Written evidence submitted by The Nuffield Trust (CLL0087)

Overview The experience of coronavirus over the last nine months has imposed an almost unprecedented stress test on the NHS and the UK’s broader abilities to protect the health of its citizens. This submission pulls together all the lessons we believe must be learnt for any future comparable disease outbreak, for other health emergencies and indeed for the smooth running of these vital services in normal times. It draws on both our research and analysis, and our tracking of data and research produced by other bodies, Government and the NHS.

Key points

 Social care was overlooked at the start of the crisis with disastrous results despite warnings from preparatory exercises that it would face serious strain. The sector needs both a higher priority both in future emergencies and a wide-ranging reform programme which addresses its severe problems in access, coverage, and financial sustainability.  The NHS entered the pandemic in a more fragile state than some other countries’ healthcare systems, running near the limit of bed capacity and with serious staffing shortages. This long term lack of a buffer in resources means coping with and recovering from shocks is more difficult.  There was disagreement about which of the bodies leading on public health was actually responsible for key tasks. At times they did not operate in a joined up manner, within the centre or in relations with local services.  The Test and Trace initiative shows examples of serious optimism bias and poor articulation of goals and priorities, both of which are well known issues in the UK health sector.  Clarity of communication is vital and has a clear effect on public behaviour. The deterrent effect of early messaging on patients seeking healthcare for non-Covid conditions was an error, as is now widely recognised. Messaging later in the pandemic suffered from a lack of clarity as restrictions grew more complex, clearly demonstrated in surveys.  Data and forecasts about the progression of the virus, Test and Trace, and other areas of the response, has often not been published or has been published with a lack of clarity about what it represents. This makes it difficult to assess some of the most expensive healthcare initiatives ever undertaken in the UK. It may have contributed to trust in government and official communications being below that of some other countries.  A strategy suited to pandemic flu, and not a new coronavirus, was followed to some extent well into the crisis. Greater flexibility and responsiveness is important.

1. The UK’s prior preparedness for a pandemic 1.1. Readiness to protect public health

The UK’s health protection efforts in the first wave of Covid-19 did not perform as well as those of several comparable countries. In hindsight, there are several lessons about how to plan for any comparable situation in future.

1.1.1. Having a strategy that reflects what is known

The Government and arms-length bodies such as PHE based their initial response on the 2014 Pandemic Influenza Response plan1 and National Incident Emergency Response Plan. Neither was

1 fully suited to Covid-19 which had no known effective antivirals, and a higher mortality rate more biased to older age groups. This may have been linked to limited initial efforts to contain the virus through steps like travel controls and widespread testing.

It is unclear whether Government had heeded lessons identified in Exercise Cygnus, a pandemic flu response test in 2016. This highlighted the exposure of social care and the lack of data available, and called for work on better understanding the public response. However, Exercise Cygnus again focused on lessons relevant to pandemic flu, assuming the disease should be allowed to spread widely and not anticipating care homes as centres of infection. 2 Other internal reports of major incidents such as Zika and MERS also existed: it is unclear whether lessons were learnt from these.

1.1.2. Clarity of roles

We understand PHE believed that it had never been given the task of expanding testing capacity, only identifying and pioneering a test. Other parts of Government, and NHS England, however, expected them to lead on this. This may have contributed to a remarkable failure, compared to the UK’s peers, to dramatically increase testing during March and early April by drawing on NHS and private laboratories.

There were similar tensions over guidance for personal protective equipment for NHS staff. NHS England and the DHSC were responsible for providing equipment and often faced shortages: PHE for issuing guidance saying what was required. This guidance was often highly contentious and frequently revised.

1.1.3. Information sharing and internal processes

PHE created incident cells to deal with aspects of the crisis. These were at times poorly updated and coordinated, unevenly linked into central Government and SAGE, and occasionally notified of strategic decisions after they had already taken place, for example around the end of contact tracing.

PHE, DHSC and the Cabinet Office relied on secondment internally and from the rest of Government for key positions. This risked exacerbating lack of cohesion, with individuals sometimes using their own contacts instead of processes. There remains a longstanding concern about the UK civil service’s reliance on high turnover, and generalists in highly specialised fields.3

Another serious issue was the cumbersome clearance model for guidance and announcements inherited by PHE. It is not clear that PHE had the capacity or the autonomy to play a leading role communicating with the public.

1.2. Readiness in NHS resources and capacity

Relative to comparable countries, the UK broadly has fewer key staff and less bed capacity.4 The NHS had consistently failed to train and retain sufficient numbers of staff to keep pace with demand, with hospitals in England facing a 10% vacancy rate for nurses.5 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/344695/ PI_Response_Plan_13_Aug.pdf 2 https://www.gov.uk/government/publications/uk-pandemic-preparedness/annex-a-about-exercise-cygnus 3 https://www.instituteforgovernment.org.uk/blog/government-right-want-reduce-civil-service-turnover-how- do-it 4 https://www.nuffieldtrust.org.uk/files/2020-07/resuming-health-services-web.pdf 5 https://www.nuffieldtrust.org.uk/nhs-staffing-tracker/hospital-services/ In spite of efforts to quickly re-enlist inactive personnel, these shortages threatened preparedness and mean staff are now even more stretched as they try to address the additional demand built up during the pandemic.

High acute care beds occupancy rates meant the NHS had less flexibility than other health systems to deal with a surge of demand. While the system acted quickly to bring in more capacity from Nightingale hospitals and the private sector, how much more these can offer both in dealing with Covid-19 and in recovering from its aftermath will be limited by staffing shortages.

The fact that the UK trails most other countries in capital investment means many parts of the NHS are working with outdated buildings, and will be challenged to take steps such as separate Covid and non-Covid wards which could allow expanded activity while maintaining infection control. Many facilities lack single occupancy rooms. Shared areas like corridors, lifts and waiting rooms are often not large enough to separate patients and maintain segregated flows.6

2. NHS Test and Trace From May, the UK moved to a model of trying to contain the virus through testing, tracing, tracking and isolating. Experiences with NHS Test and Trace present a number of important lessons, many which should perhaps be heard across the public sector.

2.1 Need for realism and optimism bias Government intended that NHS Test and Trace service in England would “play a vital role” in controlling the pandemic, and ended the first lockdown under this assumption.7 In reality, even at the time of writing, fewer than one in four recent close contacts were advised to isolate.8 This falls well below the level – at least 80% of contacts isolating – that SAGE suggested in May would be needed for an “effective” system.9 The planning fallacy also extended to the NHS app which was delayed by four months.10

The difficulties which caused these delays are real: other countries have also struggled.11 However, as we have previously pointed out, optimism bias is a very familiar cause of underperformance by the NHS so it is frustrating that this tendency remains.12

2.2. Need to articulate clear aims Policymakers failed to articulate a clear, shared purpose for the test and trace functions.

On testing, while there were stated ambitions in terms of numbers of tests, the purpose of these was not well articulated creating a risk of waste, or resources pulled away from where they were needed. With a clear aim, it might have been easier to prioritise which aspects of performance to focus on. In the event, priorities lurched reactively, in turn, from testing numbers, to testing timeliness, tracing numbers and timeliness of tracing.

6 www.nuffieldtrust.org.uk/files/2020-06/ nhs-returning-to-normal-nigeledwards-nuffield-trust.pdf. 7 https://www.gov.uk/guidance/nhs-test-and-trace-how-it-works 8 https://covid.i-sense.org.uk/ accessed on 26 November 2020 9 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/888807/ S0402_Thirty-second_SAGE_meeting_on_Covid-19_.pdf 10 https://www.ft.com/content/c0c42341-4dda-4c89-9a28-8d14d129c8b2 11 https://www.wsj.com/articles/contact-tracing-the-wests-big-hope-for-suppressing-covid-19-is-in-disarray- 11600337670 12 https://www.nuffieldtrust.org.uk/files/2018-10/learning-from-history-web.pdf Equally, clearer aims may well have uncovered what role other arms of government could have played to support the goals. With this in mind, it is worth noting that some other countries have implemented a broader set of initiatives to support and monitor adherence to self-isolation than is the case here.13 Finally, a clearer articulation of the aims may well have helped align roles, responsibilities, funding and accountability.

2.3. Attention to principles of cost-effectiveness

The costs of NHS test and trace are huge exceeding, for instance, the total costs of general practice.14 They also appear to have been underestimated. For the 2020/21 financial year, costs rose from an estimated £10 billion in the July 2020 financial statement15 to £22 billion by the November 2020 Spending Review.16 While there is no directly comparable cost or performance information for other countries, it appears higher per capita than the relative cost in, for example, Ireland.17

Given the different options for such a system – for example, whether the tracing should be locally- or nationally-led – it is imperative to have a clear breakdown of costs and performance at each of these levels. In this context, it is surprising that the head of the programme was unable to give even broad detail on the costs to the Health Select Committee.18

Key performance information – such as surveys on adherence to self-isolation – has also not been published, leaving the many experts in health service research that we have in this country generally without data on either the costs or the benefits of one of the most important health protection initiatives for decades.

3. Social care 3.1. Social care had insufficient prominence in the response

While the NHS was highly prominent in government communication from the start of the pandemic, an action plan for social care was not published until 15 April 2020. Reports of discussions at SAGE meetings suggest a lack of attention at the highest level of decision making19.

In the rapid clearing of hospital beds in the early stages of the crisis20, there was too little consideration of the fragility and lack of preparedness of the care settings into which people were being discharged.21 22 The belated focus on care homes in policy and financial support was insufficiently sensitive to the crucial role of other types of social care.23 Widening the eligibility of

13 https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3694441 14 https://www.nuffieldtrust.org.uk/resource/chart-of-the-week-the-direct-health-and-care-costs-of-covid-19- so-far 15 https://www.gov.uk/government/publications/a-plan-for-jobs-documents/a-plan-for-jobs-2020 16 https://www.gov.uk/government/publications/spending-review-2020-documents/spending-review-2020 17 https://www.irishtimes.com/news/health/coronavirus-test-and-trace-system-could-cost-700-million-says- hse-chief-paul-reid-1.4367357 18 https://committees.parliament.uk/event/2671/formal-meeting-oral-evidence-session/ 19 https://www.independent.co.uk/news/health/coronavirus-sage-meetings-care-homes-a9541321.html 20 https://www.hsj.co.uk/commissioning/coronavirus-is-a-true-test-of-integration/7027230.article 21 https://www.hsj.co.uk/commissioning/nightingale-social-care-facilities-should-have-been- mandated/7027836.article?mkt_tok=eyJpIjoiWXpNd00ySXdZakF3TURWbCIsInQiOiJTaWIrSzNCeGNVdlhzU3lW SWE1SHpna1RwSEhTZFRqMDA0SE1OQmw2SmFxTVwveWw3SHRzSG1KSjltR3JqUkd6cVBmT1Y1OVBlZWNjQTM 1dEk3eGczeWduQU1sb0lJMWlReVZMd3lUTU1ubW9PN2lJREVBWCtZQWlsN1R1OVFwNFIifQ%3D%3D 22 https://www.theguardian.com/world/2020/may/07/revealed-the-secret-report-that-gave-ministers- warning-of-care-home-coronavirus-crisis 23 E.g. Adult Social Care Infection Fund round 1 https://www.gov.uk/government/publications/adult-social- recipients of the Infection Control Fund24 to care settings beyond care homes in the second round has been a welcome approach.

Where NHS staff were prioritised for testing at the beginning of the pandemic, guidance for symptomatic social care staff until 24th April was simply to self-isolate. This put immense pressure on a system already suffering from severe staff shortages25. From 3rd July, care home staff were set to receive weekly testing26, but domiciliary care staff, like the general population, were still only eligible for free testing if symptomatic27.

3.2. The fragmentation of the social care sector complicated the response

The first wave of Covid-19 highlighted the complexity and fragility of the adult social care system28. While the NHS supply chain kicked in, the fragmented nature of social care left individual providers competing for PPE.29

Many care providers operated on slim margins before the pandemic, and this has been further exacerbated by the high costs of PPE and staff sickness. Furthermore, some sources report occupancy rates to be down by 13%30 in care homes. While funds for infection control have been welcomed, it will be crucial to sustain support and ensure resources reach all types of providers to avoid large-scale failures of care.

3.3. Lack of data is a serious obstacle in an emergency situation

The lack of data in social care31 impeded efforts early in the pandemic to track infection rates and coordinate a response. Deaths in care homes were not included in daily bulletins until late April32 and rates in domiciliary care remain unknown. The Capacity Tracker33 for care homes, mandated during Covid-19, is a welcome addition with potential to provide market intelligence. However, there are concerns about the accuracy of data entered, with implications for planning and prioritisation in central government34.

There is need for better and more consistent data to manage the social care sector even in ordinary times, let alone for any future emergency.

3.3. Long-term reform of social care is well overdue care-infection-control-fund/about-the-adult-social-care-infection-control-fund 24 https://www.gov.uk/government/publications/adult-social-care-infection-control-fund-round-2 25 https://www.nuffieldtrust.org.uk/research/closing-the-gap-key-areas-for-action-on-the-health-and-care- workforce#social-care 26 https://www.gov.uk/government/news/regular-retesting-rolled-out-for-care-home-staff-and-residents 27 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/933134/ Routes_for_Coronavirus_testing_in_adult_social_care_in_England_accessible1.pdf 28 https://www.nuffieldtrust.org.uk/news-item/responding-to-covid-19-the-underlying-complexities-of-the- social-care-provider-market 29 https://www.hsj.co.uk/coronavirus/only-2pc-of-community-providers-can-use-government-ppe- website/7027584.article 30 https://www.laingbuisson.com/wp-content/uploads/2020/07/Covid-story_v5.pdf 31 https://www.statisticsauthority.gov.uk/adult-social-care-statistics-across-great-britain-the-power-and- potential-for-change/ 32 https://analysis.covid19healthsystem.org/index.php/2020/06/08/what-measures-have-been-taken-to- protect-care-homes-during-the-covid-19-crisis/ 33 https://www.necsu.nhs.uk/capacity-tracker/capacity-tracker-about-us/ 34 https://www.laingbuisson.com/wp-content/uploads/2020/07/Covid-story_v5.pdf Far-reaching comprehensive reform to social care is long overdue. Covid-19 laid bare the inadequacies of the system and likely worsened the extent of unmet need for care. The prominence that covid-19 has given the sector in the public consciousness provides a window of opportunity for building support for change.

A collective vision for what a good social care system should look like is needed – one that reflects the diversity and complexity of the sector and is sensitive to changing patterns of demand and need. A sustainable, fair and transparent funding system that pools risk, and a long-term strategy for the workforce, need to underpin any new system35.

4. Messaging and communications 4.1. Clarity and comprehensibility of communications

From March the government faced an unprecedented need for clear public health communication to enact behavioural change across a whole population.

The slogan "Stay home. Protect the NHS. Save lives" has been described as one of the most effective pieces of government communications delivered.36 Its simplicity and ease of recall played into the apparent success of the first lockdown, visible, for example, in road travel levels falling by as much as 73%37 and the number of people in shops and recreational areas falling 78%.38

Since reducing restrictions from May the government has repeatedly changed messaging in line with its changing priorities to boost economic activity. However this change in tack, and a more complex system of restrictions which has changed several times, had a serious impact on clarity. Polling from UCL shows that public understanding fell very sharply, to a point where only 45% of people in England “broadly” understood the rules in July.39 The situation seems to have improved only slightly in subsequent months: around half of people in England said they understood the majority of the rules in October, with just 13% saying they “fully understand” current rules.40

There is a need to be acutely aware of the impact of more complex policies, and less straightforward communications, on the public’s ability to actually take new rules on board.

4.2. Impact on other NHS services

During the first wave our research with the British Heart Foundation shows that messaging around staying at home and protecting the NHS led to widespread concern about being exposed to Covid-19 or putting a burden on services.41 This changed behaviour radically - in March and April, there was a

35 https://www.nuffieldtrust.org.uk/news-item/what-principles-should-underpin-the-funding-system-for- social-care 36 https://www.campaignlive.co.uk/article/single-minded-unavoidable-government-honed- stay-home-message/1682448

37 https://www.theguardian.com/uk-news/2020/apr/03/uk-road-travel-falls-to-1955-levels- as-covid-19-lockdown-takes-hold-coronavirus-traffic

38 https://www.ft.com/content/3a654170-d53c-4efa-862a-027496fb6289

39 https://www.ucl.ac.uk/news/2020/jul/less-half-people-england-understand-current-lockdown-rules 40 https://www.ucl.ac.uk/news/2020/oct/half-public-dont-fully-understand-current-covid-19-lockdown-rules 41 https://www.nuffieldtrust.org.uk/news-item/how-has-covid-19-impacted-on-cardiovascular-services-and- patients and https://www.bhf.org.uk/what-we-do/news-from-the-bhf/news-archive/2020/april/drop-in-heart- attack-patients-amidst-coronavirus-outbreak large drop in the numbers of people presenting in emergency departments with suspected heart attacks.42 There has also been a reduction in hospital admissions for patients with conditions such as heart failure.43

The full extent of the impact of the first wave of the pandemic on non-Covid conditions – whether a result of cancellations or patient behaviour - is starting to emerge. There is evidence of a reduction in diagnosis and treatment for conditions such as cancer and heart failure.44 This includes acute issues requiring emergency care, and disruption to the management of long-term conditions through, for example, missed follow-up appointments, medication reviews or screening. The impact of this is likely to be extensive from a clinical, service and individual perspective.

Ensuring that services for non-Covid-19 conditions continue – and the public feel confident in using them– will be vital in mitigating the ongoing consequences of the pandemic. Steps have already been taken to address this such as the NHS Help Us Help You winter campaign. Given the introduction of further restrictions and lockdown measures, the impact on non-Covid patients must be carefully monitored. Those who miss out on care again must be effectively supported.

4.3. Need for greater clarity for and about vulnerable groups

Individuals considered particularly vulnerable to Covid-19 were advised in March to shield until August.45 Analysis we conducted with the British Heart Foundation showed that for people with cardiovascular disease, there was a lack of clarity about what this meant for their individual situation. This included if they had a particular condition or were taking a specific medication, whether the risk was the same if the condition was well-managed or surgery took place a long time ago, and how this was affected by other comorbidities or another long-term condition. Those not officially required to shield were unclear why, and struggled to speak to someone about their individual situation. Some were also concerned about their ability to work, especially if they were unable to work from home.

People are not currently being advised to shield again, although those over 60 and ‘clinically vulnerable’ have been advised to be especially careful in following restrictions, and “stay at home as much as possible”.46 In this wave, providing clear information and messaging on risk, and where possible providing people with an opportunity to discuss their individual situation with a healthcare professional is important. Equally important is ensuring that people are provided with appropriate practical and emotional support, both for day-to-day activities and to cope with ongoing uncertainty about the impact of the pandemic.

5. Use of data and statistics 5.1. Need to be clearer about what scenarios of risk represent

Following efforts to learn lessons from a flawed attempt by government to articulate the risk of swine flu a decade ago, there was an established principle that government should continually communicate “most probable scenarios” with the public, while also being open about the worst- case scenario.47

42 https://www.ctsu.ox.ac.uk/research/covid-19-acute-coronary-syndromes 43 https://www.bhf.org.uk/what-we-do/policy-and-public-affairs/transforming-healthcare/heart-failure-report 44 https://scienceblog.cancerresearchuk.org/2020/09/11/whats-happened-to-cancer-services-during-the- covid-19-pandemic/ 45 https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk/advice-for-people-at-high-risk/ 46 https://www.gov.uk/government/publications/covid-19-winter-plan 47 https://publications.parliament.uk/pa/cm201011/cmselect/cmsctech/498/49808.htm However, there has been continued confusion over what Government’s stated projections now are. Recently, both the Chair of the UK Statistics Authority and Professor Sir David Spiegelhalter have been critical of the data presented to justify the second national lockdown.48

5.2. Transparency and openness can build public trust

While new sources of data have been published, many crucial figures for tracking the disease and its response are not shared with the public. This presents a risk to public trust.

A failure to provide information on testing strategies or clarify on attribution of deaths, for example, meant the public were left with, at best, a very limited real-time understanding of testing levels, prevalence and the numbers dying from Covid. What is also now evident is that providing more information would have prevented mistakes. For example, clear, well presented data on testing would have surely prevented 15,841 cases not being included in daily case figures and referred to contact tracers.49

It is frustrating that it is more than two decades since the inquiry into bovine spongiform encephalopathy (BSE) the UK highlighted that trust can only be generated by openness50 and, yet, if anything the system is if anything becoming less open.

5.3. Failing to communicate data and statistics well may have even wider consequences

We highlighted early in the pandemic that there is a risk that if authorities fail to provide sufficient information this will create a vacuum to be filled by sensationalist, inaccurate or wholly fake news.51 Surveys by the Winton Centre for Risk and Evidence Communication suggest the British public is more likely to trust coronavirus information from their workplace than from government and official sources.52 It also finds that while trust in government and official sources is not low compared to Italy, Spain or the USA, it is apparently lower than in Germany and Austria, the most trusted countries by their citizens. People in the UK were among the least likely to say they “completely” trusted government information.53

The level of trust the public has in official information is not only a reflection of the effectiveness of government communications but also likely a marker of the contribution this trust may play in determining whether the public responds to social policy interventions. And as we have found out these distancing and isolation policies were not always well adhered to.

Nov 2020

48 https://www.bbc.co.uk/news/health-54831334 49 https://www.bbc.co.uk/news/uk-54422505 50 https://publications.parliament.uk/pa/cm201011/cmselect/cmsctech/498/49808.htm 51 https://www.nuffieldtrust.org.uk/news-item/risky-numbers-the-national-reporting-of-covid-19#public- understanding-and-trust 52 https://medium.com/wintoncentre/coronavirus-and-public-trust-e156c89be5d4 53 https://medium.com/wintoncentre/how-different-countries-are-reacting-to-the-covid-19-risk-and-their- governments-responses-63e35f979111