Your Time Starts Now – Vol 3

Across the Board

by Richard Angell

Universal A&E screening can protect the most vulnerable and save the NHS money

When Labour was last in government, it adopted an approach that might be termed progressive universalism: it improved services for all, but prioritised services for the poorest, disadvantaged and those experiencing inequalities. Sure Start, Building Schools for the Future and city academies all started in areas of deprivation before being deployed to rebuild the public realm for all. Baby bonds gave every child a nest egg, but poorest children the most. A similar principle is now being applied in HIV prevention, in the form of comprehensive A&E testing, with great success. Starmer’s Labour government should turbocharge a new rollout of opt-out screening, not just in pursuit of ending the HIV epidemic, but to scale up diagnostics more widely and drive down inequality in the broadest sense.

HIV is a cruel epidemic. Preying on the health inequalities in our society – and the homophobia and racism which has persisted from HIV’s emergence to the present day – it initially disproportionately hit gay and bisexual men, people who used drugs, and then the African diaspora. Today, about 106,000 people are living with HIV in the UK, including 5,150 people who have the virus but do not know it. They urgently need a test. A further 14,000 people know they have HIV, but, often as a result of the wider social determinants of health, are not taking medication. They urgently need a way back into care. If we can find these two cohorts and get those at risk to take the HIV prevention drug PrEP, we can end this epidemic. The global aim of UNAIDS is to end onward transmission of HIV by 2030. This is also the longstanding policy of the UK government and something that Labour recommitted to in its manifesto. We are currently in pole position, as a country, to be the first country in the world to reach this target. If realised, it will be the first time any government has stopped the onward transmission of any virus without a vaccine or a cure.

Labour’s manifesto pledge resolved to develop an HIV action plan to make the possible probable. Keir Starmer said it would be initiated within 100 days and published within a year. Twelve months on from the election, 4 July 2025, will also mark the anniversary of Terry Higgins being the first named person to die of an AIDS-related illness.

The modern-day fight against HIV today holds new challenges. As the number of undiagnosed people gets smaller, finding each person gets harder. We need to do more to pursue approaches that go beyond white, out gay men. In particular, while there will always be the need for community testing initiatives – my charity, Terrence Higgins Trust, runs the only year-round postal home testing kit service, with 4,000 click-and-collect sites nationally – there is an increased imperative to integrate screening into patient journeys by default.

Such strategies have a long and successful track record. In the UK, we have virtually eliminated ‘vertical transmission’ – the non-stigmatising way to describe mother-to-baby transfer of the virus – with an initiative started under Tony Blair in 2000: antenatal HIV testing. Every mother is screened unless they opt out. Very few do. Opt-out testing in maternity services has been a triumph that has now inspired a similar approach in other parts of the health system.

The next frontier is accident and emergency. Since April 2022, every adult attending A&E in London, Blackpool, Brighton, Manchester and Salford is automatically tested for HIV and hepatitis if they are having their blood taken. In 24 months, we have diagnosed over 1,200 people. This cohort is more likely to include women, people of Black African heritage, and older people. Those that are men who have sex with men are more likely to identify as not being ‘out’, ‘straight’, or ‘on the down low’ and often actively avoid LGBT health messaging. Of the 1,200 people found, at least a third had already been diagnosed but were not taking their medication. Often, the untreated virus was making them ill, hence their A&E visit.

Blanket A&E testing has two key advantages. First, it is good value for money. The scheme took £2.2m to establish but, within months, had saved the NHS £8m. The scheme currently finds a positive result for every 1,500 tests, meaning the cost of negative tests is quickly paid for by savings from diagnosing people before an ICU admission. And this is without considering the savings generated by preventing onward transmission.

Second, it is diagnosing people who don’t get tested in sexual health clinics. In its first week of rollout at Lewisham Hospital, an 85-year-old was diagnosed, much to her surprise. Recently, another London hospital identified a 68-year-old with HIV who hadn’t had sex for many years. The virus was eating away at her immune system; she now takes life-saving medication that can suppress the virus so it is undetectable in her system. Women, people of Black ethnicity, heterosexual people and older people are all diagnosed with HIV in greater numbers by this approach.

And as far as health inequalities are concerned, it turns out those who experience the worst inequalities are often sitting in A&E. A&E waiting rooms tend to be disproportionately populated by the very people who are less likely to visit or have access to a sexual health service.

What’s more, blanket screening is not only working for HIV. Most of the 34 funded hospitals also test for hepatitis C and B, and have discovered even higher rates of infection than for HIV; one in every 300 tests comes back positive for hepatitis B.

Other illnesses can be screened for too. At Ashton Under-Lyne Hospital, a trial of just 4,000 ‘opt-out’ diabetes tests was done with people waiting in A&E. They found 40 previously undiagnosed people with diabetes. That’s one per every 100 tests. An expanded diabetes testing programme along these lines could be a bargain, and transformational for public health.

Wes Streeting’s three shifts for the health service are analogue to digital, buildings to community, and treatment to prevention. These screening programmes are examples of prevention at its best, but unlike many other preventative measures, they take place in hospitals. As such, there is a danger that they are overlooked as Labour seeks to move more resources into community health.

The opportunities to expand further are extensive. Blood tests are now available for bowel and prostate cancer, as well as for syphilis, which is at its highest level since the second world war. There is currently good progress on a blood test for dementia and a new drug that can stop its onset for a decade, the combination of which could help mitigate our social care crisis significantly.

The fiscal advantages are particularly clear-cut. It’s quicker to train someone in pathology than it is to train a nurse or doctor. Blood testing labs are situated near every hospital, so their expansion would create good jobs across the UK. Plus, the more tests you buy, the more the private sector is incentivised to innovate.

Situating comprehensive diagnostic testing in A&E, at the front door of the NHS, has been proven effective by its application in HIV. It improves outcomes for patients, prioritises the poorest and most disadvantaged, and creates savings, even in the short-to-medium term. After 14 years, it is time to dust down progressive universalism and put it front and centre of the Starmer-Streeting change agenda.

Richard Angell is the chief executive of Terrence Higgins Trust

Brass tacks

by Oliver Walsh

An acute lack of resources is behind many instances of homelessness

After becoming homeless due to one missed rent payment, devoted father-of-two Leigh Midwinter was stuck in council provided temporary accommodation for three years. The accommodation was unsafe and contributed to his worsening mental and physical health. Leigh spent the little money he did have on the bus fare to see his children three hours away, but had little hope of being able to afford a rent deposit that would help him move out of homelessness. He was trapped.

Leigh’s experience of homelessness is unfortunately far too common. Quarterly homelessness statistics revealed that on at the end of 2023, 112,660 households in England were in temporary accommodation provided by local authorities, including a record 145,800 children. Those living in temporary accommodation often find it extremely difficult to find employment and access healthcare. Much of it is unsuitable and unsafe. And the distress is compounded by the fact that most households in temporary accommodation will be there for years, with no clear pathway out.

Temporary accommodation is not merely an unstable situation for those without a permanent home. It is also extremely costly for local authorities, who have a statutory duty to provide it to those experiencing homelessness. Leigh became homeless due to a missed rent payment of just £700; his stay in temporary accommodation cost the local authority tens of thousands of pounds.

With an ever-increasing number of households becoming homeless, temporary accommodation costs are one of the most significant drivers of the widespread financial difficulties currently faced by local authorities. Across the UK, council-owned accommodation is full and local authorities are finding themselves forced to pay extortionate rates to house residents in hotels and B&Bs. In the south east of England, this costs between £50–£90 per person per night, adding up to £18,250–£32,850 per person per annum.

Without providing those experiencing homelessness with a real pathway out of temporary accommodation, the homelessness crisis will only get worse. Families will remain trapped, services will continue to be overwhelmed and more local authorities will be forced to declare bankruptcy.

The new Labour government’s commitment to building 1.5m new homes and ending no-fault evictions are welcome. These measures are long overdue. Unless social housing forms the vast majority of these new homes, however, they won’t get close to ending the crisis.

Stuck in unsuitable temporary accommodation that worsened his mental health issues for three years, Leigh was desperate to move into permanent accommodation. Yet like the vast majority of those in temporary accommodation, he was unable to afford either a rent deposit to move into a private rental or the vital furnishings needed to move into unfurnished social housing – at least without falling into debt.

After three years, Leigh was eventually able to move out of homelessness after he was offered permanent housing and Greater Change, the charity I work for, funded his rent deposit so that he could move in. Greater Change, founded in 2019, supports people out of temporary accommodation by providing them with personalised budgets tailored to what each client needs to move out of homelessness for good. They can be used to pay for rent deposits as in the case of Leigh, to prevent evictions by clearing rent arrears, to fund training courses that unlock employment opportunities and in a wide range of other transformative ways. Nearly 90 per cent of those the charity supported last year were not homelessness 6-12 months on. This was at an average cost of just £1,319 – dwarfed by the resulting savings for local authorities.

As long as homeless people like Leigh lack the means to pay for the upfront costs of moving into permanent housing, hundreds of thousands of households will remain stuck in temporary accommodation, irrespective of the government’s new policies. We are calling for the new government to integrate personalised budgets into an evidence-driven strategy to end homelessness across the country. The simple policy measure could be introduced by making it a statutory requirement for local authorities to provide personalised budgets and combining this with a corresponding budget, allocated centrally, to fund the programme.

Combined with Labour’s ambitious housebuilding programme, personalised budgets have the potential to make significant strides towards tackling the homelessness crisis in the UK. By breaking down insurmountable financial barriers, they could give hundreds of thousands of households stuck in temporary accommodation a real pathway out of homelessness.

Oliver Walsh is the growth manager at homelessness charity Greater Change

Fresh start

by Natalie Perera

Reforming Ofsted can help fix our ailing education system

Bridget Phillipson has started her role in a relatively dark period for education. The gap between disadvantaged pupils and their peers is at its widest in over a decade, and regional inequalities continue to deepen.

In a constrained fiscal environment, her ability to get things back on track is limited. The government’s child poverty strategy will be key, but this will take time and not an insignificant amount of money.

So, until Labour can tackle child poverty, the new education secretary will need to focus on the levers she has and deploy one of the most powerful tools in her armoury: teachers. Outside of the home environment, we know that the quality of teaching matters the most to pupil outcomes.

Yet the profession is in serious trouble. The number of teachers is not keeping pace with pupil numbers, meaning that pupil:teacher ratios are increasing. There are a record number of vacancies for secondary teachers, and headteachers are now five times more likely to leave before retirement compared to 2010/11. Retention rates also continue to fall.

Labour’s commitment to recruit 6,500 new teachers is a laudable aim, but will take time to deliver. It will not be enough to meet demand, and will not, on its own, deal with high levels of turnover. So how can this new government stem the bleeding of existing teachers from the profession and incentivise new teachers to join? And how can they do this without spending any money? (A disclaimer: everything the government does will incur upfront costs, and this too will require some administrative spending.) The solution lies, partially, in reforming school accountability.

The issues with Ofsted are well documented. Our own research found that once a school receives a negative Ofsted grade, its intake tends to become more disadvantaged and teacher turnover increases. And the longer the school continues to have the less than good rating, the harder the process of school improvement becomes. If a school receives an ‘inadequate’ grade, that pretty much guarantees that it will be subject to changes in governance and significant upheaval for staff.

The threat of a downgraded Ofsted rating can often hang over even ‘high-performing’ schools. Incentives are skewed and can lead to undesirable behaviours by schools, including poor admissions practices, high rates of exclusion or off-rolling and a narrowing curriculum. Schools are judged primarily by how well their pupils perform in exams; these results headline school performance tables and are a considerable factor in Ofsted inspections. It is no surprise then that the system is increasingly unattractive to teachers who joined the profession wanting to have a positive impact on children’s lives.

A new government provides an opportune moment to change this status quo. The education discourse has shifted significantly since the Gove era, and there is now widespread acknowledgement that school effectiveness is about more than just exam results; it is also about school inclusion, pupil wellbeing, the offer of a broad and balanced curriculum and a system that doesn’t burn out or disillusion teachers.

Labour has already committed to reforming Ofsted judgements and to introducing a ‘balanced score care’ and should now prioritise implementing these measures. EPI’s own blueprint has shown that a more empirical approach can be an effective way of holding school leaders to account, while also enabling them to benchmark with their peers and share best practice. Alongside reforming Ofsted, building a similar model would be relatively cheap – and significantly cheaper than constantly firefighting the teacher recruitment and retention crisis.

Natalie Perera is the chief executive of the Education Policy Institute

Image credit: Testalize.me via Unsplash