Rescheduled, delayed, cancelled: the knock on impact of the pandemic on routine health care

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Recently published figures show that waiting times for some non-urgent care across the UK have risen dramatically with the pandemic squeezing the already stretched resources of the NHS. Figures from Public Health Scotland, published in June 2021 found that when comparing to pre-pandemic levels, the waiting list size is 30.3% higher than the 12-month average prior to the onset of the pandemic (Mar 19 – Feb 20), while in England figures published in August 2021 showed NHS waiting lists in England reached a “record” 5.45 million people.

In addition to strains on acute NHS care services on the frontline, there are warnings about the additional public health impacts of delays to preventative healthcare measures like screening and routine medical care as well as concerns about a surge in demand when people who have delayed seeking non-urgent diagnosis and treatment return to hospitals.

At the outbreak of the pandemic many hospitals took the decision to delay or stop entirely routine pre-planned surgeries and preventative screening and diagnostics. Some even suspended treatment for more urgent care like cancer treatment on a short-term basis. While many of these services have resumed since the beginning of the pandemic, albeit with a backlog of patients now to be seen, significant strain on the NHS as we come into the winter months because of coronavirus is still anticipated.

In many areas this has led to a backlog of care, both for those patients already in the system awaiting routine surgeries, as well as those who are yet to be diagnosed but would have been through preventative screening programmes run by the NHS.

Delays in healthcare and routine screening

Even before the coronavirus pandemic took hold, many NHS hospital trusts were under criticism because of the significant length of waiting times for people who required routine operations. Doctors across the UK are now warning that these delays could be increased further unless the NHS receives additional support to increase capacity across all areas of care not just urgent care in the coming months.

It has been suggested that delays in diagnosis and routine treatments could lead to an increased number of hospitalisations further down the line, requiring higher levels of care, longer lengths of stay, and increased hospital readmissions.

And despite the recent announcement of a new arrangement for health and care funding, commentators are quick to stress that the £1.4bn the new funding programme is expected to generate may not be enough to suitable address all of the concerns across health and social care, which they highlight has been chronically underfunded for a significant number of years, even before the pandemic exposed the frailty of parts of the system.

A reluctance to visit hospitals and use primary care services

Research from the Health Foundation found that there had been a significant reduction in the number of GP consultations since the start of the pandemic which has led to concerns about the care of non-covid patients, patients with long term health conditions and also the potential for delayed diagnosis. Primary care consultations also reduced and have remained low consistently since the beginning of lockdown.

Figures have also shown a reduction in the number of referrals, medical tests, new prescriptions and immunisations. While some of these reductions are the result of advice to delay routine referrals to free up capacity for hospitals to deal with the potentially large number of cases of Covid-19, routine referrals have still not recovered to pre-lockdown levels.

These figures, and other contributions from commentators and researchers suggest that government messages to ‘protect the NHS’ may have had the unintended consequence of discouraging people from seeking urgent medical care when it was required for fear of using services unnecessarily or for fear of contracting the virus when attending hospital or primary care settings.

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A potential future crisis for the NHS

Commentators are now warning that the treatment backlog which has been caused by the coronavirus pandemic, in addition to diagnostic delays and screening programmes, may lead to a future crisis of care or significant delays in care for people waiting to receive more routine treatment.

Delays in care have not only been reported in cases of physical health. There have also been significant delays in referrals for those seeking treatment for a mental health condition, an area of the NHS which was already facing significant delays in referral and transfer of care even before the pandemic. Research suggests that incidence of mental illness during the coronavirus pandemic increased. However, the numbers of people accessing services and being referred for treatment have not increased proportionate to this. People with mental health conditions may have been unable to access appropriate support through primary care pathways, which could potentially impact on their long-term health and care.

Finally, concerns have been raised about the wider social determinants of health such as employment and poverty. Public Health England (PHE) published a monitoring tool which looks at the wider impacts of the Covid-19 pandemic on population health, and it is likely that the knock-on impact of the virus could have far reaching consequences for public health in the future as the health implications of lockdown, lack of social interaction and rising unemployment could be significant. 

Where next?

While the NHS delivered some elective treatment during the course of the pandemic, the pressure of caring for large numbers of patients, many of whom were seriously unwell with COVID-19 has led to longer delays for the growing number of patients on waiting lists. Figures also show that access to elective treatment fell further in the most deprived areas of England during 2020. Tackling the backlog, and working towards the “levelling up” agenda to reduce health inequalities, both of which have been significantly exacerbated by the pandemic will be a key component of the work in health and social care over the coming months and years.


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How have health librarians been responding to the Covid-19 pandemic?

The impact of the coronavirus pandemic over the past 18 months has highlighted the vital role of information and knowledge services in supporting health and social care, public health, and medicine.

Last month’s Annual CILIPS Conference included a presentation about #HealthLibrariansAddValue – a joint advocacy campaign between CILIPS and NHS Education for Scotland (NES) which aims to showcase the skills of health librarians and demonstrate the crucial role of health libraries.

Library and knowledge services in the health sector have faced increased pressures and a multitude of challenges throughout the pandemic as they have continued to develop and deliver vital services and resources to colleagues under unprecedented restrictions and changed working practices. With the demand for trustworthy and reliable health information higher than ever, it is clear that well-resourced, coordinated and accessible knowledge services are essential.

Supporting the frontline

Throughout the pandemic, the work of health librarians has been vital in supporting frontline workers including doctors, nurses, pharmacists, and social workers. Hospital library services have been directly involved in medical decision-making, providing evidence and resources to support patient care and the training of medical staff. As the information needs of the medical workforce have changed through the course of the pandemic, health libraries have had to be fast and flexible to provide time sensitive and urgent information to those on the frontline.

A project undertaken by the NHS Borders Library Service saw the creation of a new outreach service for local GPs, which involved the delivery of targeted current awareness bulletins, resource lists, and Covid-19 research updates, all of which directly informed the provision of primary patient care and helped to keep GPs up to date on emerging knowledge about the coronavirus.

Health Education England’s (HEE) Library and Knowledge team adapted their services to meet changing workplace needs, ensuring 24/7 access to digital knowledge resources, gathering evidence on how to keep staff safe while working, and developing training programmes to support virtual working practices for healthcare staff.

Supporting decision-making across sectors

Health librarians have played a major role in informing the UK’s pandemic response at a national level, aiding public health decision-making and facilitating partnership working across sectors.

Librarians from Public Health Scotland’s (PHS) knowledge services have worked closely with PHS colleagues to coordinate Scotland’s response to the pandemic. Their work included the creation of daily Covid-19 updates for PHS’ guidance teams, distributing the latest and most relevant research on key topics, and adapting these updates in line with PHS’ changing priorities (for example as their focus shifted from virus transmission to vaccine efficacy). Librarians at PHS have also been involved in creating evidence summaries to support specific Covid-19 research projects, such as an investigation into the relationship between Covid-19 and vitamin D. The evidence gathered by knowledge services helped PHS to formulate their response on the issue and make national recommendations relating to vitamin D intake.

On 12 July 2021, PHS launched their Covid-19 research repository, which is managed and maintained by the library team and collects, preserves, and provides access to Scottish Covid-19 research. This project aims to support policymakers, researchers, and the public by bringing together Scotland’s Covid-19 research in one place and making it easily accessible for all who need it. It is also aimed at reducing duplication of effort, which health librarians had recognised as a concern during the pandemic.

Similarly, Public Health England (PHE)’s library aimed to tackle the duplication of effort across England by creating their ‘Finding the evidence: Coronavirus’ page which gathers emerging key research and evidence related to Covid-19 and makes it accessible in one place. Many resources on the site are freely available and include a wide range of resources including training materials, and search and fact checking guidance.

Health libraries have also been informing decision-making across the social care and third sectors, with NES librarians facilitating digital access to research and evidence via the Knowledge Network and Social Services Knowledge Scotland (SSKS), and providing training and webinars to help users make the most of such services. NES librarians have been involved in partnership working with organisations such as the Care Inspectorate, SCVO, and Alliance.

Keeping the public informed

A key challenge for health librarians during the pandemic has been in dealing with the information overload and spread of harmful misinformation around Covid-19.

Library and information professionals have had a key role to play in providing trustworthy information to patients and the public, helping people to make informed choices about their health and wellbeing. As previously mentioned, librarians have helped agencies like PHS to deliver clear, meaningful, and authoritative guidance to the public, as well as making up-to-date and reliable Covid-19 research centralised and widely accessible to the public.

The World Health Organization (WHO) emphasises the importance of health literacy in enabling  populations to “play an active role in improving their own health, engage successfully with community action for health, and push governments to meet their responsibilities in addressing health and health equity”. Health librarians have been at the forefront of efforts to promote and improve health literacy during the pandemic.

NES’ knowledge services have been delivering training and webinars to health and social care staff on how to improve people’s health literacy, and health librarians working with HEE have created targeted Covid-19 resources for specific groups such as older people and children and young people.

Final thoughts

Clearly, the work of health librarians has been crucial to the UK’s pandemic response and recovery so far, and advocacy campaigns like #HealthLibrariansAddValue are central to highlighting this important work and demonstrating its impact.

Looking forward, it is clear that innovative and high-quality knowledge services will be essential in a post-pandemic world as they continue to aid recovery, promote health literacy and support the health and social care workforce. As set out in HEE’s Knowledge for Healthcare framework, investment is required at a national and local level to build expertise and support the digital knowledge infrastructure which will be required.


Further reading: more on health from The Knowledge Exchange blog

A nudge in the right direction? Using behavioural insights in health

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Behavioural insight is a term which has been increasingly heard across a range of policy areas worldwide in the past decade. Essentially it involves using a combination of psychology, economics and studies of behaviour and decision making to better understand how people react to specific interventions, and evaluating and learning lessons from the way people react to help decision makers to develop better, more effective policies.

Its application has been widespread in the USA and Europe. In the UK, first under the Conservative-Liberal Democrat coalition and then more recently under the Conservative administrations in the UK, the approach has gained increasing traction, with the establishment of a UK government “behavioural insights team”.

The Behavioural Insights Team, also known as The Nudge Unit, is now a social purpose company. It is partly owned by the Cabinet Office, employees and Nesta

The coronavirus crisis has posed a big challenge for those who need to be seen to be creating policies that protect and support the public. It has also been challenging for those trying to predict how people will respond, whether they will comply and how we can “nudge” the public to make what the government sees as “better” choices.

As well as informing steps to ease lockdown and the recovery from coronavirus, behavioural insights is being more widely applied to understand how people make choices in relation to their health, and how these can be applied to preventative health measures and health based inequalities.

Nudging as part of policymaking

Nudging as a technique has been used widely across a number of different policy areas, including criminal justice and education. Its application in relation to public health has been wide ranging and has had significant implications for health policy of previous governments.

Key policy areas in public health for the UK behavioural insight team include:

  • antimicrobial resistance
  • vaccination
  • obesity
  • mental health

Using behavioural insights across all of these areas, the idea is to develop an understanding of how people think about these topic areas as issues and how their behaviour is influenced by their own thoughts, patterns of behaviour and environmental factors like ease of access to services.

Techniques like direct incentives (such as vouchers in return for healthy behaviour), measures that restrict choice (like restricting takeaways from schools), and outright bans (such as the restriction on smoking in public places) are all interventions designed in one way or another to “nudge” us towards certain behaviours.

Steps like text message reminders for appointments, offering salads or fruit instead of fries as a side, or opt out organ donation are further examples of how behavioural science techniques are being applied to encourage people to make healthier choices and reduce the strain on health services.

Many of the steps being taken are designed not only to save time and money for the public and organisations delivering services, but also to help encourage early intervention and preventative action, a key focus of public health strategies in the UK.

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A crucial role to play in understanding vaccine rollout

Vaccination decisions can be a complicated and emotive process, but with the rollout of the coronavirus vaccine understanding the routes to uptake and how people make decisions on vaccination are more important than ever.

Behavioural scientists have been at the forefront of the vaccinations programme, looking to create a better and more thorough understanding of how to manage the rollout and develop an understanding of how people see the benefits and challenges of vaccination, both collective and individual.

The ‘Increasing Vaccination Model’ they say is a helpful framework for categorising the barriers to vaccination and possible behavioural interventions. The evidence indicates that closing the ‘intention–behaviour gap’ in vaccination behaviour by improving ease of access (and thus removing practical barriers to vaccination) is the most effective type of intervention. In contrast, focusing on motivation or educational interventions appears to be less helpful.

However, behavioural scientists have noted that in relation to the coronavirus vaccine even more barriers exist, with one survey reporting that 16 per cent of UK adults would ‘probably’ or ‘definitely’ avoid a COVID-19 vaccine. There is a suggestion that compressed development timelines, misinformation and media reporting could all undermine confidence and therefore uptake. Behavioural scientists are working hard to understand what steps could be taken to understand vaccine hesitancy and improve uptake across all communities in the UK and internationally.

Final thoughts

Behavioural insights, data analytics and “nudge” techniques have been part of policy making for the best part of ten years. They aim to help policymakers understand people’s reactions to policies and use this insight to help more effective policy in the future.

The coronavirus pandemic has presented a new and challenging opportunity for behavioural insights and has required them to apply their knowledge and understanding of how policy is applied and received like never before, with vaccine rollout being just one key area, along with other lockdown measures which require mass compliance in order to be effective.

How behavioural insights will continue to inform the recovery and public health strategies more widely remains to be seen, but it does appear that for the meantime at least, the “nudging” will continue.


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Devolving health and social care in England: an opportunity to transform how we approach health and care?

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In recent years, the Department of Health and Social Care (DHSC) has increasingly encouraged the transfer of powers over health and social care in England away from central government and towards city regions. These bodies, DHSC argues, are uniquely placed to understand the challenges faced by their local populations, the capacities and expertise of their local NHS and to develop plans for the future. This should enable them to approach health at a local level, promoting increased delivery of care in the community, and a greater integration between health and care services.

Putting local places at the centre of “Build back better”

In August 2020 the Health Devolution Commission launched its final report, Building back health and prosperity. Among other themes, like taking a “health in all policies approach”, the report found that devolving accountability and power to a more local level creates the potential to understand communities and places better, and to meet their needs.

The NHS Long Term Plan has also outlined a new direction for the NHS based on the principle of collaboration rather than competition, and the introduction of new structures such as Integrated Care Systems, Integrated Care Providers and Primary Care Networks. These partnerships bring health and social care commissioners together to plan and deliver integrated and person-centred care.

In the context of “building back better”, awareness of how our external experiences and contexts impact our health and wellbeing (for example the impact of poverty, deprivation, housing, and unemployment) is increasingly important.

Beyond the immediate recovery from the pandemic, health devolution could be one way of opening up the possibility of integrating not just disparate services within the NHS – or even NHS and social care services in a locality – but bringing together in a combined strategy and structure all of the services, systems and partners in a community that have an impact upon the health of a local population, and the care services to better meet their health needs.

“It doesn’t have to be a battle”- partnerships and balance are the key to effective devolution

The move away from centralised processes and organisations towards more local ones can sometimes be portrayed as a rejection or an attempt to “break free” from central government. However, practitioners have been increasingly stressing that devolution does not mean complete independence, and that while improved local decision making will improve outcomes for local people, that does not mean that the need for some centralised decision making is completely removed.

On the contrary, some decisions should and will be taken at a national level, but the ability to distribute power, decision making and accountability to a local level will have significant positive impacts for improving “citizen voice”, transparency and co-production in decision making.

This is where the Health Devolution Commission argues that balance, communication, and partnership between the local and national infrastructure needs to be aligned so that devolution can be successful and sustainable. Integrated planning and management of long-term health care strategies is important, as is the ability to bring citizens and local decision makers into discussions about national health policy.

The Voluntary, Community and Social Enterprise (VCSE) sector, including patient voice and carers organisations, also plays an important role in linking together services and communities. As well as partnering to deliver services, these organisations also often offer vital bridges between statutory systems and those communities which can often be excluded from engagement with services or who can find it harder to access them. The commission also emphasised the importance of bringing these bodies into the conversation on devolution going forwards as they will be invaluable partners in the process.

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DevoManc providing the blueprint?

In 2016, as part of a pilot, control of the health and social care budget for Greater Manchester was transferred to a partnership team in the area comprising local authorities, clinical commissioning groups, NHS foundation trusts and NHS England.

The combined authority identified that the health of its population was one of the key obstacles to its economic growth. By relating the concept of regional economic prosperity with health, they began to see health in a completely different way – as part of a wider plan and an investment for growth, not a burden.

“It’s better to have decisions made locally, because local people understand what local problems are and what Greater Manchester needs. We need to work together.”

Lord Peter Smith, Chair of Greater Manchester Health and Care Board

The Greater Manchester Health and Social Care Partnership are working in partnership with other sectors including education and housing to support everything from good eating habits and exercise to education and everyone’s ability to earn a decent living. The partnership is taking action to give children the start they need, support independence in old age, tackle illness earlier on and even prevent it altogether by improving the lifestyles of local people.

Other areas of England are also currently undertaking their own health devolution journeys, including London, West Yorkshire and Harrogate, as well as some other combined authority areas. However, one of the big challenges is that currently, while we can learn from the experiences of those already on their devolution journey, there is no common, consistent or comprehensive understanding of what good heath devolution looks like, full evaluations of the benefits it brings or overarching strategies on how it should be developed.

This is something that will need to be addressed if health devolution is to be successfully rolled out across England.

Final thoughts

Devolution of health to a more local level provides an opportunity to tackle the big public health challenges of our time at source, and to create a better, more joined up community health ecosystem. It also provides the chance to share and collaborate, learning from best practice and delivering improved health and social care services at a regional and national level.

It has been suggested that the coronavirus pandemic, while traumatic in more ways than one for the NHS and its staff, may provide the re-setting point needed to implement some of the changes proposed in relation to greater health devolution. Proponents of this view argue that improved funding to support effective and high quality care, improved integration between health and social care, and greater positioning of health and assessment of the impact of decisions on health across all policy areas, should be among the top priorities as the country looks to recover from the pandemic.

As the Health Devolution Commission underlines:

The pandemic has shown we cannot go back to the way things were. We need a ‘new normal’ and we believe that comprehensive health devolution is the only viable solution to the challenges the country now faces.”


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Cross-border handshakes: what’s next for digital contact tracing?

As we enter a new year, and a new phase of the Covid-19 pandemic, we are reminded of the need to follow public health advice to stop the spread of the virus. The emergence of new variants of Covid-19, which appear to be more transmissible, has resulted in tougher restrictions across the world. Although the emergence of new variants of Covid-19 can seem frightening, we are not powerless in preventing the spread of the virus; face coverings, social distancing, regular handwashing and self-isolating remain effective.

Additionally, the development and subsequent roll-out of numerous vaccines should provide us all with hope that there is light at the end of the tunnel. However, although vaccines appear to protect people from becoming seriously ill with the virus, there is still uncertainty regarding the impact vaccines will have on viral transmission of Covid-19.

Therefore, the need for those with symptoms to self-isolate, get tested and undergo contact tracing when a positive case is detected is likely to remain. This will become even more important in the months ahead, as we see the gradual re-opening of hospitality, leisure and tourism sectors.

Effectiveness of contact tracing

Contact tracing is a tried-and-tested public health intervention intended to identify individuals who may have been in contact with an infected person and advise them to take action that will disrupt chains of transmission. Prior to Covid-19, contact tracing was often used to prevent the spread of sexually transmitted infections, and has been heralded as vital to the eradication of smallpox in the UK.

According to modelling, published by the Lancet Infectious Diseases, a combination of self-isolation, effective contact tracing and social distancing measures, may be the most effective and efficient way to control the spread of Covid-19.

However, for contact tracing to be at its most effective, the modelling estimates that for every 1,000 new symptomatic cases, 15,000 to 41,000 contacts would have to be asked to self-isolate. Clearly, the logistical burden of operating a manual contract tracing system is high. As a result, governments have chosen to augment existing systems through the deployment of digital contract tracing apps, which are predominantly built using software developed by Apple and Google.

Digital contact tracing

As we go about our day-to-day lives, especially as restrictions are eased, it may not be possible to name everyone you have encountered over the previous 14 days if you later contract Covid-19. Digital contact tracing provides a solution to this issue by harnessing the Bluetooth technology within our phones to help identify and remember potential close contacts. Research by the University of Glasgow has found that contact tracing apps can contribute substantially to reducing infection rates when accompanied by a sufficient testing capability.

Most countries have opted to utilise a system developed by Apple and Google, known as Exposure Notifications, as the basis for digital contact tracing. Public health authorities have the option to either provide Apple and Google with the criteria which defines when an alert should be generated or develop their own app, such as the Scottish Government’s Protect Scotland.

Exposure notification system

In order to protect privacy, the exposure notification system can only be activated by a user after they have agreed to the terms; the system cannot be unilaterally activated by public health authorities or Apple and Google. 

Once activated, the system utilises Bluetooth technology to swap anonymised IDs with other users’ devices when they come into close contact. This has been described as an anonymous handshake. Public health authorities set what is considered as a close contact (usually contact at less than a 2-metre distance for over 15 minutes), and the app calculates proximity measurements over a 24-hour period.

Anonymised IDs are not associated with a user’s identity, change every 10-20 minutes and collected anonymised IDs are securely stored locally on user devices for a 14-day period (incubation period of Covid-19) before being deleted.

If a user tests positive for Covid-19, the public health authority will provide them with a code that confirms their positive diagnosis. This will then provide users with an option to upload collected anonymous IDs to a secure public health authority server. At least once a day, the user’s phone will check-in with this server to check if any of the anonymised IDs collected in the previous 14-days match up with a positive case. If there is a match, and the proximity criteria has been met, a user may receive a notification informing them of the need to self-isolate.

Analysis conducted by the National Institute for Health Research highlights that the use of contact tracing apps, in combination with manual contact tracing, could lead to a reduction in the number of secondary Covid-19 infections. Additionally, the analysis revealed that contact tracing apps identified more possible close contacts and reduced the amount of time it took to complete contact tracing. The analysis concluded that the benefits of digital contact tracing include the ability to trace contacts who may not be known to the infected individual and the overall reliability and security of digitally stored data, rather than an individual’s memory or diary.

Therefore, it could be said that digital contract tracing apps will be most effective when restrictions ease and we are more likely to be in settings where we may be in close contact with people we may not know, for example, when we’re on holiday or in a restaurant.

Cross-border handshakes

Covid-19 naturally does not respect any form of border, and as restrictions on domestic and international travel are relaxed, opportunities will arise for Coivd-19 to spread. In order to facilitate the reopening of the tourism sector, there have been calls for countries which have utilised the Exposure Notification system to enable these systems to interact.

Examples of interoperability already exist internally within the UK, as an agreement exists between Scotland, England and Wales, Northern Ireland, (plus Jersey, Guernsey and Gibraltar), that enables users to continue to receive exposure notifications when they visit an area they do not live in, without the need to download the local public health authority app.

EU Exposure Notification system interoperability, European Commission, 2020

Additionally, the European Union has also developed interoperability of the Exposure Notification system between member states, with a commitment to link 18 national contact tracing apps, establishing the world’s largest bloc of digital contact tracing. The EU views the deployment of linked apps as vital to re-establishing safe free movement of people between member states, for work as well as tourism.

Over the next few months, it is likely that links will be created across jurisdictions. For example, the Scottish Government has committed to investigating how interoperability can be achieved between the Scottish and EU systems. The interoperability of Northern Ireland and Ireland’s contact tracing app highlights that on a technical level there appears to be no barrier for this form of cross-jurisdiction interaction.  

Therefore, as restrictions ease, the interoperability of digital contact tracing apps may become a vital way in which to ensure safe travel, as we learn to live with the ongoing threat of Covid-19.

Final thoughts

Covid-19 has proven itself to be a persistent threat to our everyday lives. However, the deployment of effective vaccines provides us with hope that the threat will be minimized soon. Until then, the need to utilise contact tracing is likely to remain.

As the roll-out of mass-vaccination programmes accelerates, and restrictions are relaxed, we are likely to be in more situations where we will be in contact with more people, not all of whom we may necessarily know. This will be especially true as domestic and international tourism begins to re-open. In these scenarios, the Exposure Notification system, and interoperability between public health authority apps, will become increasingly vital to the operation of an effective contact tracing system.

In short, digital contact tracing may prove to be key to the safe re-opening of the tourism sector and enable users to easily and securely be contact traced across borders.


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Further reading: articles on COVID-19 and digital from The Knowledge Exchange blog

Why are we still talking about healthy places?

In recent years, there has been a wide ranging debate across the housing, planning, health and infrastructure sectors about the development of healthy places in both regeneration and newly approved projects.

In 2016, Town and Country Planning Journal published an article on building health and wellbeing into the built environment (Town and Country Planning, Vol 85 No 11 Nov 2016, Knowledge Exchange customers can login to view the article here) In 2017 and 2018 the talk was all about healthy towns initiatives, and a Design Council report in 2018 looked at the relationship between healthy placemaking and the impact on our communities. In 2019 the Town & Country Planning Association (TCPA) called on members to “reunite” health and planning

It is clear that everyone involved in placemaking agrees building places that promote health and wellbeing for all is of vital importance to our communities, The Covid-19 pandemic brought this into sharp focus, and the idea remains at the forefront of design policy, particularly in urban city contexts. But, over four years after the initial conversations and thought pieces, why are we still talking about it, and what actions still need to be taken to integrate the idea of a healthy place into planning to the extent that it just becomes the norm in the planning and design of our places?

Preventing avoidable disease

The phrase ‘healthy placemaking’ has been defined by Design Council as: “Tackling preventable disease by shaping the built environment so that healthy activities and experiences are integral to people’s everyday lives”.

Public Health England defined healthy placemaking as: “Placemaking that takes into consideration neighbourhood design (such as increasing walking and cycling), improved quality of housing, access to healthier food, conservation of, and access to natural and sustainable environments, and improved transport and connectivity”

Research has shown preventable diseases linked to lifestyle and environment are among the most significant threats to public health. Lifestyle-related conditions like heart disease and cancer, as well as being health problems in their own right, can also contribute to the development of other chronic conditions, exacerbate symptoms and create complications with care which are costly to the NHS.

Creating healthy spaces is not just about encouraging people to live more active lifestyles by facilitating active travel and improving the environment around buildings, although this is a significant part of it. “Healthy places” include approaches to improve air quality, reduce loneliness, allow people to age well in place, promote mental as well as physical wellbeing, reduce deprivation and inequality through projects like housing, infrastructure development, and high street regeneration.

Healthy places also have a preventative role to play in public health management, not just a health improvement role; such interventions are essential to help avert the onset of disease, improve people’s quality of life and reduce health inequalities. And evidence shows the return on investment from public health interventions is high and creates value of different kinds – economic, social and personal.

In short people who live in healthy places, tend to live healthier lives, place less strain on services and “contribute” more to society, both economically through work or spending and socially through community engagement.

Victoria Park, Belfast. Image: Fiona Ann Paterson

Enabling planning practitioners to think about creating healthy places

Research published in 2020 by the Royal Town Planning Institute (RTPI) explored local, national and international planning practices that enable the creation and delivery of healthy places. While a lot of research draws attention to the barriers to building healthy places – including a lack of funding, different requirements from developers and conflicting policy priorities – the RTPI report instead sought to identify important challenges faced by planners who try to integrate healthy placemaking principles in their decisions and then offer potential solutions to these in practice. Key themes emerging from the report include a need to improve collaboration, knowledge sharing and the skills of planners.

The report provides case studies looking at: the place standard tool; the livewell development accreditation; connecting communities in Tower Hamlets; health planning in South Worcestershire; and train station district rejuvenation in Grasse, France. It also identifies seven steps to plan for healthier environments

Across the sector there have been calls for planners to be allowed to be innovative, creative and take a “visionary” approach to planning to help make places healthier in order to address the convergence of challenges around public health, the climate emergency, and economic recovery from Covid-19.

How has the coronavirus pandemic changed how we think about healthy spaces?

The lockdowns  imposed as a result of the coronavirus pandemic have thrown the importance of quality space into sharp focus. Places that facilitate health and wellbeing among the people who live there, and places where the indoor living quality is as important as the outdoor space have become incredibly important.

The pandemic has highlighted what it really means to have a healthy space. It has also demonstrated how wider socioeconomic deprivation and inequality – linked to living conditions as well as other factors – is having an impact on infection and hospital admission rates, with those groups who live in more deprived areas being found to be at a higher risk of becoming seriously ill or being admitted to hospital with Covid-19. 

The 2018 Design council report found in its survey of practitioners that focus was given far more to outdoor space than to indoors, as it was easier and more cost effective to make changes that could produce demonstrable impacts (an increase in cycling, for example). But the pandemic and the increased time we have been forced to spend indoors has encouraged designers and urban planners to think even more creatively about quality space in their developments.

Where now?

Public Health England (PHE) which for many years was a strong voice in the conversations around healthy placemaking has been disbanded and will be replaced by a National Institute of Health Protection. It remains to be seen how, or if this new organisation will fit into the conversation going forward. But reflecting on recent reports on the significant public health crisis facing the UK in the long term, it is clear that the work must continue, driven collectively by those in planning, urban design and public health.


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The Covid-19 knock-on: public health and the impact of delays in non-urgent treatment and diagnosis

Since the beginning of the pandemic, concerns have been raised about the wider public health impacts of coronavirus. In addition to strains on acute NHS care services on the frontline, there are warnings about the additional public health impacts of delays to preventative healthcare measures like screening and routine medical care in the form of pre-planned operations for long-term chronic and non-urgent conditions.

At the outbreak of the pandemic many hospitals took the decision to delay or stop entirely routine pre-planned surgeries and preventative screening and diagnostics. Some even suspended treatment for more urgent care like cancer treatment on a short term basis. While many of these services have resumed since the beginning of the pandemic, albeit with a backlog of patients now to be seen, significant strain on the NHS as we come into the winter months because of  coronavirus is still anticipated. As a result, many hospitals are not working at full capacity in order to prepare for potential increases in admissions due to coronavirus or staff shortages over the winter.

In many areas this has led to a backlog of care, both for those patients already in the system awaiting routine surgeries, as well as those who are yet to be diagnosed but would have been through preventative screening programmes run by the NHS.

Delays in healthcare and routine screening programmes 

Even before the coronavirus pandemic took hold, many NHS hospital trusts were under criticism because of the significant length of waiting times for people who required routine operations, which in some parts of the UK can be as long as three years. Doctors across the UK are now warning that these delays could be increased further unless the NHS receives additional support to increase capacity across all areas of care  not just urgent care in the coming months.

Data released by NHS England in October 2020 showed the numbers waiting over a year for hospital treatment have hit a 12-year high, with almost 2 million patients waiting more than the target time of 18 weeks for routine care.

It has been suggested that delays in diagnosis and routine treatments could lead to an increased number of hospitalisations further down the line, requiring higher levels of care, longer lengths of stay, and increased hospital readmissions.

A reluctance to visit hospitals and use primary care services

Government messages to ‘protect the NHS’ may have had the unintended consequence of discouraging people from seeking urgent medical care when it was required for fear of using services unnecessarily or for fear of contracting the virus when attending hospital or primary care settings.

Research from the Health Foundation found that there had been a significant reduction in the number of GP consultations since the start of the pandemic which has led to concerns about the care of non-covid patients, patients with long term health conditions and also the potential for delayed diagnosis. Primary care consultations also reduced and have remained low consistently since the beginning of lockdown.

Figures have also shown a reduction in the number of referrals, medical tests, new prescriptions and immunisations. While some of these reductions are the result of advice to delay routine referrals to free up capacity for hospitals to deal with the potentially large number of cases of Covid-19, routine referrals have still not recovered to pre-lockdown levels.

 

A potential future crisis for the NHS and a ticking time bomb for public health

Doctors are now warning that the treatment backlog which has been caused by the coronavirus pandemic, in addition to diagnostic delays and screening programmes, may lead to a future crisis of care or significant delays in care for people waiting to receive more routine treatment.

Delays in care have not only been reported in cases of physical health. There have also been significant delays in referrals for those seeking treatment for a mental health condition, an area of the NHS which was already facing significant delays in referral and transfer of care even before the pandemic. Research suggests that incidence of mental illness during the coronavirus pandemic increased. However, the numbers of people accessing services and being referred for treatment have not increased proportionate to this. People with mental health conditions may have been unable to access appropriate support through primary care pathways, which could potentially impact on their long term health and care.

Finally, concerns have been raised about the wider social determinants of health such as employment and poverty. Public Health England (PHE) published a monitoring tool which looks at the wider impacts of the Covid-19 pandemic on population health, and it is likely that the knock-on impact of the virus could have far reaching consequences for public health in the future as the health implications of lockdown, lack of social interaction and rising unemployment could be significant. 

Where next?

While the challenges of the coronavirus pandemic for the NHS will not be going away anytime soon, it is clear that it will be necessary for the NHS and other supporting services to act now to prevent a longer term public health crisis. It is critical that we not only focus on the acute care of Covid-19 patients, but also proactively manage patients without Covid-19, particularly those with time-sensitive, complex and long term conditions who are postponing their care. We must also consider the knock-on impacts of delayed diagnosis for those people who missed out on routine screening or who were unable or too afraid to visit their GP or hospital. This is important not only to sustain health and life, but to preserve hospital and NHS capacity in the future.


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Virtual knowledge: recent webinars on public and social policy

Earlier in the summer, we shared some of the information our Research Officers had picked up while joining webinars on public and social policy.

Since then, we’ve taken part in more of these virtual seminars, and in today’s blog we’re providing an overview of the wide range of topics covered.

Low traffic neighbourhoods

Earlier this month, Project Centre, which specialises in public realm regeneration and sustainability, organised a webinar on the challenges of implementing Low Traffic Neighbourhoods.

Low Traffic Neighbourhoods (LTNs) are a group of residential streets where through traffic is removed or discouraged, and any remaining traffic must operate at a pedestrian pace. The focus is not only to reduce congestion and improve safety by getting traffic back onto main arterial road networks, but also to provide environmental benefits, improve public health, community cohesion and encourage people to spend more, quality time in the areas where they live by making places “liveable”.

This webinar looked at the design and implementation of Low Traffic Neighbourhoods, with guest speakers from two local authority areas (Waltham Forest and the Liverpool City Region), as well as designers from Project Centre who support the implementation of Low Traffic Neighbourhood Schemes. The speakers discussed their own experiences designing and implementing low traffic neighbourhoods and shared potential lessons for those looking to implement their own scheme.

The speakers all emphasised some key elements to effective design and implementation of LTNs they included:

  • LTNs are not just about transport, they can have health and wellbeing, community cohesion and crime reduction and economic impacts for local businesses as people are encouraged and enabled to shop more safely in their local areas.
  • schemes should be done with communities, not to them
  • LTNs should be designed with everyone in mind to bring pedestrians and cyclists “on par” with cars in terms of the use of street space
  • effective data and evaluation can help build a case for wider roll outs.

The new long life: a framework for flourishing in a changing world

This webinar was delivered by the International Longevity Centre (ILC) and included a number of speakers from a range of backgrounds who came together to discuss the impact of longevity and ageing on our engagement with work and the labour market, particularly in relation to digital technology and the changing nature of work post COVID-19. Speakers included Prof. Andrew Scott, Caroline Waters, Jodi Starkman, Stefan Stern, Lily Parsey and George MacGinnis.

Many of the speakers highlighted the difference between the ageing agenda and the longevity agenda, explaining that while many of us will live and work for longer than ever before, the nature of work and the stages of life are changing in a way that for many will be unrecognisable as the “traditional life journey”.

They stressed the need to move away from “traditional linear thinking” about how we age, with education at the start, mid-life being punctuated by work and potentially parenthood, then retirement, and that ageing in the future will be full of more “life stages” and more mini cycles where career breaks, learning and other life “punctuations” will take place at different times of life. It was suggested that the nature of work will change so much that re-learning and at times re-training will be a necessity at multiple points in life, and not just by those who change career deliberately.

Ageing well must, according to speakers, remain high on the policy agenda of future governments to ensure that the growing population of older people can live lives that are enjoyable, purposeful and productive and can contribute to wider society well into what would currently be considered “old age”.

Clearing the air

This has been a year like no other. But while attention has rightly focused on the number of Covid-19 fatalities – more than 800,000 worldwide – there is another hidden killer which has been responsible for more deaths than coronavirus, HIV and malaria combined. Research has found that air pollution caused an extra 8.8 million deaths around the world in 2015.

We’ve written before about efforts to improve air quality, and in July a webinar organised by Catapult Connected Places looked at further innovative ways to understand and tackle air pollution across the globe.

Eloise Marais,  an Associate Professor in Physical Geography at UCL talked about TRACE – the Tool for Recording and Assessing the City Environment – that she is developing using satellite observations of atmospheric composition. Satellites offer more complete and consistent coverage than surface monitors, and satellites can also monitor many air pollutants, such as sulphur dioxide, ozone, nitrogen oxides and fine particulate matter.

But while satellites have a long and well sustained record of recording data – some have been in space for more than a decade – their measurements have limitations in terms of spatial resolution. At the moment, these can only cover city-wide air quality, rather than providing postal code measurements. Eloise explained that, while satellite data has been used to show that air quality improvement policies have been effective in London as a whole, they cannot yet confirm that in some parts of the city pollution levels are not falling. Even so, Eloise noted that spatial resolution is improving.

Later in the webinar, Bob Burgoyne, Market Intelligence Team Lead at Connected Places Catapult talked about the Innovating for Clean Air India Programme. India is home to 14 of the world’s most polluted cities. One of these, the city of Bangalore is especially badly affected, and Bob described a project which aims to improve the city’s air quality and enable a transition to electric vehicles. The Catapult network has been working with academic and professional bodies, and with small and medium sized enterprises in India to measure and demonstrate the impact of pedestrianizing a major street in Bangalore on Sundays. The long term goal is to permanently pedestrianise the street, and to demonstrate active and electric mobility solutions.

Back on track: London’s transport recovery

This webinar, organised by the Centre for London, discussed the impact of the Coronavirus pandemic on London’s transport systems and explored the impact of changes to Londoners’ travel habits on the actions required for recovery.

The event included contributions from Rob Whitehead, Director of Strategic Projects at Centre for London, Cllr Sophie McGeevor, Cabinet Member for Environment and Transport at London Borough of Lewisham, and Shashi Verma, Chief Technology Officer and Director of Strategy at Transport for London.

A major concern raised by speakers was that current trends indicate that car usage is returning to normal levels faster than any other form of transport. Public transport, such as bus and tube, is slowly recovering but its usage is often linked to changes to lockdown restrictions, with surges in use as restrictions are lifted that very quickly level off. Additionally, although it appears that active transport use has increased, this increase tends to be at weekends and is more apparent in outer London.

As a result of these trends, there is a serious concern that levels of traffic in London may exceed the levels experienced prior to the lockdown. Currently, road traffic is at roughly 90% of normal levels, if this rises to 110%, the resulting congestion will result in gridlock and could have major implications for London’s economy.

How should we use grey literature?

This webinar was organised by the CILIP Health Libraries Group, for CILIP members to learn about and discuss how grey literature is used by libraries, and the benefits and challenges of making use of such content.

The main talk was delivered by two members of the library team from the King’s Fund – Deena Maggs and Kathy Johnson – who emphasised the importance of grey literature as a means of delivering timely and up to date information to users, particularly in the context of health and social care policy, where information needs tend to be very immediate.

The session involved discussions about the usefulness of grey literature in terms of Covid-19 recovery planning, as well as the challenge of determining the credibility of content which is not peer reviewed or commercially published.

The speakers gave practical advice around selecting and evaluating such sources, and highlighted the broadening range of ‘grey’ content that libraries can make use of, such as audio recordings, blog posts, and Tweets.


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The dash from cash: can public transport providers balance the needs of staff and customers?

One of the unexpected repercussions of the coronavirus outbreak has been an increased use of card, mobile and contactless payments instead of cash. Concerns about handling money during the pandemic have prompted shops and public transport services to encourage customers to use contactless payment methods. However, many people relying on public transport to access work and health services have no alternative but to use cash.

A brief history of contactless payments

Contactless payments include credit and debit cards, key fobs, closed loop smart cards and other devices, including smartphones. These applications use radio-frequency identification (RFID) or near field communication (NFC) for making secure payments. An embedded circuit chip and antenna enable consumers to make a payment by holding their card or device over a reader at a point of sale terminal.

The first contactless payment was made available in the United States at the end of the 1990s. In the UK the first contactless cards were issued in 2007.

The UK’s public transport contactless revolution began in 2014, when it became possible to access London’s Tube network, Docklands Light Railway (DLR), London Overground and most National Rail services using only a bank card. By 2019, payments with contactless bank cards or mobiles made up 60% of all Tube and rail pay-as-you go journeys in London. Public transport authorities elsewhere in the UK have followed London’s lead.

The move towards cashless payments

Even before the current public health emergency, cash payments in the UK were in decline. In the past few years, there has been a shift towards the use of debit cards, while contactless payments have soared:

  • in the ten years up to 2019, cash payments dropped from 63% of all payments to 34%;
  • in 2017, contactless payments increased by 99% to 4.3 billion;
  • in the same year, 3.4 million UK consumers managed their spending almost entirely without using cash.
  • by 2028, forecasts suggest that fewer than one in 10 UK consumer payments will be made using cash.

The emergence of chip and pin, contactless cards, digital wallets and mobile apps has made many aspects of our lives much more convenient, notably when paying bills, purchasing goods and using public transport.

But although more and more people are moving away from cash payments, 2.2 million people rely almost wholly on cash – up from just 1.6 million in 2014. A Bank of England review in 2019 found that around eight million people  would find life “near impossible” without cash.

How Covid-19 is changing public transport

With high numbers of people in confined spaces and a large number of common touch points such as handrails and ticket machines, buses and trains are potentially high risk environments for Covid-19 transmission. At the same time, public transport is critical for sustaining the economy, and ensuring that people have access to shops, services, work and health care.

Public transport authorities around the world have been responding to the emergency in a number of ways, including increased disinfection and sanitisation, and encouraging physical distancing between passengers. Another key measure adopted by public transport bodies has been an acceleration away from cash payments and towards contactless and mobile ticketing.

While some bus operators have announced that they will no longer accept cash payments, others have warned that drivers could face disciplinary action if they refuse cash. Earlier this year, the trade union representing bus workers called for the abolition of cash payments on all UK buses to reduce infection rates among drivers.

Serving the ‘unbanked’

A recent webinar organised by Intelligent Transport explored the implications of the coronavirus public health emergency for public transport. One of the key points was that public transport operators now need to maintain a balance between protecting their staff while meeting the needs of passengers who may have no alternative but to make cash payments.

The webinar heard that there is a growing sense among public transport operators of a shift in perception concerning cash payments as a result of the global pandemic. However, cash payments remain vital for the 1.3 million UK adults who do not have a bank account (the ‘unbanked’), many of whom are on low incomes. Contactless cards may be unaffordable for lower-income passengers, while many unbanked passengers worry that contactless credit cards could lead to accidental overdraft.

As the webinar noted, public transport providers have been trying to overcome these obstacles. Some have continued to accept cash payments, while others have offered passengers their own prepaid cards that can be topped up with cash in shops or transport stations.

Final thoughts

It’s likely that public transport authorities will continue the drive towards cashless and contactless payment. Lower maintenance costs, speed and flexibility are some of the advantages provided by contactless applications, and transport companies can also benefit from the data on transport usage generated by electronic payment systems.

However, the migration from payments using physical money risks leaving over a million UK citizens behind. In the ‘new normal’ for a world living with the coronavirus, transport organisations will have to find innovative ways to balance the safety of their staff with the needs of their passengers.


Further reading
Articles on public transport on The Knowledge Exchange blog

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Guest post: Economic effects of coronavirus lockdowns are staggering – but health recovery must be prioritised

By Pushan Dutt, INSEAD

In all my years as an economist, I have never seen a graph like the one below. It shows unemployment claims in the US – observe the spike for the week ending March 21. The global financial crisis, the dot-com crash, Black Monday, oil price shocks, 9/11, none of these historic shocks are even visible in the graph.

Figures: US Department of Labor

 

The spike in unemployment claims is the proverbial canary in the goldmine. We should expect a swathe of bad economic numbers coming down the pipeline. The head of the St. Louis Fed expects a 30% unemployment rate and a 50% drop in US GDP by summer. More importantly, as the health crisis rises and crests at different times in different parts of the world, the horrifying numbers on GDP growth, unemployment, business closures are not likely to let up in the near term. Multiple countries are in a recession, and eventually, the whole world will fall into a deep recession.

The plunge from prosperity to peril will be as swift as the switch to lockdown protocols in most countries. We cannot even rely on the data we have to reveal the speed and depth of the crisis since this is collected and updated with lags. For instance, the US monthly jobs report for March collects data in the second week of March, failing to capture the massive spike in unemployment claims that appears after March 12.

In the meantime, sources such as restaurant booking website OpenTable can offer some insights into the magnitude of things. The figures below show the recent plummet in diners eating at restaurants in four countries. Observe a sudden stop in the entire restaurant industry by the third week of March.


Annual % change in restaurant diners from end of February to end of March.

Data: OpenTable

 

Combine a black swan event with missing data, and it is not surprising that markets are swinging violently.

Deep freeze

The question is not one of whether we are in a recession – we are. The more pertinent questions are: how long it will last? How deep it will be? Who will be impacted the most? And how swift will the recovery be?

These questions are complicated and even top economists must admit a lack of confidence in their answers. We are not experiencing a standard downturn. Nor is it simply a financial crisis, a currency crisis, a debt crisis, a balance of payment crisis or a supply shock.

We have not seen anything like this since the flu pandemic of 1918. Even there, identifying the effects of the flu is confounded by the first world war that took place at the same time. What we have here is something different. At its heart, we are experiencing a healthcare crisis with various parts of the world succumbing in a staggered fashion.

To slow down this global health crisis (the “flatten the curve” mantra), we have chosen to put the economy into deep freeze temporarily. Production, spending, and incomes will inevitably decline. Decisions to reduce the severity of the epidemic exacerbate the size of the contraction. While the initial decision to reduce labour supply and consumption are voluntary, this will likely be followed by involuntary reductions in both, as businesses are forced to lay off workers or go bankrupt.

Of course, government policies will attempt to mitigate these effects. Some are using traditional monetary and fiscal policies (cutting interest rates, quantitative easing, increasing unemployment insurance, bailouts). Others are trying out non-traditional methods (direct cash transfers, loans to businesses conditional on maintaining unemployment, wage subsidies).

Public health priority

How long the economic impact lasts depends entirely on how long the pandemic lasts. This, in turn, depends on epidemiological variables and health policy choices. But even when the pandemic ends, the resumption of normalcy is likely to be gradual. Countries will persist with a strict containment regime like in China today, and continue to impose travel restrictions to various parts of the world where the disease continues to spread.

The many factors at play in this complex, interlinked crisis that affects both people’s health and the global economy introduces massive uncertainty into anyone hazarding the pace, the depth and the length of the impact. As a result, we should treat any precise estimates (such as “GDP will decline by X%” or “markets have reached their bottom”) with scepticism.

Especially frustrating is the idea that there is a conflict between academic disease modellers and hard-edged economists saying that steps to slow the spread of coronavirus has trade offs. This could not be further from the truth. Among economists there is near unanimity that countries should focus on the healthcare crisis and that tolerating a sharp slowdown in economic activity to arrest the spread of infections is the preferred policy path. In a recent survey carried out by the University of Chicago, respondents universally agreed that you cannot have a healthy economy without healthy people.

The health crisis has naturally created a crisis of confidence. This, in turn, can have damaging long-term effects with continuing uncertainty leading firms and households to postpone investment, production and spending. Restoring confidence requires a singular focus on containing and reversing the spread of COVID-19.

Slowing the rate that people fall ill with COVID-19 is not the end in itself. It is a means to temporarily reduce the pressure on hospitals and give time to identify treatments and a vaccine. In the interim, we must build testing capacity, perform contact tracing, setup the infrastructure for extended quarantines, rapidly expand the production of masks, ventilators and other protection equipment, build and repurpose facilities into hospitals, add intensive care capacity and train, recall and redeploy medical personnel.

All of this is also the way to restore the economy’s health and economic policy must complement it. In the short run, economic policies should mitigate the impact of lockdowns and ensure that the current crisis does not trigger financial, debt or currency crises. It should focus on flattening the recession curve, ensure that the temporary shutdown has only transient effects, and facilitate a quick recovery once the economy is taken out of the deep freeze.

In the meantime, it’s important to also recognise that this is an unprecedented crisis. Everybody has their role to play, but nobody is infallible and uncertainty is inevitable.

Pushan Dutt, Professor of Economics, INSEAD

This article is republished from The Conversation under a Creative Commons license. Read the original article.


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