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2nd Edition April 24th, 2020 Andrew Eccles

Covid-19, social care, and the impact of British exceptionalism

Events, data and argument are in flux as the Covid-19 crisis unfolds. But one theme is emerging with greater clarity; that the policy response of the United Kingdom government has moved from being disconcerting to more deeply troubling. The concerns are fourfold. First the response strategy was fatally weakened by indecision at a crucial stage; the UK had its very own ‘ten days that shook the world’ in March. While politicians leaned on the notion that they were following the scientific advice and it was the scientific advice that was changing (a position uncritically adopted by the BBC), what was changing more significantly was the politics; specifically the political acceptability of the projections of fatalities in the ‘herd immunity’ strategy that the UK government had adopted. Second, the advantage of advance warning was spurned. The World Health Organisation announced on January 30th that Covid-19 represented a global emergency. Italy moved to ‘lockdown’ on March 10th, the same day that saw the start of the Cheltenham festival, attended by 68,000 on March 13th alone, and one week after the UK Prime Minister indicated that, during his recent hospital visit, ‘I shook hands with everybody’. Third, the framing of the crisis has been around war: the Prime Minister announced ‘We must act like any wartime government… this enemy can be deadly’; there is a ‘war cabinet’, while media management of the crisis has been all too evident –  fromthe BBC referring to a hospital ICU as  ‘the frontline in a war’- to the passivity of questioning at press briefings. This is no accident: critical enquiry can more easily be framed as subversive in this climate. The unprecedented length and pointedness of rebuttals by the Department of Health and Social Care to critical journalism are matched by their language; uncharacteristically unscientific, and more evidently political. Fourth, the crisis has revealed the threadbare condition of the UK’s public services. Exercise Cygnus, in October 2016, modelled the UK’s preparedness for a pandemic. The report itself remains classified, but the few public announcements from it point to very serious shortcomings in the ability of health and social care services to cope. The lack of Personal Protection Equipment (PPE) is the most visible sign of disarray, but contingency planning for the provision of ventilators, and systematic access to testing have been woeful by comparable European standards.

These introductory comments are based on sifting through a mass of contemporary commentary; for the sake of brevity of referencing, the New York Times, Financial Times, Guardian and Economist are to the fore; specific data further on will be referenced in full. But the comments are representative, because so few offer vindication of the Government’s strategy to date. I now want to explore what has happened here, with a focus on British exceptionalism; exceptionalism in the language of crisis, in the condition of social care provision, and in the willingness of policy making to pursue a decidedly unconventional approach. 

The surface elements of British exceptionalism are all too visible: in part, the language – Johnson’s rambunctious remark that ‘perhaps you could take it on the chin’ or his father’s comment that Johnson himself ‘almost took one for the team’. The contrast with the gravitas of Merkel or Macron is sharp. But this British exceptionalism has also been evident, more concretely, in social care policy for the past decade, where social care provision – the preponderance of which is for older people – has variously been highlighted as at a ‘tipping point’ (Care Quality Commission, 2017), ‘beyond crisis’ (Collinson, 2016). Data from the Institute for Fiscal Studies (Phillips and Simpson, 2018) indicate a real terms per person funding decrease in adult social care by local authorities, comparing fiscal years 2009-10 with 2017-18, of 9%. Within this overall figure, the thirty areas of highest deprivation in England saw cuts, per person, of 17%. The gravity of the issue is reflected in the title of the recent Parliamentary report Social care funding: time to end a scandal (HL 792: 2019), which offered ample evidence of the scale of the crisis in social care and of the multiple stalled policy initiatives of the past two decades. 

Part of the reason for this crisis in social care – aside from the multiple impacts of ‘austerity’ has been another example of British exceptionalism; that is, the UK – more than anywhere globally – has invested heavily in a speculative policy – going back to 2006 – around the efficacy of care technologies, such as Telecare, as a key solution to the social care crisis. This has prompted a long running, but largely ignored, critique; ‘a hazardous investment’ as Pols and Willems (2011: 6) noted; as indeed it has proved to be, without a social care ‘plan B’ in its wake. Thus a perfect storm of misguided policy and the multiple impacts of ‘austerity’ has left social care in the UK in a particularly exposed place (Eccles, 2020). 

British exceptionalism in policy language also accompanied Johnson’s appointment as Prime Minister. In his victory address he stated:  ‘I am announcing now that we will fix the crisis in social care once and for all’ (Reuters, 2019 para. 10). Given the baseline – the cumulative impact of a decade of austerity, negligible workforce development and an underperforming Telecare strategy, this was an improbable claim. The remark was political theatre, but leaves Government potentially held electorally hostage. 

I now want to consider this remark in light of the most immediate crisis in social care presented by Covid-19: deaths in care homes. Reliable – official – figures have been extraordinarily difficult to obtain and, unlike hospital deaths, appear particularly open to interpretation. Academic analysis from Comas-Herrera et al, as of April 17th 2020, has ‘5 countries for which we have official data (Belgium, Canada, France, Ireland and Norway), and where the number of COVID-related deaths [of the total] in care homes ranges from 49% to 64%’. The, authors, the analysis continues: ‘have considered that it is not possible to draw accurate estimates from the data that is currently in the public domain in the United Kingdom’.

Extrapolating from the total number of hospital deaths in the UK would indicate that the estimate of 7,500 deaths from Covid-19 put forward by the National Care Forum on April 20th and Care England on April 21st is reasonable. Given that there has been no testing of care home residents returning after hospital visits with suspected Covid-19, the wholesale lack of accurate testing for care workers, and that the incubation period for the virus is most commonly five days, these figures can be expected to increase. Given the sheer scale of care homes where the virus is now present – the official figure as of mid-April was 13.5%, but as of April 20th the largest care home networks estimated it to be 50% to 70% – the question might better be reframed as: how greatan increase can we expect?

How have we ended up here? The ‘herd immunity’ strategy – whereby 60-80% of the population would contract the virus – was the Government’s preferred approach, based – as it continues to argue – on the ‘available scientific evidence’. But this was not the only scientific evidence. The World Health Organisation had already sounded the alarm on the nature of the Covid-19 in January, as subsequently had the Lancet, and yet ‘herd immunity’ held sway into March. Two factors, theoretically, underpin the validity of this approach: the cocooning of ‘vulnerable’ citizens, based on a robust testing regime, and the ability to deal with the likely levels of hospitalisation from mass infection. It may be that the ‘scientific evidence’ was not adequately linked to the abject lack of preparation for either factor. In terms of testing, the United Kingdom currently sits at less than 25% of the numbers tested in Italy, Spain and Germany, while its critical care beds, per capita, are, respectively, less than 50%, 70% and 20% of these countries. The absence of these contingencies should, presumably, have made a ‘herd immunity’ approach an outstandingly unacceptable risk.

This brings us back to the policy aspect of British exceptionalism and one that may offer an explanation for such an apparently counter-intuitive strategy; that is, the influence of political advisers at the heart of the Prime Minister’s office. Political advisers are not, of course, unique to Britain, but the success of the Brexit campaign has emboldened their status. The recruitment specification for an advisory team, outlined by Johnson’s Chief Adviser Dominic Cummings, calls for ‘Data scientists and software developers; economists; policy experts; project managers; communication experts […] weirdos and misfits with odd skills’. The Chief Adviser’s own public writing has a consistent thread: a utilitarian approach to problem solving. Whilst social work involves a degree of utilitarian calculus (it forms the basis of most resource allocation) it – crucially – also adheres to codes of ethics where respect for the individual, regardless of circumstance, is of paramount consideration. Social workers understand this tension. Thus the stark utilitarian approach in policy potentially sets it at odds with a key social work value. By proceeding with ‘herd immunity’ without adequate safeguards for ‘vulnerable’ citizens and care workers, allied to the dire state of pandemic readiness already exposed in Exercise Cygnus, there is evidence of a strategy plagued by acts of serious omission. As David Hunter, writing recently in the New England Journal of Medicine (382:e31), notes: ‘Nobody appears to have asked [of the advisers] whether they were working from empirical experience of a highly contagious infectious disease that may be lethal for several percent of older people’. Elsewhere, The German Society for Gerontology and Geriatrics urged its Government, even as the deaths of older people in Germany were at a much lower rate than in the UK, ‘to refrain from measures, the reasons for which are only age based’. Social workers now need to be asking the same questions about the remarkable acts of omission in the UK’s strategy.

Andrew Eccles, Lecturer in Social Work and Social Policy 

References

Eccles (2020) Remote care technologies, older people and the social care crisis in the United Kingdom: a Multiple Streams Approach to understanding the ‘silver bullet’ of telecare policy Ageing & Society doi:10.1017/S0144686X19001776

Hunter, D (2020) Covid-19 and the Stiff Upper Lip — The Pandemic Response in the United Kingdom N Engl J Med 2020; 382:e31 DOI: 10.1056/NEJMp2005755

Parliament. House of Lords. (2019) Economic Affairs Committee. Social care funding: time to end a national scandal. HL392. London, The Stationery office

Pols, J, and Willems, D (2011) Innovation and evaluation: Taming and unleashing telecare technology. Sociology of Health & Illness 33, 3, 484-98.