and Policy 16 (3): 453–​75. Salisbury, H (12 May 2020) ‘GPs still have no access to coronavirus testing’, BMJ 2020;369:m1881. Salisbury, H (2 June 2020) ‘Testing times for GPs’, BMJ 2020;369:m2180. Sample, I (2 August 2020) ‘Secrecy has harmed UK Government’s response to COVID-​ 19 crisis says top scientist’, The Guardian, https://​www.theguardian.com/​world/​2020/​aug/​02/​secrecy-​ has-​harmed-​uk-​governments-​response-​to-​covid-​19-​crisis-​says-​top-​ scientist. Skills for Care (2020) The State of the Adult Social Care Sector and Workforce in England, Leeds: Skills for Care. Smith, M (15 July 2020) Why Won’t Britons Wear Face Masks?, London: YouGov. Smith, L E, Potts, H W W, Amlôt, R, Michie, S and Rubin, G J (2020) Adherence to the Test, Trace and Isolate System: Results from a Time Series of 21 Nationally Representative Surveys in the UK. Preprint. London: CORSAIR study. Social Care Sector COVID-​19 Support Taskforce (18 September 2020) Final Report, Advice and Recommendations, London: DHSC. Soulsby, P (7 July 2020) ‘COVID-​19 in Leicester’, Unpublished paper. Spiegelhalter, D (30 April 2020) ‘Coronavirus deaths: how does Britain compare with other countries?’, The Guardian. Spiegelhalter, D (2 August 2020) ‘Why has the UK done so badly on COVID-​19? There are still no simple answers’, The Guardian, https://​www.theguardian.com/​commentisfree/​2020/​aug/​02/​ uk-​covid-​19-​excess-​deaths. Sridhar, D (23 December 2020) ‘With COVID mutating, it’s clearer than ever that we must eliminate this virus’, The Guardian. Tapper, J (30 August 2020) ‘UK care homes still denied Covid test despite Hancock pledge, officials warn’, The Observer, https://​www. theguardian.com/​ s ociety/​ 2 020/​ a ug/​ 2 9/​ u k-​ c are-​ h omes-​ s till-​ denied-​covid-​tests-​despite-​hancock-​pledge-​officials-​warn. Tarrant, A and Hayes, L (20 May 2020) Suspension of Routine Inspections Renders Care Homes Invisible to Scrutiny and Costs Lives, London: LSE British Politics and Policy Blog. Tinsley, B (3 July 2020) Coronavirus in Care Homes: What the Latest ONS Research Tells Us, London: ONS blog. Tinson, A and Clair, A (2020) Better Housing is Crucial for our Health and the COVID-​19 Recovery, London: The Health Foundation. Torjesen, I (17 July 2020) ‘COVID-​19: is the UK government marginalising scientists?’, BMJ 2020;370:m2874.

94 Notes UKHCA (UK Homecare Association) (2012) An Overview of the UK Domiciliary Care Sector, London: UKHCA. Vize, R (21 May 2020) ‘How the erosion of our public health system hobbled England’s COVID-​19 response’, BMJ 2020;369:m1934. Vize, R (11 June 2020) ‘Too slow and fundamentally flawed: why test and trace is a teak and inequitable defence against COVID-​19’, BMJ 2020;369:m2246. Vize, R (2 July 2020) ‘England’s new COVID-​19 monitoring outfit: the Joint Biosecurity Centre’, BMJ 2020;370:m2604. Wain, R and Sleat, D (17 August 2020) Taking the UK’s Testing Strategy to the Next Level, London: Tony Blair Institute for Global Change. Webster, C (1998) The National Health Service:  A Political History, Oxford: Oxford University Press. Weible, C M, Nohrstedt, D, Cairney, P, Carter, D P, Crow, D A, Durnová, A P, et al (2020) ‘COVID-​19 and the policy sciences: initial reactions and perspectives’, Policy Sciences 53: 225–​41. West, A, Czypionka, T, Steffen, M, Ettelt, S, Ghislandi, S and Mateus, C (2020) Reporting COVID-​19 Deaths in Austria, France, Germany, Italy, Portugal and the UK. Social Policy Working Paper 10–​20, London: LSE Department of Social Policy. West, D (15 September 2020) ‘Revealed:  NHS Test and Trace:  top team includes just one public health expert’, Local Government Chronicle, https://​www.lgcplus.com/​services/​health-​and-​care/​ revealed-​top-​leadership-​team-​at-​nhs-​test-​and-​trace-​includes-​just-​ one-​public-​health-​expert-​15-​09-​2020/​. Whately, H (13 October 2020) Evidence to the HoC Health and Social Care and Science and Technology Committees, HC 877, Qs 94 and 109. WHO (World Health Organization) (16 March 2020) Director General’s opening remarks at the media briefing on COVID-​19, Geneva. WHO (10 May 2020) Interim Guidance on Contact Tracing, Geneva: WHO. Wise, J (27 April 2020) ‘COVID-​ 19:  leading statistician slams UK’s reporting of swab tests as “travesty of science”’, BMJ 2020;369:m1664. Wise, J (21 September 2020) ‘COVID-​19: experts divide into two camps of action –​shielding versus blanket policies’, BMJ 2020;370:m3702.