A critical juncture for public services: lessons from COVID-19 Contents

Chapter 2: Insufficient support for prevention and early intervention

14.Rosie Lewis is Deputy Director of the Angelou Centre, a charity working with Black, Asian and Minority Ethnic (BAME) women in the North East of England. She underlined how the pandemic had affected different groups of people in different ways:

“COVID has reflected already inherent inequalities. The socioeconomic inequalities are so important; we have to think about them in parallel to health, because we know health outcomes are linked to diet, exercise, wellbeing, mental health, stress and environmental factors at work. We cannot look at just one strand or the other; we have to look at those multiple conflicting factors.

“Bangladeshi communities are the highest-affected group. That correlates with them also being the most socioeconomically deprived, and it has gone on for a couple of generations. It has equally affected African-Caribbean communities, and again correlates with that.”10

15.This chapter asks why the pandemic has had an unequal impact on different groups. It considers the role that prevention and early intervention can play in health, education and justice services, in order to deliver better outcomes and correct the inequalities that many of our witnesses described.

Poor health prevention and the impact of COVID-19

16.The initial NHS response to the pandemic was widely viewed by witnesses as effective. However, the UK went into the pandemic with poor national health; it has been described as one of the “sickest” countries in Europe.11 We heard that in the years preceding COVID-19, a lack of investment in services that prevent ill-health had resulted in the prevalence of chronic diseases such as obesity and diabetes. This meant that the country lacked resilience when the pandemic hit, which placed additional pressures on the NHS. People with preventable chronic diseases were more likely to be hospitalised than others.

17.But the health impacts of COVID-19 were not felt equally. While avoidable ill-health is widespread, it disproportionately affects poorer people. The chronic diseases which made people more susceptible to COVID-19 are concentrated in deprived areas, where death rates from the virus were highest. Many of these deaths could have been avoided if there had been a greater investment in preventative services.

Initial NHS response to the COVID-19 pandemic

18.Witnesses such as the British Medical Association (BMA) and Josh Hardie, Deputy Director-General of the Confederation of British Industry (CBI), praised how the National Health Service had responded to the immediate health crisis precipitated by COVID-19—for example by constructing Nightingale Hospitals.12

19.Saffron Cordery, Deputy Chief Executive of NHS Providers, the membership organisation for NHS hospital, mental health, community and ambulance services, described how the additional capacity created in the NHS included 30,000 new Intensive Care Unit beds and 30 per cent more ambulance vehicles to deal with the expected surge of patients. There was an increase of 105 per cent in the number of calls received by the NHS, which developed new mental health accident and emergency services and 24-hour mental health lines in order to lessen the burden on acute trusts.13

Underfunding of prevention

20.We heard, however, that support for the NHS during the initial response to the pandemic, while necessary, should not have come at the expense of preventative and public health services. Dr Jeanelle de Gruchy, President of the Association of Directors of Public Health, said that “in the earlier days, a lot of the response was an NHS response, not a public health response to the pandemic”.14

21.Our evidence suggested that the COVID-19 crisis would not have been as acute if preventative services had received sufficient funding and emphasis in the past. Dr De Gruchy reported: “We have had to play catch-up because of the cuts over time to the public health system.”

22.Professor Sir Michael Marmot, Director of the Institute of Health Equity at University College London, described how the historical underfunding of preventative services had had a disproportionate impact on the poorest communities.15

23.Chris Naylor, Senior Fellow at the King’s Fund, a health think tank, made a similar point:

“Some of the place-based inequalities we talk about happen at a very local level. If we … take the example of two neighbouring areas of Clapham in south London that are directly adjacent to each other, the gap in healthy life expectancy for men is 12 years and for women it is seven years.”16

Health inequalities and COVID-19

24.We heard that the historical failure to fund and support prevention had led to adverse outcomes for COVID-19 patients from disadvantaged areas, which had put further pressure on the NHS. For example, a high proportion of those who died from COVID-19 were living with obesity or Type 2 diabetes, or both—preventable conditions which are overrepresented in the UK’s most deprived communities.17 Public Health England reported that:

25.Type 2 diabetes and obesity are particularly prevalent among BAME people, meaning that they are more likely to die from COVID-19 than are the wider population.22 The Richmond Group, a coalition of voluntary organisations working in England’s health and care system, warned that “those communities with higher levels of multimorbidity” were “more vulnerable generally” to the virus and would be “at higher risk in the case of a … future pandemic”.23

26.The pandemic revealed the significant health disparities affecting BAME people. For example, we heard that:

27.Prevention would help reduce health inequalities for BAME people in other ways. Dr Angelo Ercia of the University of Manchester wrote:

“Another important aspect [of] the unequal impact of COVID-19 … on BAMEs is the role of social determinants of health. Social determinants … include economic, environmental and social conditions in which BAMEs live, work, learn, play and socialise. For example, a higher proportion of BAMEs experience poverty and deprivation compared to their White counterparts.”29

28.The Richmond Group called on the Government to look further than the health system if it is to make prevention a priority. It proposed that any strategy that considered greater funding for preventative health and care services should recognise the importance of the provision of transport and employment services in addressing the wider social determinants of physical and mental health. 30

29.Professor Sir Michael Marmot said that the NHS Long-Term Plan,31 NHS England’s 10-year strategy, put insufficient focus on these social determinants:

“The health service accounts for between 10 per cent and 20 per cent of the health of the population, and that could be enhanced because the healthcare system could be doing more to address the conditions in which people live … ‘Why treat people and send them back to the conditions that made them sick?’ The COVID-19 pandemic has exposed that to a much greater degree.”32

Policy responses

30.We heard how public services could work together successfully to deliver preventative strategies. Greater Manchester Combined Authority (GMCA) had put in place or accelerated several such strategies during the COVID-19 pandemic. An anti-smoking programme aimed at rough sleepers continued with modifications to ensure social distancing, and moved services online. The programme built on opportunities to “engage at scale with rough sleepers as part of humanitarian support efforts”. Its aim was to help smokers to quit, “given emergent evidence of a link between smoking and more severe COVID-19 illness and outcomes for smokers”.

31.The GMCA argued: “As we move into a recovery phase, these strategies will remain of significant importance, particularly in mitigating the impacts of a ‘second wave’ of the disease and protecting the city region’s health infrastructure.”33

32.While Dr Jeanelle de Gruchy recognised that services would need to respond to people’s immediate needs, she suggested that preventative and early intervention services would be central to reducing inequalities in the longer term. Other witnesses called on the Government to set out a comprehensive response to the 2019 green paper Advancing our health: prevention in the 2020s34 that would take the effects of the pandemic into account.35 They proposed that the response should reflect the findings of Health equity in England: the Marmot review 10 years on, a major recent review of health inequalities.36

33.In its 2019 general election manifesto, the Government promised to “invest in preventing disease as well as curing it”. It planned to achieve this aim by dealing with the “underlying causes of increases in NHS demand, for example via a long-term strategy for empowering people with lifestyle-related conditions such as obesity to live healthier lives, as well as tackling childhood obesity, heart disease and diabetes”. The aim of this approach is encapsulated by the Government’s commitment “to extend healthy life expectancy by five years by 2035, and to narrow the gap between the richest and poorest”.37 The Richmond Group told us that the Government shift away from the prioritisation of acute services towards greater funding for services that focus on obesity, smoking and alcohol consumption.38

34.On 18 August 2020, the Government announced that it planned to replace Public Health England with a National Institute for Health Protection (NIHP).39 The NIHP will be modelled, in part, on Germany’s national public health agency, the Robert Koch Institute (RKI). We heard from Rudolf Henke, Member of the German Bundestag and COVID-19 lead for its Health Committee, that the RKI works closely with local public health networks to deliver a preventative health strategy and strengthen community resilience when health crises arise (see Box 1).40

Box 1: The German public health system

41 42 43

Rudolf Henke, COVID-19 lead for the Bundestag Health Committee, described the public health system in Germany. He said that there were 375 local health offices, or Gesundheitszentrum, which “take their own decisions”.41

John Kampfner, an author and journalist who is an expert on German public policy, outlined the health offices’ role in responding to the pandemic:

“They were there to protect public health in case of a pandemic such as one caused by water treatment problems, the possibility of swine flu, this or that. … They had these 375 offices that were underfunded, that were not really doing things, but they were there. They had an infrastructure there.

“What was remarkable in the early period of COVID was that they then sprang into action. People were seconded from across the public sector, from across the municipalities: people who worked in forestry departments, in museums or at swimming pools; traffic wardens; anybody who was doing work that was not really needed at the time.”42

For Kampfner, the system “speaks to a country that thinks ahead on the basis of what possible crises might befall it”. He suggested that the UK should adopt a similar approach, by prioritising “long-term planning and provision for future crises rather than salami-slicing. Now, that is not an exhortation for a spending free-for-all, but it is about building slack into any health and social care system on the basis of a rainy day principle, which we have not done for reasons of fiscal prudence but which has come back to bite us.”43

35.It is unclear whether the NIHP will play the same role in supporting preventative services as its predecessor organisation.44 The Government has announced the formation of an advisory group of public health stakeholders who will make recommendations on the future of Public Health England’s preventative role.45

36.Preventable long-term diseases disproportionately affect the UK’s poorest communities. People who are obese, who smoke, who are diabetic and who live in unhealthy social, economic and physical environments are at higher risk of dying from COVID-19.

37.An approach to public health that focused on preventing health inequalities over the long term would pay dividends by increasing the resilience of communities and reducing pressures on the NHS when a crisis occurs. If such an approach had been adopted before the pandemic, it would have reduced the number of deaths resulting from COVID-19.

38.The Government’s commitment in its 2019 general election manifesto to extend healthy life expectancy by five years by 2035—and to narrow the gap between the richest and poorest—is welcome. It should now publish its strategy to achieve this manifesto commitment and its response to the green paper Advancing our health: prevention in the 2020s. Both documents should set out how central Government will work in active partnership with individuals, communities, local government, the NHS, businesses and charities to design and deliver preventative services to improve the health of the poorest communities.

39.The Government should confirm as soon as possible how preventative services will be delivered, either through the new National Institute for Health Protection or other agencies. It should also confirm how the National Institute for Health Protection’s relationship with and accountability to the Department for Health and Social Care will differ from that of its predecessor, Public Health England.

Prevention and the criminal justice system

40.People who interact with the police and justice services are often vulnerable; they might have underlying issues of trauma, addiction and mental ill-health. We heard how the number of people taken into custody had not significantly reduced since the lockdown. Rick Muir, Director of The Police Foundation, a think tank, called on the police to use the pandemic as an opportunity to explore a “trauma-informed” preventative approach.46 This would involve training police officers to recognise where offences might have been influenced by the complex needs of the people with whom they were interacting. Police services could then divert individuals to appropriate community-based, harm reduction interventions and help people access a range of services to prevent re-offending.47

41.Revolving Doors Agency, a charity working with people who come into contact with the criminal justice system, also argued that the wider public service system needed to take a preventative approach when dealing with those with complex needs. It suggested:

“Too often the criminal justice system ends up being a ‘service’ of last resort that ends up trying to support people with a range of mental and physical health issues, substance misuse, homelessness, poverty and assorted childhood abuse and trauma. That service is ill-equipped to manage these issues effectively.”

42.Instead the organisation recommended greater cooperation between the justice system and preventative services. This would include “rolling out alternatives to custody that focus on treatment and better services that focus on rehabilitation and preparation for release from prison”.48 Collective Voice, an alliance of drug and alcohol treatment charities, wrote that “even before the crisis there were serious issues” with the integration of the prison system and preventative addiction services, which “impeded continuity of care from prisons to community treatment”.49

43.Revolving Doors therefore advocated diverting people into relevant services. It pointed to the NHS Health and Justice Liaison and Diversion Service as an example of an effective preventative service that “should be embedded into local services to spot need before it reaches crisis point”.50

44.We recommend that the Home Office and Ministry of Justice draw up joint guidance on how the police, the prison system and National Probation Service should work with homelessness, mental health and addiction services to support people whose complex needs may have deteriorated during the pandemic. It should also outline the level of resource that the police and justice system should invest in preventative services

Early intervention in education

45.Early intervention can provide valuable support for disadvantaged pupils.51 The Early Intervention Foundation, an organisation which supports early intervention to improve outcomes for disadvantaged children, set out how cuts to local authority budgets over the last decade had affected local authorities’ ability to provide early intervention services. “Most prevention expenditure is non-statutory and therefore had been de-prioritised to ensure statutory duties were met,” it wrote. It called for “resourcing for children’s services” to be at a “sufficient level to enable meaningful investment in early help and targeted services in addition to statutory social care”.52

46.The Children’s Commissioner Office (CCO) told us that disadvantaged children were at a higher risk of school exclusion. It stated: “The Department for Education has invested millions of pounds in looking at different responses to children who have been permanently excluded;” this money would be better spent on preventative services “to intervene before a child reaches the point of exclusion”.53

47.The CCO argued that this approach would also improve outcomes for disadvantaged children. Its research had found that:

48.School attendance plays an important role in early intervention for vulnerable children because education is central to determining children’s opportunities in later life. Missing school can affect vulnerable children more than others. Research suggests that children from disadvantaged backgrounds fall behind their peers during the regular six-week summer break.55

49.Only 10 per cent of children defined by the Government as vulnerable attended school or early years education during the first lockdown.56 The Early Intervention Foundation highlighted the education attainment gap that affects disadvantaged children and warned of an increased risk that such children would fall further behind due to school closures during that lockdown. It argued that to close the gap, support should be targeted at the “local level for the children who are particularly vulnerable to a sustained impact … on their cognitive and social and emotional development”.57

50.There is a serious risk that disadvantaged children will fall further behind as a result of school closures during the pandemic. The Government should set out how it will support early intervention in education services to close the attainment gap, reduce exclusions and ensure that disadvantaged children’s education will not suffer adverse long-term effects from the first lockdown. The Government should consult with Ofsted and the Children’s Commissioner on how to hold schools to account and measure progress made in supporting disadvantaged children to catch up.

51.Successive governments have failed to invest sufficiently in a preventative approach to health, education, justice and other public services. Investing in future potential can be difficult for governments due to a political cycle that prioritises immediate returns over long-term benefits to future generations; cost over social value; and the measurement of increased outputs over improved outcomes.

52.The Government should recognise that investing in prevention and early intervention can reduce the pressures placed on the NHS and the justice system, and that supporting children to avoid poor life outcomes brings financial savings and economic benefits. A future inquiry might investigate further a preventative approach to public services.

10 Q 63

11 Gunther Deuschl et al, ‘The burden of neurological diseases in Europe: an analysis for the Global Burden of Disease Study 2017’, The Lancet, vol 5, (October 2020): https://www.thelancet.com/action/showPdf?pii=S2468–2667%2820%2930190-0 [accessed 7 November 2020] and Richard Horton, ‘Alarming new data shows the UK was the “sick man” of Europe even before COVID’, The Guardian (18 October 2020): https://www.theguardian.com/commentisfree/2020/oct/18/alarming-data-britain-sick-man-europe-before-covid?CMP=Share_iOSApp_Other [accessed 7 November 2020]

12 Q 51, Q 96, written evidence from NHS Providers (PSR0005), British Medical Association (BMA) (PSR0071) and Claire Kennedy and Simon Morioka, PPL (PSR0110)

13 Q 19

14 Q 35

15 Q 66

16 Ibid.

17 Written evidence from the Richmond Group (PSR0029)

18 Public Health England, Disparities in the risk and outcomes of COVID-19 (August 2020), p 7: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/908434/Disparities_in_the_risk_and_outcomes_of_COVID_August_2020_update.pdf [accessed 7 November 2020]

19 Ibid., p 63

20 Public Health England, Excess weight and COVID-19: insights from new evidence (July 2020), p 26: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/907966/PHE_insight_Excess_weight_and_COVID-19__FINAL.pdf [accessed 7 November 2020]

21 Ibid., p 21

22 Written evidence from Dr A Ercia (PSR0003)

23 Written evidence from the Richmond Group (PSR0029)

24 Ibid.

25 Written evidence from Dr A Ercia (PSR0003)

26 Ibid.

27 Written evidence from Our NHS, our concern (PSR0035)

28 Written evidence from the Muslim Council of Britain (PSR0108)

29 Written evidence from Dr A Ercia (PSR0003). Shortly before this report was published, the Office for National Statistics published a report which argued: “Ethnic differences in mortality involving COVID-19 are most strongly associated with demographic and socio-economic factors, such as place of residence and occupational exposures, and cannot be explained by pre-existing health conditions using hospital data or self-reported health status.” Office for National Statistics, Updating ethnic contrasts involving the coronavirus (COVID-19), England and Wales: deaths occurring 2 March to 28 July 2020 (16 October 2020): https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/updatingethniccontrastsindeathsinvolvingthecoronaviruscovid19englandandwales/deathsoccurring2marchto28july2020 [accessed 23 October 2020]. The ONS report appeared too late in our inquiry for our witnesses to comment; however its findings would appear to strengthen witnesses’ arguments that the social determinants of health must be taken into account when designing preventative strategies.

30 Written evidence from the Richmond Group (PSR0029). See also Q 67 (James Bullion).

31 NHS, ‘The Long-Term Plan’, (January 2019): https://www.longtermplan.nhs.uk [accessed 20 October 2020]

32 Q 67 (Professor Sir Michael Marmot and Chris Naylor)

33 Written evidence from Greater Manchester Combined Authority (PSR0017)

34 Cabinet Office and Department of Health and Social Care, Advancing our health; prevention in the 2020s—consultation document (22 July 2019): https://www.gov.uk/government/consultations/advancing-our-health-prevention-in-the-2020s [accessed 20 October 2020]

35 Written evidence from the Richmond Group (PSR0029), Action on Smoking and Health (ASH) (PSR0065) and the Association of Directors of Public Health (ADPH) (PSR0069)

36 Q 8, Q 43, written evidence from Association of Directors of Public Health (ADPH) (PSR0069); Professor Sir Michael Marmot et al, The Marmot Review 10 years on, The Institute of Health Equity (February 2020): https://www.health.org.uk/publications/reports/the-marmot-review-10-years-on [accessed 23 October 2020]

37 Conservative Party, Conservative Manifesto 2019 (November 2019): https://assets-global.website-files.com/5da42e2cae7ebd3f8bde353c/5dda924905da587992a064ba_Conservative%202019%20Manifesto.pdf [accessed 20 October 2020]

38 Written evidence from the Richmond Group (PSR0029)

39 Department of Health and Social Care, ‘Government creates new National Institute for Health Protection’ (18 August 2020): https://www.gov.uk/government/news/government-creates-new-national-institute-for-health-protection [accessed 20 October 2020]

40 Q 157

41 Ibid.

42 Ibid.

43 Q 161

44 Department of Health and Social Care, ‘Government creates new National Institute for Health Protection’ (18 August 2020): https://www.gov.uk/government/news/government-creates-new-national-institute-for-health-protection [accessed 20 October 2020]

45 Department of Health and Social Care, The future of public health : the National Institute for Health Protection and other public health functions (15 September 2020): https://www.gov.uk/government/publications/the-future-of-public-health-the-nihp-and-other-public-health-functions/the-future-of-public-health-the-national-institute-for-health-protection-and-other-public-health-functions#the-future-of-health-improvement-prevention-and-wider-phe-functions [accessed 20 October 2020]

46 See Q 75.

47 Elsa Corry-Roake, ‘COVID-19: The role of policing in recovery’, Revolving Doors (17 April 2020): http://www.revolving-doors.org.uk/blog/covid-19-role-policing-recovery [accessed 12 November 2020]. See written evidence from Clinks (PSR0053) on the criminal justice response to COVID-19.

48 Written evidence from Revolving Doors (PSR0090)

49 Written evidence from Collective Voice (PSR0050)

50 Written evidence from Revolving Doors (PSR0090)

51 A pupil is classed by the Department for Education as disadvantaged if they have been eligible for free school meals within the five years before sitting GCSE exams, or if they have been in care or adopted from care. See: Children’s Commissioner, Briefing: Tackling the disadvantage gap during the COVID-19 crisis (April 2020): https://www.childrenscommissioner.gov.uk/wp-content/uploads/2020/04/cco-tackling-the-disadvantage-gap-during-the-covid-19-crisis.pdf [accessed 10 November 2020]

52 Written evidence from the Early Intervention Foundation (PSR0020)

53 Written evidence from the Children’s Commissioner’s Office (CCO) (PSR0106)

54 Ibid.

55 Children’s Commissioner, Tackling the disadvantage gap during the COVID 19 crisis (April 2020): https://www.childrenscommissioner.gov.uk/wp-content/uploads/2020/04/cco-tackling-the-disadvantage-gap-during-the-covid-19-crisis.pdf [accessed 20 October 2020]

56 Department for Education, Coronavirus (COVID-19) attendance in educational and early years settings in England (24 April 2020): https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/881662/COVID19_attendance_in_education_settings_240420.pdf [accessed 12 November 2020]

57 Written evidence from Early Intervention Foundation (PSR0020). See also Equality and Human Rights Commission (EHRC), How coronavirus has affected equality and human rights (October 2020), p 24: https://www.equalityhumanrights.com/sites/default/files/equality_and_human_rights_commission_how_coronavirus_has_affected_equality_and_human_rights_2020.pdf [accessed 23 October 2020]

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