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    This is the twelfth week of the SHA COVID-19 blog in which we have responded to emerging issues in the pandemic response, from a politics and health perspective. As it stands the UK has performed “like lions led by donkeys”. The NHS and care home staff, plus all the other essential workers in shops, delivering mail and answering phones have been heroic, risking their lives, working long hours and generally going well above and beyond the call of duty, supported by armies of volunteers, delivering food to neighbours, sewing protective clothing, organising suitably distanced entertainment, and generally rising to the occasion. While the Tory Government, led by Johnson “advised” by Cummings, on the other hand, has done very badly in comparison to the governments of some of our European neighbours as well as many countries further away in Asia and Australia/New Zealand.

    Germany and Greece 

    UK government advisers have told us that the UK could not easily be compared with Germany. This was a surprise to most people as Germany, France and the UK have over many years had comparable levels of social and economic development. We have drawn attention in earlier Blogs to Germany’s quick response to lockdown, how it closed its borders and uses test and trace widely with leadership in regional Public Health departments. The latest data shows that Germany, with a population of 83m people, has had 8,500 deaths which is a crude death rate of 10/100,000 population. This compares very favourably to the UK, with a population of 68m, which has had 38,400 deaths with a crude death rate of 58/100,000. The UK was slow to lockdown, has not closed its borders but promises to introduce quarantining in a weeks time and is struggling to introduce test, track and isolate having not developed its local public health capacity.

    So if we don’t compare well to Germany – what about relatively poor Greece which has in recent years been ridden with national debt? Greece locked down in early March, before many cases were identified and ahead of any COVID-19 related deaths. They enforced lockdown vigorously, closed schools and for their population of 11m, they have had 175 deaths at a population crude death rate of 1.6/100,000. They have now been opening up in comparative safety with shops on May 4th and shopping Malls on the 18th May along with Archaeological sites. They are now advertising for summer tourists to come from countries like Germany and Eastern Europe: but from the UK only if we get COVID under control!

    Test, trace and isolate

    The COVID-19 SARS virus has many troubling characteristics, such as its infectivity while people are not showing symptoms and its ability to cause serious systemic illness in adults and particularly older people. However it behaves much like other respiratory viruses; transmission can be blocked by isolating infected people, hand washing, cleaning surfaces and maintaining physical distance from others to prevent droplet/aerosol spread. Facemasks have also been shown to reduce spread from individuals hosting the virus in their nose and throat. These control measures are not ‘modern’ or technically complex – they are basic public health interventions to prevent infectious diseases spreading and they have been shown to work over many years. The government’s belated control measures, such as stay at home, isolate and maintain social distancing, use these infection control measures. They have worked as infection rates have reduced but are in danger of now being undermined.

    The testing process has been problematic, as we have said before, not least in the slow pace of increasing capacity. In order to try and catch up politicians have plucked large round numbers out of the sky, announced them at the Downing Street briefings without any explanation as to why that number and how it all fits together strategically.  They then commission inexperienced private sector consultancies and contractors to try and build a new system of testing de novo, which has also involved Army squaddies to deliver. This has led to serious organisational and quality problems, results taking too long to be useful, and not being fed back to the people who need to know other than the patient, namely GPs, local Public Health England teams and local Directors of Public Health. The big question has always been why did they not invest in the PHE system to scale up and at the same time invest in local NHS laboratories to tool up? Local NHS laboratories could have worked with university research labs and local private sector laboratories in the area to utilise machinery and skilled staff. This new capacity would have built on established NHS and Public Health systems and avoided the confusion and dysfunction. The answer is they decided to save the money! They chose to ignore the findings of Cygnus, which foretold all this, because they were intent on cutting the funding of the NHS to the bone and privatising everything that could be turned into a profit-making enterprise.

    Tracing contacts is a long standing public health function often done from sexual health and other NHS clinics but also in local authority-based Environmental Health departments, which are used to visiting premises where food is handled, and following up outbreaks of food poisoning and infectious diseases. GPs are also used to being part of the infectious disease control procedures with Sentinel Practices, set up to provide early warning of infectious diseases such as meningococcal meningitis and helping to track e.g. influenza incidence in the community. It should NOT have been left until LAST WEEK to start seriously engaging with local public health departments and their local microbiology laboratories and primary care! These local leaders and partners should have, as in Germany, been what the community control of the pandemic was built on. This did not need to wait for SERCO to set up a telephone answering service and train people on you tube videos with a malfunctioning (and in some areas totally non-functioning) IT system.

    Typically the Government made an announcement that Tracing was going to start before arrangements were in place, and local Directors of Public Health were left to make bids for investment after the starting gun had been fired! To this day the data that ‘comes down’ to local level is from the Office of National Statistics (ONS) and Public Health England (PHE) and is on a Local Authority population level. There is no postcode or other data that would help local surveillance and understanding where infected people live or indeed where deaths have already taken place.

    The NHS has data by GP practice and hospital, but again there remain issues about identifying where those individual patients reside, who have been hospitalised or, sadly, died. These data could be analysed but that job has not been undertaken and so Directors of Public Health do not have the “Information Dashboard” (or data visualisation software) they need to be credible local leaders in the testing, tracing and isolating work that needs to be done to monitor the local situation and intervene with control measures. Hopefully we are on the road to getting a more balanced approach with national standards and the introduction of a mobile app to support contact tracing. Why did the government not learn lessons from South Korea, Singapore and Germany where they have been successful?

    Independent SAGE

    SAGE is the Scientific Advisory Group on Emergencies which is supposed to be independent. The SHA is delighted that Sir David King has taken the initiative and established a credible Independent SAGE group. We are pleased to see that SHA President Professor Allyson Pollock has been invited to contribute as well as others known to be supportive of our approach such as Professor Gabrielle Scally a former regional Director of Public Health and public health adviser to Andy Burnham.

    The way that the Chief Medical Officer (CMO) and Chief Scientific Adviser (CSA) have been played into the Downing Street briefings has been problematic and the secrecy behind who was giving the government scientific and public health advice and what specifically that advice was has been exposed as unacceptable. The CSA has belatedly started to share the membership and minutes (suitably redacted of course) but this has only come about because of political pressure. The SHA were not alone in expressing horror that Dominic Cummings (Johnson’s senior special advisor or SPAD) and his sidekick Ben Warner were allowed to attend these meetings and in fact intervene in the debates! It is the job of the CSA to Chair the meetings of SAGE and discuss the advice for Government, and then summarise the advice for the politicians.

    The independent SAGE group has a very different outlook and its aims are to:

    1. Provide clear and transparent reasons for government policy
    2. Remove ambiguity – messages should be very precise about what behaviours are needed, how they should be carried out and in what circumstances.
    3. Develop detailed, personalised advice that can be tailored to specific groups of people and specific situations depending on their risk from infection.
    4. Messaging should emphasise collective action, promoting community cohesion and emphasising a sense of civic duty and a responsibility to protect others.
    5. Avoid any appearance of unfairness or inconsistency. Any easing from lockdown must be clearly communicated and explained to prevent loss of trust in the Government.

    By adopting this SAGE Scientific Pandemic Influenza Group on Behaviour (SPI-B) terms of reference it is hard for government to be critical! In response to recent government decisions on easing lockdown and opening primary schools further the independent SAGE group finds that:

    “We have already been critical of the recent change in the content of the messages from Government, from the clarity of ‘Stay at Home’ to the vagueness of ‘Stay Alert’ (breaching recommendations 1-3). Now there is a clear risk that the gain delivered from the long period of lockdown will be lost as a result of recent events, further breaching recommendations 4 and 5, with the potential that many take less seriously current and further public health messages from the Government.  The recommendation about collective action is especially important in rebuilding trust that has been eroded.  Working in close and respectful partnership with organisations across society including those representing disadvantaged communities and working people will be vital in this process”.

    The new group will also work in a more transparent way by engaging in:

    “an open debate on the topics on the agenda. This evidence session was live streamed on Youtube so the public can see the evidence presented and understand the debate within the scientific community on the most appropriate course of action for the UK government”.

    We will “provide a series of evidence-based recommendations for the UK government based on global best practice”.

    When should a School Reopen?

    The Independent SAGE group have published their report on school reopening after their public hearing:

    “We all found hearing directly from the public incredibly valuable, and have updated our report accordingly by:

    • Developing a risk assessment tool to help schools and families work together to make return as safe as possible
    • Emphasising further the importance of providing a full educational experience for children as soon as possible – including the many children who will not be returning to school soon. This should include educational opportunities for children over the summer holidays, through a combination of online learning, summer camps and open-air activities. Teachers cannot be the primary workforce for such activities and other options such as scout leaders, sport coaches and other roles should be explored.
    • Explaining further the risks of reopening for children, staff and communities based on our modelling and taking into account SAGE modelling released on 22nd May
    • Emphasising the need to support black and minority ethnic (BAME) and disadvantaged communities, whose members are at higher risk of severe illness and death from COVID19.

    The group went on to say that the decisions to reopen schools should be done on a case-by-case basis in partnership with local communities. They pointed out the risks of going too early while recognising the needs of children who remain at home and their right to education.

     

    What is the strategy, the science and where are we going?

    There is increasing concern that the government have lost the plot and are now making sudden decisions based on the Prime Minister’s wish to move the debate on from the appalling behaviour of Dominic Cummings his adviser. We have lost the step-by-step changes undertaken with care, built on the published science and giving time for organisations to adapt and respond to the new requirements. There is a pattern of behaviour – policy announcement incontinence – amongst Ministers asked to attend the Downing Street briefings. Announce on Sunday evening, flanked by advisers, and expect delivery to start on Monday morning!

    The English CMO seems locked into this format, which has disabled him from establishing a rapport with the public. His advice and the advice of other CMOs across the UK is meant to be independent professional advice on public health and health care. Similarly the CSA should be there to report on the SAGE findings and recommendations. There is no reason for them to both attend as sentinels at these briefings. Indeed it would be welcome for the CMO to illustrate his independence to have regular slots with the media to explain some of the findings and the rationale for his recommendations. He should have become a trusted adviser – the Nation’s Doctor – and steer clear of the shady political manoeuvring.

    There is increasing evidence too that SAGE scientists are getting restless that the finger of blame will be pointed at them – to become scapegoats when the blame game truly starts. That is why the secrecy around SAGE should not have been permitted and the role of the CSA should have been clearer – to transmit the advice to the government. The Independent SAGE group has shown how this can be done and how you can also engage the wider professional community and public voice in the discourse. The SHA has always advocated for co-production of health and wellbeing.

    The Prime Minister’s newspaper the Sunday Telegraph has today (31st May) applauded him for not sacking his adviser, admits that mistakes have been made but points the finger of blame quite unfairly on PHE. They declare that the ‘system needs structural change’ after the pandemic. The last period we had such changes were during austerity which cut back the NHS and Local Government and the implementation of the disastrous Andrew Lansley disorganisation.

    Scientists need also to beware as the government casts around to blame someone else and we have long been concerned about the claims that they have been ‘following the science’. Several senior SAGE advisers have had to break ranks to say that in their view the government is relaxing the lockdown in England too early. As we have said repeatedly the UK has not performed well in controlling the pandemic and we have had a terrible death toll. It will be shameful if politicians point to scientists, PHE and their own professional advisers as the cause of the dither and delay at the start and the poor decision making since on ‘game changers’ and digital apps. The chaotic introduction of private consultancies and contractors have hindered a joined up public health partnership response and wasted resources which could have been invested in re-building capacity in local government, PHE and the NHS.

    31.5.2020

    Posted by Jean Hardiman Smith of behalf of the Officers and Vice Chairs of the SHA.

    1 Comment

    This is a collective statement on behalf of SHA bringing together public health evidence and other opinions on a key Covid policy issue.

    The Westminster Government announced on May 10th that:

    “As a result of the huge efforts everyone has made to adhere to strict social distancing measures, the transmission rate of coronavirus has decreased. We therefore anticipate, with further progress, that we may be able, from the week commencing 1 June, to welcome back more children to early years, school, and further education settings. We will only do this provided that the five key tests set by the government justify the changes at the time, including that the rate of infection is decreasing. As a result, we are asking schools, colleges, and childcare providers to plan on this basis, ahead of confirmation that these tests are met”

    We believe that the 5 tests will not be fully met by June 1st and that this announcement was premature. This decision has been taken without transparency about the evidence that has been used on the direct and indirect health impacts. We now see French schools having to reclose.

    We also believe that the Government should have attempted to agree a consensus with Local Authorities and Teaching Unions before announcing a country wide directive around schools in general. The announcement has left schools without clear expectations, without a structure for managing this. We understand that many Local Authorities and schools will now have to seek the skills and information to figure this all out themselves. We believe that this uncertainly will lead to decisions that could adversely affect the health of children, teachers, families, and vulnerable people in their communities. We do not want a repeat of the mistakes in respect of care homes.

    In addition, it breaks the consensus across the four nations in the UK and shows little regard for regional variation or for impacts on inequities in health outcomes for everyone, and educational outcomes for children. Educational opportunities are a powerful determinant of long-term health outcomes.

    The SHA believes that the education sector has been systematically under-resourced and discouraged by this Government since 2010 under austerity, which leaves many schools with insufficient staff, increasing class sizes and inadequate environments that are less able to meet the stringent conditions to enable them to open as safely as possible in such a short timescale.

    We believe that the Government should have considered the following:

    1. How risks would be minimised, and benefits maximised:
      1. In the school environment, such as through safe distancing, handwashing, and other logistic measures to minimise transmission of COVID19, where staffing levels may not be sufficient and school buildings are not always suitable. Children use their bodies to learn.
      2. To children, in particular those in deprived neighbourhoods, in vulnerable groups, children from BAME families, and those with special needs. There is no clarity on alternative arrangements that could have been much more robust to safeguard, and to ensure their nutrition, learning and emotional needs. This should not rely on schools to provide these solutions now
      3. Allowing for the full autonomy of schools and their local authorities within their safeguarding obligations on an area basis
      4. To other groups, such as teachers, communities, and vulnerable groups, and weigh these against the benefits and risks to the wider society
    1. How harm would be minimised, and benefits maximised:
      1. To children who may be missing education which is likely to have a long-term impact on those from more deprived neighbourhoods and those who are less likely to have received equitable support at home
      2. To children who become infected, including asymptomatically and to their immediate household and contacts
      3. To the wider community, especially those that have had a high incidence of COVID19 and remain at high risk of further outbreaks and resurgences. These have disproportionately affected more deprived communities and those with a high proportion of BAME people
    2. How the overall public health response would support this move:
      1. How potential school outbreaks would be identified and managed in the absence of a fully functioning test/ treat/ isolate programme, particularly as some businesses are reopening at the same time.
      2. How schools will be supported by local public health services unless further resources and decision-making powers are decentralised to allow a robust and appropriate and rapid local multi-agency response

    The SHA believes that this decision has been reached without a clear rationale on the benefits and risks, and without demonstrating that the 5 key tests have been met:

    Test one: Making sure the NHS can cope

    Test two: A ‘sustained and consistent’ fall in the daily death rate

    Test three: Rate of infection decreasing to ‘manageable levels’

    Fourth test: Ensuring supply of tests and PPE can meet future demand

    Fifth test: Being confident any adjustments would not risk a second peak that would overwhelm the NHS

    We would add a Sixth: A fully functioning test/ treat/ isolate programme

    The SHA believes that the decision has been reached without sufficient consultation with key stakeholders and before the 5 tests have been fully met. In addition, the National Education Union has set 5 tests specific to educational settings, and we support their belief that in many areas these have not been met.

    We expect a more supportive response from the Dept for Education including investment into online learning and into a revived Sure Start model.

    The SHA believes that schools should be reopened at the right time but that the Government should make the best efforts to ensure that there is a consensus for when this should happen based upon relevant expert input rather than political pressure.  This has clearly not been achieved, as it has been in other countries that have gradually opened schools.

    We encourage Local Authorities and Academy Trusts to follow the example of LAs such as Liverpool, Haringey, North of Tyne, Hartlepool, and Brighton – and devolved governments in Wales, Scotland, and NI – in making it clear that they will not reopen schools until they feel it is safe.

    Sources

    Actions for schools during the coronavirus outbreak updated 18th May. Department of Education for England

    https://www.gov.uk/government/publications/covid-19-school-closures/guidance-for-schools-about-temporarily-closing

    NEU five tests for Government before schools can re-open

    https://neu.org.uk/neu-five-tests-government-schools-can-re-open

    ONS figures reveal 65 COVID-related deaths in education workforce

    https://schoolsweek.co.uk/ons-figures-reveal-65-covid-related-deaths-in-education/

    Which occupations have the highest potential exposure to the coronavirus (COVID-19)? ONS May 11th https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/employmentandemployeetypes/articles/whichoccupationshavethehighestpotentialexposuretothecoronaviruscovid19/2020-05-11

    Coronavirus (COVID-19) related deaths by occupation, England and Wales: deaths registered up to and including 20 April 2020 May 11th https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesofdeath/bulletins/coronaviruscovid19relateddeathsbyoccupationenglandandwales/latest

    https://www.tes.com/news/coronavirus-doctors-back-teachers-fears-over-schools-reopening?fbclid=IwAR2JD0Np1x_lgG49xo1Hig4T9ozNto36vsG09Ue-mvAtMrTvhWVyegtphBE

    Prof John Edmunds

    https://www.theneweuropean.co.uk/top-stories/john-edmunds-tells-lords-decision-to-re-open-schools-is-political-1-6660526?utm_source=Twitter&utm_medium=Social_Icon&utm_campaign=in_article_social_icons

    Prof Devi Shridhar, Professor of Global Public Health, Edinburgh Uni &  Ines Hassan.

    https://www.theguardian.com/commentisfree/2020/may/20/british-schools-science-children-education-testing-tracing

    https://www.newschain.uk/news/young-children-will-still-socially-distance-school-health-chief-says-8334

    Schools re-close in France after 70 new Covid cases following re-opening  6-11yr classes. NB. French schools starting age is 6 not 3.

    https://www.independent.co.uk/news/world/europe/coronavirus-france-school-cases-reopen-lockdown-a9520386.html

    Comparative school age starts

    https://data.worldbank.org/indicator/SE.PRM.AGES

    NB. Denmark is also 6 and easier to manage s/d. long term impacts of formal learning too soon

    https://www.newscientist.com/article/mg22029435-000-too-much-too-young-should-schooling-start-at-age-7/#

    Formal learning in early years linked to criminality in teens

    https://www.res.org.uk/resources-page/the-impact-of-school-starting-age-on-teenage-criminality–evidence-from-denmark-.html

    Posted by Brian Fisher on behalf of the Policy Team.

    Comments Off on SHA statement on reopening schools in England during the COVID19 pandemic

    Vested interest alert – yes I’m claiming that word back – I come from a family of school staff, teachers, TAs, school governors. The dedication and hard work of all school staff, caretakers, cleaners, cooks, governors have shown for the safety, education, well-being, in many instances feeding, their pupils throughout this crisis has been extraordinary.

    I am totally dismayed at any criticism. Staff have the well being and safety of their pupils at their very heart. Their views on the total opening of schools and the views of their representatives have to be totally respected. The issue is complex. In Liverpool, the elected City Mayor has chosen not to open schools on June 1st as a safe-guarding issue as this wonderful city is still reeling from a high rate of infection. Questions are being asked as to why Mayor Joe Anderson has taken this stance when schools in Denmark, led by our sister party, are opening. Joe has never said Liverpool can’t open its schools, he has said when it’s safe to do so and only then. Each local authority has its own characteristics, not only in terms of levels of this dreadful pandemic, but the physical nature and age of its school buildings, levels of deprivation, staffing, the amount of public funding available and not available, the differing needs of its pupils. Country by country comparison is far too simplistic. This is an educational, health and societal issue.

    We all want all our children back in school and we are most worried about our most vulnerable, where home-schooling in a cramped flat with no outdoor space is stretching our children’s educational and physical and mental health well-being. I have family members with differing views – what I do know is that they are taking decisions based on local circumstances and always with the education and health of their pupils and staff foremost in their thinking. What is clear is that our health and education services, so starved of resources in this dangerous and false economy of austerity, especially in cities like Liverpool, have to be funded properly based on demographic need. I sincerely hope this Government remembers that but I fear not. Is it safe to open schools to children other than those of key workers or classed as vulnerable? There will always be risk – the question is how to reduce it. We must now learn from other countries – transmission from children to adults, children returning to schools in Italy presenting with multisystem inflammatory syndrome weeks after exposure.

    The UK did not have community testing, contact tracing and isolation early. Surely the question is are schools safe enough to open? Which means we need information and monitoring at a local level, the amount of new cases locally and rates of transmission. Local data should be driving policy and assuming a date for the entire country is ideologically rather than data driven. We need to get children back into education, but a locally managed data driven approach has to be the only way. Prioritising testing over a date. Listening to our teaching staff and our unions.

    For Liverpool in present circumstances – I’m with Joe.

    Theresa Griffin Labour MEP North West 2014-2020

    Member SHA

    1 Comment