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Late: The word that defines the UK’s Coronavirus pandemic management

Picture the scene. We are in Downing Street and the news media are awaiting another coronavirus press conference. Professor Chris Whitty, the Chief Medical Officer for England is ready. Sir Patrick Vallance the Chief Scientific Advisor is ready. Where is the Prime Minister (PM)? Late again.

I have this vision of our PM frantically scurrying around like the White Rabbit in Alice in Wonderland humming “I’m late I’m late for very important date”. We might all smile at this vision but I’m afraid the analogy of being late is not a laughing matter when it is applied as the major theme for the UK governments management of what I described in a previous blog as the worst public health crisis in my lifetime. I also recall the PM famously using the phrase “A stitch in time saves nine” which is indeed true however in a pandemic being late or not sewing that stitch in time can and has cost thousands of lives.

In the week that has seen the UK pass 100,000 deaths it is right to reflect on the tragic loss of life. The call from government saying this is not the time to analyse why the UK has done so badly is in my view the wrong line to take. The government could learn a thing or two from the UK health care professions who for years have developed themselves as reflective practitioners. Donald Schon (1983) wrote extensively about reflection in terms of the creation of learning organisations who can both reflect in and on action. It is the former that has been sadly lacking in the UKs response to the coronavirus crisis. Reflection needs to be on the table throughout the pandemic and had it been, we may not have repeated the same mistakes. The management of pandemics is well documented in the medical literature. Professor Chris Whitty the Chief Medical Officer for England outlines how to manage a pandemic in this useful lecture at Gresham College.

Indeed it is also important to remind us of the words of Sir Patrick Vallance who when recommending the urgency of action in a pandemic implored that we “go earlier than you think you want to, go a bit harder than you think you want to and go broader than you think you want to in terms of restrictions.” My observation of the UK pandemic response leads me to conclude that we failed to do any of these. However, for this blog let’s focus on timing. Going early in terms of restrictions and other actions can have an enormous beneficial impact.

The last year has been to coin an overstated phrase “unprecedented” with many arguing that any government would have been overwhelmed and struggled to manage the crisis. Is this fair? One can look at other countries who have managed the situation better and as such have had better outcomes. New Zealand, Australia, Korea for example. Others will point to the differences between countries in terms of geography, population, culture, transport, relative poverty, healthcare systems, reporting mechanisms and living conditions which make comparisons inherently complex. 

With the current death toll in the UK so high and continuing to rise, and many scientists telling us that things will inevitably get worse before they get better the question everyone is asking is : What has gone wrong? In this blog I’m going to argue that in large part our problems are based on a lack of urgency in acting. I’m arguing that we have not followed Sir Patrick Vallance’s recommendation and in particular we have been late to act throughout. Below I will set out the evidence for this and propose some tentative reasons as to why this has been the case.

Firstly, despite a pandemic being recognised as the largest threat to any country (it will always be top of any country’s risk register) the UK was slow to recognise the impending crisis and late to recognise the implications of a virus of this nature and how quickly it can spread globally.  History informs us of how quickly Spanish flu spread in 1918. The UK was never going to be immune. Late recognition and poor pandemic preparedness meant we were late to get in place the critical infrastructure required to mount a response. Despite several warnings and meetings of the civil contingencies committee (COBR) the health secretary Matt Hancock was dismissive of the threat playing it down. Indeed, the PM failed to attend several early meetings giving the impression that the UK were not taking this as seriously as they should.

When faced with a looming medical/public health emergency it is important that the scientific advisors are in place early (which they were) and that their advice is acted upon. The evidence clearly points to a slow response to this advice which manifested itself in several critical late decisions early in the pandemic. The UK did not close its borders and implement quarantine measures allowing the virus to seed extensively in all parts of the community. Once community transmission had been established it was too late. It did not have in place a substantive testing regime, largely because we were unprepared. It very quickly became clear when we switched from community testing to testing only those in hospital with Covid symptoms that we lacked critical mass testing capacity and hence spent months trying to catch up. Evidence from previous outbreaks of SARS and MERS demonstrated how important mass testing was in controlling the spread, a position advocated by the World Health Organization (WHO). The UK saw case numbers grow rapidly and was slow to get the important public health messages out. Consequently, hospital admissions increased, and the death toll leapt. We were in serious danger of the NHS becoming overwhelmed with critically ill Covid patients.

Public health, medical and scientific experts suggested through their modelling exercises that the death toll, if we didn’t act quickly, could exceed 500,000; a situation socially and politically unpalatable. Therefore, in the absence of no known treatments and no vaccine we would have to resort to the tried and tested traditional methods for the suppression of a respiratory borne virus. Robust hand hygiene, respiratory/cough etiquette and maintaining social distance to reduce close social interaction. The logical conclusion was that to radically reduce social contacts we needed to lockdown. It is widely acknowledged now that the UK was at least a week late in introducing the first lockdown in March 2020.

In the meantime, the virus was sweeping through vulnerable elderly groups in care homes. We were again late to recognise this threat and late to protect them despite Hancock’s claims of throwing a ring of protection around them. The death toll continued to mount. At this stage both the Health (NHS) and care sectors were under enormous pressure and ill equipped to manage. The greatest worry at that stage was lack of adequate Personal Protective Equipment (PPE). Due to our ill preparedness we were late to provide appropriate PPE to both the NHS and the care home sector, exposing healthcare workers to undue risk. The death toll of healthcare workers in any pandemic is high and we were now starting to see this rise in the UK.

Another major criticism during the earlier months was how slow we were in ramping up testing capacity, tracking, tracing cases and ensuring isolation measures were in place. Indeed, concerns about test, trace and isolation continue today. However, lockdown and other public health measures did reduce the case numbers through the summer but inevitably the virus, which thrives in cold damp conditions started to cause further problems as we approached autumn and winter. Combined with this the UK saw a new variant of the virus emerge in the autumn with greater transmissibility. Cases started to rise again along with the inevitable hospital admissions and deaths. It appeared despite warnings from all scientists and health professionals that a second wave was highly possible we were late to recognise the emergence of a second wave of infections. The signs of which were there in September 2020. This led to a second lockdown in November when the advice from the scientific advisors was to lockdown in mid-October or earlier. This decision was compounded by a complex tiered restrictions arrangement to manage outbreaks locally aimed at the avoidance of unnecessary restrictions. Meanwhile the death toll continued to mount.

Notwithstanding the emergence of a new variant of the virus during the second lockdown everyone’s attention was switched to Christmas. The advice offered from government that restrictions would be relaxed for five days was met with incredulity by health professions who argued that this would simply allow the virus to be spread exponentially through greater household mixing. All the evidence at this stage pointed to household mixing as the primary source of transmission. As the situation worsened following the release of lockdown in early December it became obvious that the Christmas guidance had to change. To no ones surprise the advice was changed at the last-minute meaning everyone would have to rearrange their plans. The late change to the Xmas guidance probably meant more family mixing than would have happened had the advice been robust and communicated to the public earlier. Very quickly after Christmas we saw rapid changes to the tier management despite calls for a further lockdown. Cases rose rapidly, hospital admissions were now worse than in the first wave and scientists called for a lockdown. Consequently, we were late implementing Lockdown 3.

Throughout the pandemic the government has provided detailed guidance on restrictions, care homes, travel arrangements and education. It’s difficult to get this right all the time but the issuing of guidance was at times so late it became difficult to interpret the issues with clarity. Probably one the best examples of this relates to the advice provided to schools. Should they stay open or close? What should the Covid secure measures be? How do you construct bubbles of students to reduce social contact? Covid testing of pupils and staff? examinations and assessment guidance? However, the final straw was surely when schools opened in January after the Christmas break to only be told they had to close the very next day as we moved into Lockdown 3.

In conclusion it is said that to manage a pandemic you need a clear, robust strategic plan. The evidence presented here would suggest a lack of strategic planning with crisis decision making on the hoof. Some have argued that we have a PM who struggles to take the big decisions required, who procrastinates and inevitably is left with Hobson’s choice. If you couple this with a group of key ministers who appear to lack the competence to carry their portfolios we have the recipe for a disaster. The consequence of which means the UK has experienced a terrible outcome across a whole set of health, education and economic indicators.

References
Schon, D. (1983) The reflective practitioner: how professionals think in action Basic Books, New York
Whitty, C. (2018) How to Control an Epidemic https://www.youtube.com/watch?v=rn55z95L1h8

Ho ho homeless: Boris and reasons to be cheerful.

rough sleeper

“Homeless Rough Sleeper” by Deadly Sirius is licensed under CC BY-NC-ND 2.0 

A week has passed since the election and our political parties have had time to reflect on their victory or demise.  With such a huge majority in parliament, we can be certain, whether we agree with it or not, that Brexit will be done in one form or another.  The prime minister at the first meeting of his cabinet, and as if on cue ready for my blog, in front of the cameras repeated the pre-election promise of 40 extra hospitals and 50,000 extra nurses.

Putting aside my cynicism and concern about how we, as a country, are going to grow enough money trees without our foreign agricultural workers after Brexit, I welcome this much needed investment.  I should add here that in the true sense of fairness, pre-election, other parties were likewise offering wonderful trips to fairyland, with riches beyond our wildest dreams.  Trying to out trump each other, they managed to even out trump Trump in their hyperbole.

However, rather appropriately as it turns out, whilst sitting in the waiting room at a general hospital on election day, I read a couple of disturbing articles in the i newspaper.  Pointing to the fact that makeshift shelters are becoming increasingly common in British cities one article quoted statistics from Homeless Link showing that rough sleeping had increased by 165% since 2010 (Spratt, 2019).  Alongside, another article stated that A&E admissions of homeless patients had tripled in the last eight years with 36,000 homeless people attending in the last year (Crew 2019).  Whilst I am always cautious regarding statistics, the juxtaposition makes for some interesting observations.

The first being that the promised investment in the NHS is simply a sticking plaster that attempts to deal with the symptoms of an increasingly unequal society.

The second being that the investment will never be enough because groups in society are becoming increasingly marginalised and impoverished and will therefore become an increasing burden on the NHS.

Logic, let alone the medical profession and others, leads me to conclude that if a person does not have enough to eat and does not have enough warmth then they are likely to become ill both physically and probably mentally.  So, alongside the homeless, we can add a huge swathe of the population that are on the poverty line or below it that need the services of the NHS.  Add to this those that do not have job security, zero-hour contracts being just one example, have massive financial burdens, students another example, and it is little wonder that we have an increasing need for mental health services and another drain on NHS resources.  And then of course there are the ‘bed blockers’, a horrible term as it suggests that somehow, it’s their fault, these are of course the elderly, in need of care but with nowhere to go because the social care system is in crises (As much of the right-wing pre-Brexit rhetoric has espoused, “It’ll be better when all the foreigners that work in the system leave after Brexit”).  It seems to me that if the government are to deal with the crises in the NHS, they would be better to start with investment in tackling the causes, rather than the symptoms*.

Let me turn back to the pre-election promises, the newspaper articles, and another post-election promise by Boris Johnson.

My recollection of the pre-election promises was around Brexit, the NHS, and law and order.  We heard one side saying they were for the people no matter who you were and the other promising one nation politics.  I don’t recall any of them specifically saying they recognised a crisis in this country that needed dealing with urgently, i.e. the homeless and the causes of homelessness or the demise of the social care system.   Some may argue it was implicit in the rhetoric, but I seem to have missed it.

In her article, Spratt (2019:29) quotes a Conservative candidate as saying that ‘nuisance council tenants should be forced to live in tents in a middle of a field’.  Boris Johnson’s one nation politics doesn’t sound very promising, with friends like that, who needs enemies?**

* I have even thought of a slogan: “tough on poverty, tough on the causes of poverty”.  Or maybe not, because we all know how that worked out under New Labour in respect of crime.

** The cynical side of me thinks this was simply a ploy to reduce the number of eligible voters that wouldn’t be voting Conservative but, I guess that depends on whether they were Brexiteers or not.

 

Crew, J. (2019) Homeless A&E admissions triple. i Newspaper, 12 Dec 2019, issue 2824, pg. 29.

Spratt, V. (2019) You Just didn’t see tents in London or in urban areas on this scale. It’s shocking’: Makeshift shelters are becoming increasingly common in British cities. i Newspaper, 12 Dec 2019, issue 2824, pg. 29.

Care Leavers, Criminal Justice and Higher Education

“These children are in our care; we, the state, are their parents- and what are we setting them up for…the dole, the streets, an early grave? I tell you: this shames our country and we will put it right.”

David Cameron MP, Prime Minister October 2015 at the Conservative Party Conference.

Well, I think it would be fair to say that politicians’ minds have not been exercised unduly over the fate of care leavers since David Cameron made the above promise in 2015. I worked with children in care and care leavers involved in the youth justice system for over thirty years and although his analysis of the outcomes for care leavers was simplistic and crude, tragically Cameron’s statement rings true for many of those leaving care.

With regard to the criminal justice system, Lord Laming’s independent review “In Care, Out of Trouble” http://www.prisonreformtrust.org.uk/Portals/0/Documents/In%20care%20out%20of%20trouble%20summary.pdf, notes that there is no reliable data on the numbers of looked after children in custody. However, based on data from a number of sources, the review came to the conclusion that around 400 looked after children are in custody at any one time. The total number of children in custody for July 2019 is 817. So, slightly less than half of those children in custody are looked after children according to the best estimates available, drawn from different sources. http://youthjusticeboard.newsweaver.co.uk/yots2/1g2x6m3h9q315chudc9elc?email=trueYJBulletin

Moving the spotlight, a huge 40% of care leavers are not engaged in Education, Training or Employment and only 6% of care leavers gain entry to university https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/464756/SFR34_2015_Text.pdf . This at a time when around 50% of children now have access to Higher Education and the opportunities that this can provide. Also, 20% of young people who are homeless have previously been in care.

Naturally, we have to be careful to provide a level of balance to the above rather desperate and shocking figures. Lord Laming’s review found that 94% of children in care did not get in trouble with the law. However, children in care are six times more likely to be cautioned, or convicted of an offence than children in the wider population. Furthermore, children in care who come to police attention are more likely to be prosecuted and convicted than cautioned when compared to the wider child population.

So, what has happened since 2015 when David Cameron declared his intention to “put it right”? In truth, there have been some steps forward and these need to be celebrated and built upon. The Care Leaver Covenant, a promise made by private, public or voluntary organisations to provide support for care leavers aged 16-25 has meant the availability of employment opportunities for young care leavers in the Civil Service, local authorities and a range of private sector organisations. Closer to home, here at the University of Northampton, we have launched a new package of support for care leavers who want to study with us. The package offers the possibility, from 2020, of a fully funded place in our Halls of Residence for the first academic year, a contract which extends their accommodation lease to include the summer vacation. A block for many care leavers entering Higher Education is the very real issue of where to live at the end of the academic year, so this tries to address this issue. Another block experienced is financial hardship; the offer provides a non-means tested financial award of up to £1,500 per year to help with course and living costs, and this alongside the local authority’s statutory responsibility to support access to higher education may also help. We also have a designated member of support staff to provide advice and guidance. All these demonstrate our commitment to widening participation and encouraging ambition.

Of course, this is only part of the picture. Arguably, our engagement with young people in care needs to start shortly after their transition to secondary school. The wider social structures which perpetuate disadvantage and poverty will continue to challenge those who are children in care and leaving care. The “adverse childhood experiences” – a rather unedifying term for physical, sexual, and emotional abuse perpetrated by carers or parents-will still have an impact for this group and potentially impair their ability or commitment to study.

If however, I learnt anything from my years working with children in care and children leaving care, it is that you should not underestimate their ability to overcome the obstacles placed in their way. With the right support and a child centred approach, education can provide the right framework for opportunities. Victor Hugo famously said that if you open a school door, you close a prison. Let’s kick open the door of Higher Education a little wider and increase the life chances of these children in OUR care.

As a footnote, I should say that my mum was in care from the age of four until she was fifteen when she was adopted. I would therefore be happy to acknowledge that this has some influence on my perspective and my interest in this group of young people.

Dave Palmer Lecturer in Criminal Justice Services

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