Covid 19

Current awareness updates

Latest data reinforces the safety of COVID-19 vaccinations in pregnant women.
UK Health Security Agency (UKHSA); 2022.
[The UK Health Security Agency (UKHSA) urges pregnant women to get vaccinated as latest data reinforces previous findings on the safety of COVID-19 vaccines in pregnancy.]

Coronavirus: adult social care key issues and sources.
House of Commons Library; 2022.
[This briefing provides an overview of key issues facing the adult social care sector during the coronavirus (Covid-19) pandemic, and provides links to some of the key official guidance for the sector. Updated 28 January 2022.]

Measures implemented in the school setting to contain the COVID-19 pandemic: a rapid review. [Abstract]
Krishnaratne S. Cochrane Database of Systematic Reviews 2022;1:CD015029.
[OBJECTIVES: To assess the effectiveness of measures implemented in the school setting to safely reopen schools, or keep schools open, or both, during the COVID-19 pandemic, with particular focus on the different types of measures implemented in school settings and the outcomes used to measure their impacts on transmission-related outcomes, healthcare utilisation outcomes, other health outcomes as well as societal, economic, and ecological outcomes. ]


Public Health

Current awareness updates

Avian influenza: guidance for managing human cases.
UK Health Security Agency (UKHSA); 2021.
[Information to assist with the management of possible and confirmed human cases of avian influenza.]

Heart valve disease presenting in adults: investigation and management.
National Institute for Health and Care Excellence (NICE); 2021.
[This guideline covers investigation and management of heart valve disease presenting in adults. It aims to improve quality of life and survival for people with heart valve disease through timely diagnosis and appropriate intervention.]

Acute heart failure: diagnosis and management.
National Institute for Health and Care Excellence (NICE); 2021.
[This guideline covers diagnosing and managing acute heart failure or possible acute heart failure in people aged 18 and over. Heart failure may indicate acute myocardial injury in patients with COVID-19. See the recommendations in NICE COVID-19 rapid guideline on managing COVID-19. In November 2021, NICE withdrew the recommendations on valvular surgery and percutaneous intervention because they have been replaced by the NICE guideline on heart valve disease.]

Public health commissioning in the NHS: 2021 to 2022.
Department of Health and Social Care (DHSC); 2021.
[Information about NHS England’s objectives and funding arrangements as it commissions public health services in the ongoing context of coronavirus (COVID-19).]

Cause for concern: Australian youth engaged with alcohol and other drug services are falling behind our community progress in reducing tobacco use.[Abstract]
Hallam KT. Early Intervention in Psychiatry 2021;15(6):1789-1792.
[Tobacco use is decreasing in the general youth population yet little evidence is tracking changes in young people who are engaged with youth alcohol and other drug (AOD) services that are often disengaged from school and work settings. Conclusion: The results highlight a need for the adoption of evidence-based tobacco early intervention programs in youth AOD services to address this significant health risk.]

Quality improvement project to decrease unnecessary investigations in infants with bronchiolitis in Cork University Hospital.[Abstract]
Jansen L. BMJ Open Quality 2021;10(4):DOI: 10.1136/bmjoq-2021-001428.
[Conclusion: An evidence-based protocol improved physicians’ ability in diagnosing and managing infants with bronchiolitis. This led to a reduction in unnecessary and potential harmful investigations, thereby improving patient quality of care. This improvement will contribute to decreased healthcare cost and appropriate use of resources during the high-pressured winter period.]

Covid 19

Current awareness updates

COVID-19: letter to patients on end of shielding programme.
UK Health Security Agency (UKHSA); 2021.
[Reference-only version of letter from the government to patients on the end of the shielding programme.]

COVID-19 rapid guideline: managing the long-term effects of COVID-19.
National Institute for Health and Care Excellence (NICE); 2021.
[This guideline covers identifying, assessing and managing the long-term effects of COVID-19, often described as ‘long COVID’. On 11 November, NICE made new recommendations and updated existing recommendations on identification; planning care; multidisciplinary rehabilitation; follow up, monitoring and discharge; and service organisation. NICE also updated the list of common symptoms, emphasising that these may be different for children.]

COVID-19 booster vaccine programme for winter 2021 to 2022: JCVI statement, November 2021.
Department of Health and Social Care (DHSC); 2021.
[This statement sets out further advice from JCVI on extension of the booster programme to revaccinate adults aged 40 to 49 years against COVID-19. The main aim of this booster vaccination programme is to reduce deaths, serious disease and hospitalisations from COVID-19 over the 2021 to 2022 winter period and through 2022.]

Why we think you should say yes to the COVID-19 vaccine.
Leeds Clinical Commissioning Group; 2021.
[An information leaflet about the COVID-19 vaccine where clinicians and faith leaders highlight the importance of having the vaccine. The leaflet has been translated into the following languages: Amharic, Arabic, Bengali, Czech, Farsi, Kurdish Sorani, Polish, Punjabi, Romanian, Slovak, Tigrinya and Urdu. Audio versions of the leaflet are available for each of those languages.]

No one wants to see my baby: challenges to building back better for babies.
Parent-Infant Foundation; 2021.
[This report explores the continued impact of Covid-19 on babies. It consists of a survey of professionals, in-depth studies with 11 families and a review of the literature, conducted with partner organisations Home-Start and Best Beginnings. The report shows that many services across the UK are not operating as they were before the pandemic, and babies and their families are missing out as a result.]

Essential and Invisible: Filipino irregular migrants in the UK’s ongoing COVID-19 crisis.
Kanlungan Filipino Consortium; 2021.
[For many in the United Kingdom, it might feel as if the “crisis” of the COVID-19 pandemic is coming to an end. Yet for irregular migrants, the pandemic has become a protracted struggle to survive. This report is based on interviews with Filipino irregular migrants based in the UK conducted in Spring 2021, compared to the same interviewees’ responses in Spring 2020.]

Coronavirus: support for landlords and tenants.
House of Commons Library; 2021.
[This briefing explains measures during the coronavirus outbreak to help renting households retain their homes. It covers calls for more assistance to prevent evictions and homelessness.]

Covid 19

Current awareness updates

Protecting Nursing Homes and Long-Term Care Facilities From COVID-19: A Rapid Review of International Evidence.
Dykgraaf SH. Journal of the American Medical Directors Association 2021;22(10):1969-1988 .
[High-quality evidence of effectiveness in protecting LTCFs from COVID-19 was limited at the time of this study, though it continues to emerge. Despite widespread COVID-19 vaccination programs in many countries, continuing prevention and mitigation measures may be required to protect vulnerable long-term care residents from COVID-19 and other infectious diseases. This rapid review summarizes current evidence regarding strategies that may be effective.]

Coronavirus: lessons learned to date.
House of Commons Library; 2021.
[This inquiry looked at six key areas of the response to the pandemic in England: the country’s preparedness for a pandemic; the use of non-pharmaceutical interventions such as border controls, social distancing and lockdowns to control the pandemic; the use of test, trace and isolate strategies; the impact of the pandemic on social care; the impact of the pandemic on specific communities; and the procurement and roll-out of covid-19 vaccines.]

The Big Ask: The Big Answer.
The Children’s Commissioner; 2021.
[The Children’s Commissioner’s Big Ask set out to hear the voices of as many children in England as possible, to amplify them, and to deliver improved life chances for this generation and beyond, following recovery from the pandemic.]

The digital divide: Amplifying health inequalities for people with severe mental illness in the time of COVID-19. [Editorial]
Spanakis P. British Journal of Psychiatry 2021;219(4):529-531.
[People with severe mental illness face profound health inequalities (eg. a >20-year mortality gap). Digital exclusion puts this population at risk of heightened or compounded inequalities. This has been referred to as the ‘digital divide’. For new digital means introduced in clinical practice to augment healthcare service provision, issues of accessibility, acceptability and usability should be addressed early in the design phase, and prior to implementation, to prevent digital exclusion.]

Time use and mental health in UK adults during an 11-week COVID-19 lockdown: A panel analysis.
Bu F. British Journal of Psychiatry 2021;219(4):551-556.
[To examine the associations between specific activities (or time use) and mental health and well-being among people during the COVID-19 pandemic. Conclusions: These results are relevant to the formulation of guidance for people obliged to spend extended periods in isolation during health emergencies and may help the public to maintain well-being during future lockdowns and pandemics.]

COVID-19 vaccination: women of childbearing age, currently pregnant or breastfeeding.
UK Health Security Agency (UKHSA); 2021.
[Information for all women of childbearing age, those currently pregnant or breastfeeding on coronavirus (COVID-19) vaccination. 8 October 2021: Updated ‘COVID-19 vaccination: a guide on pregnancy and breastfeeding’ and links to translated versions of the poster and social media cards.]

Delivering safe, face-to-face adult day care.
Social Care Institute for Excellence (SCIE); 2021.
[The latest updates to the guidance include: Isolation and vaccination info; Lifting of restrictions (Step 4); Webinar recording on day care; How to access testing; What to do in case of an outbreak; Free provider PPE until March 2022.]

Covid 19

Current awareness updates

COVID-19 rapid guideline: managing COVID-19.
National Institute for Health and Care Excellence (NICE); 2021.
[In October, NICE added new recommendations on casirivimab and imdevimab. New data on the use of heparins (from the REMAP-CAP trial results) does not change the current recommendations.]

The consequences of COVID-19 lockdown for formal and informal resource utilization among home-dwelling people with dementia: results from the prospective PAN.DEM study.[Abstract]
Vislapuu M. BMC Health Services Research 2021;21(1):1003.
[The care situation for PwD changed dramatically in the early phase of the COVID-19 pandemic, especially for those living alone who received less support from homecare services and visiting caregivers. For future crises and the forthcoming post-pandemic period, health authorities must plan better and identify and prioritize those in greatest need.]

The impact of the COVID-19 pandemic on patterns of attendance at emergency departments in two large London hospitals: an observational study.[Abstract]
Vollmer MAC. BMC Health Services Research 2021;21(1):1008.
[Our study findings reflect broader trends seen across England and give an indication how emergency healthcare seeking has drastically changed. At ICHNT, we find that a larger proportion arrived by ambulance and that hospitalisation outcomes of patients without COVID-19 did not differ from previous years. The extent to which these findings relate to ED avoidance behaviours compared to having sought alternative emergency health services outside of hospital remains unknown.]

Remote schooling through the coronavirus (COVID-19) pandemic, England: April 2020 to June 2021.
Office for National Statistics (ONS); 2021.
[How remote learning has affected the amount of learning materials covered by pupils and the dependence of remote learning on parental input over the course of the coronavirus (COVID-19) pandemic.]

Inequalities in accessing dementia care and support during COVID-19.
The Mental Elf; 2021.
[Catherine Talbot reviews a recent qualitative study on accessing post-diagnostic dementia care before and since COVID-19, which highlights the need to reduce inequalities in dementia care.]

COVID-19: provision of immunisation sessions for outbreaks in schools.
Public Health England (PHE); 2021.
[Guidance for School Age Immunisation Services on the provision of immunisation sessions in schools where there are cases or an outbreak of COVID-19.]

UKHSA review into IPC guidance.
Department of Health and Social Care (DHSC); 2021.
[Recommendations for changes to COVID-19 infection prevention and control (IPC) advice to help ease pressure on the NHS.]

Impacts of the COVID-19 pandemic on youth mental health among youth with physical health challenges.[Abstract]
Hawke LD. Early Intervention in Psychiatry 2021;15(5):1146-1153.
[CONCLUSIONS: Mental health concerns are highly prevalent among youth with physical health concerns, and also appear to be exacerbated by the COVID-19 pandemic. Physical health concerns appear to constitute risk factors for heightened mental health responses to the pandemic situation. System planners striving to adapt mental health services to meet distancing recommendations are urged to consider youth with physical health conditions and ensure that integrated supports are available to them.]

NDNS: Diet and physical activity – a follow-up study during COVID-19.
Public Health England (PHE); 2021.
[This report presents the findings from a follow-up study of National Diet and Nutrition Survey Rolling Programme (NDNS RP) participants which aimed to describe and assess the impact of the COVID-19 pandemic on the diet and physical activity of people in the UK in 2020.]

Vaxzevria (AstraZeneca) Covid-19 vaccine: Recognition of batches manufactured in India.
House of Commons Library; 2021.
[This briefing provides an overview of the regulatory concerns associated with batches of the Vaxzevria (previously called AstraZeneca) vaccine which were manufactured in India.]


Long COVID

MEDBOX issue brief on Long COVID

The MEDBOX team publishes issue briefs on different topics around COVID-19. They have prepared a new issue brief on the long-term effects of coronavirus infection, Long COVID (also known as long-haul COVID, post-acute COVID-19, long-term effects of COVID, or chronic COVID). The issue brief includes many links to relevant reports and guidance about long COVID.

Read the brief here

Covid 19

Current awareness updates

Preventing and controlling outbreaks of COVID-19 in prisons and places of detention.
Public Health England (PHE); 2021.
[Information for prisons and other prescribed places of detention on coronavirus (COVID-19).]

COVID-19 rapid guideline: managing COVID-19.
National Institute for Health and Care Excellence (NICE); 2021.
[In September 2021, NICE added new recommendations on non-invasive respiratory support and doxycycline, and updated existing recommendations on heparins.]

COVID-19 shared learning from NHS trusts.
NHS Employers; 2021.
[Despite the relentless pressures of COVID-19 on NHS trusts, we have seen innovation, transformational change, and real improvements to enhance the experience of staff across the service. This page presents seven examples of good practice from trusts that have adapted and innovated during the pandemic.]

Debate: Is there a true global children and young people’s mental health crisis, fact or fiction?[Abstract]
Ford T. Child and Adolescent Mental Health 2021;26(3):272-273.
[Following COVID-19, there has been increasing concern about the well-being of children and young people across the United Kingdom; however, our major problem is the lack of robust data. We discuss emerging research capturing the impact of restrictions and experiences of COVID-19 on children and young people.]

Debate: The toll of the COVID-19 pandemic on children’s risk for suicidal thoughts and behaviors.[Abstract]
Melhem NM. Child and Adolescent Mental Health 2021;26(3):274-275.
[The consequences of the COVID-19 pandemic on risk for suicidal thoughts and behaviors (STBs) in children are still not fully known. However, COVID-19 and the mitigation strategies to limit its transmission have affected children and adolescents through increased parental morbidity and mortality, increased poverty and financial strain, social isolation, and lost connectedness to school, peers, and afterschool activities.

Experiences of maternity care during the COVID-19 pandemic in the North of England.
Stacey T. British Journal of Midwifery 2021;29(9):516–523.
[During 2020, UK maternity services made changes to service delivery in response to the COVID-19 pandemic. This study aimed to explore service users’ and their partners’ experiences of maternity services in the North of England during the COVID-19 pandemic. Respondents (n=606) completed a co-produced survey during August 2020. Data were analysed using descriptive statistics and content analysis.]

Covid 19

Current awareness updates

Daily Insight: Covid can’t peak too soon.
HSJ: Health Service Journal (Daily Insight) 2021;:7030598.
[Confirmed covid cases in the community fell again on Tuesday, offering further hope that the current wave could have peaked. Most experts are highly cautious about saying so – there is likely to be further growth following ‘freedom day’. Also: In the Cheshire and Merseyside ICS, the nine local authorities have issued a series of “red lines” and pre-conditions to health service leaders. 28 July.]

Daily Insight: Covid puts one in 10 beds to sleep.
HSJ: Health Service Journal (Daily Insight) 2021;:7030631.
[A major hospital trust has made its highest number of bed closures “for many years” due to covid staffing pressures. Newcastle upon Tyne Hospitals Trust lost 933 bed days in the first week of June due to staff testing positive for covid or being required to isolate. Also: Latest figures show just 3 per cent of A&E attendances nationally are ‘booked’ through the 111 First service. And Healthwatch England says the NHS has not done enough to publicise this new service. 3 August.]

New study into COVID-19 vaccine dose interval for pregnant women.
Department of Health and Social Care (DHSC); 2021.
[The Preg-CoV clinical trial has been launched to help determine optimal gap between doses as well as explore potential side-effects in more detail. Research shows pregnant women more likely to become seriously ill from COVID-19 and 98% of those in hospital due to COVID-19 are unvaccinated.]

Coronavirus: the consequences for mental health.
Mind; 2021.
[This research with almost 12,000 people found that those with mental health problems report an increase in the severity of challenges they’re facing now and concerns about the future. The authors call for services to be ready for the increase in severity of people’s mental health problems, and to take into account the trauma that people have experienced over the past year and how this might affect the support they need.]

Coronavirus: Adult social care key issues and sources.
House of Commons Library; 2021.
[House of Commons Library research Briefing updated 23 July 2021. An overview of key issues facing the adult social care sector during the coronavirus (Covid-19) outbreak, with links to some of the key official guidance for the sector.]

Coronavirus and the social impacts of ‘long COVID’ on people’s lives in Great Britain: 7 April to 13 June 2021.
Office for National Statistics (ONS); 2021.
[Indicators from the Opinions and Lifestyle Survey covering the period 7 April to 13 June 2021 to understand the impact of the coronavirus (COVID-19) pandemic on people by their self-reported long COVID-19.]

Covid 19

Current awareness updates

Inequalities in healthcare disruptions during the Covid-19 pandemic: Evidence from 12 UK population-based longitudinal studies.
medRxiv; 2021.

[The research, led by UCL and the University of Glasgow, found further evidence that minority ethnic groups were more likely to have their healthcare affected by the Covid crisis than white people, with the combined results of the 12 studies suggesting minority ethnic groups reported 19% more problems during the epidemic. This article is a preprint and has not been certified by peer review.]

An obesity strategy to reduce COVID-19 morbidity and mortality.
Glasper A. British Journal of Nursing 2021;30(10):612-614.

[In 2020 Prime Minister Boris Johnson launched a series of policy initiatives as part of his government’s new obesity strategy. The prime minster himself was admitted to an intensive care unit after being infected with the SARS-CoV-2 coronavirus and succumbing to COVID-19. Following his successful treatment and discharge from hospital he acknowledged that his deterioration was probably linked to his own excess body weight.]

Importance of patient bed pathways and length of stay differences in predicting COVID-19 hospital bed occupancy in England.[Abstract]
Leclerc QJ. BMC Health Services Research 2021;21(1):566.

[We identified five bed pathways, with substantial variation in LoS by bed type, pathway, and geography. This might be caused by local differences in patient characteristics, clinical care strategies, or resource availability, and suggests that national LoS averages may not be appropriate for local forecasts of bed occupancy for COVID-19.]

Delivering routine immunisations in London during the Covid-19 pandemic: lessons for future vaccine delivery.
Skirrow H. British Journal of General Practice Open 2021;(18 May)

[Mixed-methods study of immunisation delivery in London including an online survey of GP practices and interviews were used to explore new immunisation delivery models which built on existing local knowledge, experiences and networks.]

Strategies and action points to ensure equitable uptake of COVID-19 vaccinations: A national qualitative interview study to explore the views of undocumented migrants, asylum seekers, and refugees.
Deal A. Journal of Migration and Health 2021;4(-):100050.

[Report of in-depth semi-structured qualitative interviews (n=32) of recently arrived migrants (foreign-born, >18 years old; <10 years in the UK) to the UK with precarious immigration status, seeking their input into strategies to strengthen COVID-19 vaccine delivery and uptake.]

Community-based volunteering in response to COVID-19: the COV-VOL project.
NIHR Applied Research Collaboration, Kent, Surrey and Sussex; 2021.

[A study by a team from the University of Kent, Brighton and Sussex Medical School and Sussex University shows how voluntary community and social enterprise (VCSE) organisations have made a significant, positive impact on the well-being of older people self-isolating at home during the first COVID-19 lockdown. The pandemic has highlighted the importance of volunteers and community and the role VCSE organisations can play as key and essential partners in our health and social care systems.]

The 3 R’s of Social Care Reform: How constructive risk taking, respectful relationships and a sense of reciprocity characterised a positive response to the Covid-19 pandemic.
Think Local Act Personal; 2021.

[TLAP has been talking to people across social care, and including those who draw on care and support, about their experiences during the pandemic. This paper reflects on these conversations and identifies drivers of the promising examples of practice, marked by changes in behaviour and increased levels of trust. It suggests that positive risk-taking, respectful relationships and a sense of reciprocity are key ingredients in characterising a positive response to the pandemic.]

Unlocking the digital front door – keys to inclusive healthcare.
National Voices; 2021.

[This report explores how the move to remote service models impacted people and how the Voluntary, Community and Social Enterprise sector (VCSE) has led innovative ways to deliver healthcare and support to people during the COVID 19 pandemic. Also available is a literature review and insight data, personal narratives and recommendations for better practice, better policy, and better innovations.]

School closures and parents’ mental health.
Institute for Social and Economic Research (ISER); 2021.

[In this study, researchers from the universities of Essex, Surrey and Birmingham, funded by the Nuffield Foundation, consider the dynamics of parents’ mental health during the pandemic. The study is the first of its kind to look specifically at the impact of having children at home as a result of school closures, separating it from other factors affecting parents’ mental health during the pandemic.]

Outsourcing as a threat to public health: the case for insourcing public sector cleaners and facilities management.
New Economics Foundation; 2021.

[The evidence cited in this report suggests that outsourced health facilities management services pose a threat to public health. This represents a major weakness in the UK’s ability to cope with subsequent waves of Covid-19. As a matter of public health, this paper recommends that the government should launch an urgent and independent inquiry into the outsourcing of key workers.]

Targeted AF detection in COVID-19 vaccination clinics.
Getting It Right First Time (GIRFT), Oxford AHSN; 2021.

[This document brings together learning from several pilot sites which have been carrying out targeted detection of atrial fibrillation (AF) in COVID-19 vaccination clinics. The aim is to provide guidance for systems wishing to develop a standard operating procedure for offering targeted rhythm checks for AF detection in mass vaccination clinics.]

Coronavirus and vaccination rates in people aged 70 years and over by socio-demographic characteristic, England : 8 December 2020 to 9 May 202.
Office for National Statistics (ONS); 2021.

[Difference in vaccination rates by sociodemographic group, sex, ethnicity, religion, main language, living in areas of deprivation, and disability.]


Covid 19

Current awareness updates

Fairer foundations: How has the pandemic affected young people’s mental health? Infographic
The Health Foundation; 2021.

[This infographic highlights the unequal mental health effects of the pandemic among young people. Young people’s lives have been significantly impacted by the pandemic – disrupted schooling, lost employment and not being able to see friends. But the effects of the crisis have not been the same for everyone, including a divergence of mental health experiences.]

Coronavirus and depression in adults, Great Britain: January to March 2021.
Office for National Statistics (ONS); 2021.

[Analysis of the proportion of the British adult population experiencing some form of depression in early 2021, by age, sex and other characteristics. Includes comparisons with 2020 and pre-pandemic estimates.]

Care pathway and prioritization of rapid testing for COVID-19 in UK hospitals: a qualitative evaluation.[Abstract]
Hicks T. BMC Health Services Research 2021;21(1):532.

[This study sought to understand the care pathways in place in UK NHS hospitals during the first wave (March-July 2020) for identification of patients with COVID-19 and to learn lessons to inform optimal testing strategies within the COVID-19 National Diagnostic Research and Evaluation Platform (CONDOR). During the winter months, priority for provision of rapid testing at admission should be given to hospitals with limited access to laboratory services and single room availability.]

Adult social care and COVID-19 after the first wave: assessing the policy response in England: Our analysis of the national government policy response for social care between June 2020 and March 2021.
The Health Foundation; 2021.

[In this briefing, the Health Foundation analyse policies to support adult social care during the height of the second wave of the pandemic in January and February 2021, and in the months leading up to it. We provide a narrative summary of central government policies related to adult social care in different areas, such as policies on testing and support for the workforce. We also provide a summary of the latest publicly available data on the impacts of COVID-19 on adult social care.]


Happy to help: the welfare effects of a nationwide micro-volunteering programme.
London School of Economics and Political Science (LSE); 2021.

[This paper estimates the wellbeing benefits from volunteering for England’s NHS Volunteer Responders programme, which was set up in response to the Covid-19 pandemic. It found that active volunteers report significantly higher life satisfaction, feelings of worthwhileness, social connectedness, and belonging to their local communities. A social welfare analysis shows that the benefits of the programme were at least 140 times greater than its costs.]


Coronavirus Act report: May 2021.
Department of Health and Social Care (DHSC); 2021.

[The seventh two-monthly report on which powers in the Coronavirus Act 2020 are currently active.]


Vivaldi study: results.
Department of Health and Social Care (DHSC); 2021.

[Results for the Vivaldi study for antibody and cellular immune responses to coronavirus (COVID-19) in approximately 340 care homes.]

Deaths involving COVID-19 in the care sector, England and Wales: deaths registered between week ending 20 March 2020 and week ending 2 April 2021.
Office for National Statistics (ONS); 2021.

[Provisional figures on deaths involving the coronavirus (COVID-19), an investigation into wave 1 versus wave 2 within the care sector, in England and Wales.]