There has been a rise in “economic inactivity” in the UK among people of working age since the start of the COVID pandemic. Although the trend peaked last year, an additional 420,000 people are now in this category compared with early 2020.

People classed as economically inactive are neither working nor actively seeking employment. They include students, retired older people, and those in poor health or caring for others at home. Helping these people return to work would alleviate current UK labour shortages that are increasing workloads for existing staff, limiting output and business growth.

According to the Annual Population Survey from the Office for National Statistics, there are around 1.65 million inactive people in the UK that say they would like to work, but they need support. There have been calls to widen access to existing UK government-funded programmes and make services more tailored to people’s needs.

But people who are economically inactive are not typically well served by mainstream national employment support. Inactivity rates vary widely between areas, and have done for many years. For example, in 2022 in East Lindsey, Lincolnshire, 36% of the working-age population was economically inactive, whereas it was just 9% in Wandsworth.

Our joint research with Anne Green from the University of Birmingham and Paul Sissons from the University of Wolverhampton, shows a more local approach to employment support could help tackle this challenge.

This would involve working with local policymakers and organisations to design policy and programmes. Such localised initiatives could focus on helping people with multiple or complex barriers such as debt, poor health and limited childcare – depending on the most pressing issues in the area. These employment support services could also prioritise moving people into better-paid work, rather than the first job that becomes available.

What are the benefits of a more local approach?

Localising employment support could address gaps in the help that is already on offer, while reducing duplication between different government services. Involving local stakeholders in designing employment support could also enable policy to be better targeted.

For example, Connecting Communities was an employment support pilot that ran in the West Midlands between 2018 and 2021, as part of a government pilot employment scheme. It took a place-based approach to employment support, offering tailored, intensive support to people in nine neighbourhoods.

In order to reach people who do not traditionally engage with employment support, providers varied how and where participants were engaged. For example, they sought to facilitate engagement by reaching out to people at food banks, community centres and supermarkets.

An evaluation of the scheme by the Institute for Employment Studies and Birmingham University’s City Region Economic and Development Institute (City-Redi) suggested that personalised, place-based employment support programmes can be effective in reaching people with significant barriers to work. It can also help participants become more aware of, and work towards, employment opportunities.

Other criticisms of mainstream provision are that it emphasises sanctions rather than support. After a pandemic lull, the number of applied benefit sanctions reached 52,000 in March 2022. Most sanctions are imposed for fairly minor issues, such as missed or late arrivals at meetings. Research on sanctions also suggests there is little accountability for the decisions made by employment advisers.

Some evaluations suggest a local approach that builds more trusting relationships between jobseekers and advisers could be more successful in moving people into sustainable employment. Another opportunity lies in developing local approaches that extend access to support to economically inactive people, rather than narrowly targeting it at those on benefits who are required to actively look for work.

Why isn’t this happening?

The UK has traditionally pursued a highly centralised approach to employment support. Local Jobcentres mainly implement national policy priorities. The support on offer is relatively limited, covering work search reviews and guidance, vacancy referrals, and access to some training, education and work experience programmes.

This is also largely targeted at moving active jobseekers on benefits into a job, so will exclude many who are economically inactive. To keep their benefit payments, jobseekers are required to engage with this provision and to meet a range of requirements set by their adviser.

Local councils and authorities do not have the power to implement locally specific employment support programmes right now. Fewer evaluations exist of locally designed policies than nationally designed policies. However, some recent government pilots have explored the potential to pursue different approaches to employment support in different city regions.

The Local Government Association has called for further devolution and partnership working under a “Work Local” model. This would enable a more integrated and supportive approach.

And, while not a central theme in its 2023 budget, the government did announce a trial of an integrated approach to work and health support in local areas. It also promised a “co-design approach” to all future contracted employment support in Manchester and the West Midlands. The Labour Party also wants to expand employment support, including devolving it to local authorities and embedding career advisers in health services to help people into work.

Recent proposals for local approaches to employment support are a step in the right direction, but they are unlikely to bring inactivity levels down. Comparatively speaking, the UK spends relatively little as a percentage of its GDP on active labour market programmes, including public employment services. The government needs to focus more on how national employment support is targeted and funded. The reliance on sanctions to push people into the first job they can find is also not working.

Overall, our research indicates that a different approach is needed. Initiatives that fit people to jobs that more closely meet their requirements, and that also align with local needs, could help get people back to work and tackle the labour shortages that are damaging the UK economy.

Abigail Taylor along with colleagues at the City-Region Economic Development Institute (City-REDI at the University of Birmingham received funding from the West Midlands Combined Authority to undertake an evaluation of the Connecting Communities employment support pilot and they also acknowledge the support of WMREDI funding from Research England. Abigail is a member of the Social Policy Association's Employment Policy group.

Ceri Hughes receives research funding from the ESRC for her PhD research and is co-lead of the Social Policy Association's Employment Policy group.

Read More

By Lia Tadesse

As we commence 2023, the world is still grappling with the direct and indirect effects of the COVID-19 pandemic. In retrospect, the pandemic tested Ethiopia’s health system like no other challenge in recent history and amplified its existing strengths and weaknesses. The crisis also gave us an opportunity to rebuild our system with new insights, gained from the response to this once-in-a-generation pandemic.

I was appointed as Minister of Health in Ethiopia the day our health system detected the first COVID-19 case in the country, 70 days after the first case was detected in Wuhan. Two to three months following this, we noticed a significant decline in the utilization of essential health services like vaccines, antenatal care, HIV care, and others. The Ministry’s identification and awareness of this worrying trend was made possible through our District Health Information System, which enabled health officials to plan for—and execute—mitigation measures including non-visit care through teleconsulting; multi-month dispensing; and strong effective community monitoring. These measures helped Ethiopia to be among the few African countries that have maintained essential health services during the pandemic.

However, there were also pitfalls and lessons for improvement. The health system was aware of only a proportion of the cases and deaths from COVID-19, even though the Government rapidly expanded testing sites from zero to 85, in less than six months. During these first few months, we implemented strict public health and social distancing measures that were being recommended globally and used by many countries in the region. We quarantined travellers, contacts, and suspects in health facilities, schools, and other public facilities and admitted all positive cases. In hindsight, there was already community spread by the time we were implementing these interventions, making our response ineffective and less appropriate for the stage of the outbreak. We also quickly learned that we did not have the physical infrastructure, nor the resources required for isolating thousands of people and had to make a shift.

As I look forward to 2023, I single out two priority investment areas that are required to build a more resilient system that will be better equipped to handle future health shocks.

Investing in health information systems that generate individual-level patient data should be a priority in 2023. This will support vital registration efforts, enable contact tracing, assessment of the quality of care, and provide near-real time outcome data to guide the health system with evidence.

Investing in a strong primary health care (PHC) providing diverse care. Ethiopia has prioritized investment in PHC, but to date, most of these investments have been narrowly focused on preventing and treating infectious diseases and maternal and childhood illnesses and only recently expanded to noncommunicable diseases (NCDs). However, in order to respond effectively to future outbreaks, our PHC should have the capacity to address a broader range of health challenges like NCDs, mental health, emergencies, and others. The benefits of community outreach through house-to-house surveillance by health extension workers, was also a valuable lesson to continue investing in community health for a strong PHC.

Read More

COVID vaccines are very effective, but for some groups they don’t generate as strong an immune response. These groups include older adults and people with weakened immune systems, for example due to cancer or other medical conditions. They tend to already be at heightened risk from COVID.

Likewise, obesity – and its association with several other conditions such as type 2 diabetes, high blood pressure and chronic kidney disease – leads to an increased risk of severe COVID.

The effect of obesity on COVID vaccine effectiveness, however, has not been well understood. But our new study in Nature Medicine finds obesity is linked to faster loss of immunity from COVID vaccines.

We know people with obesity have an impaired immune response to other vaccines including those for influenza, rabies and hepatitis.

COVID vaccines generate antibodies which recognise the spike protein, a protein on the surface of SARS-CoV-2 (the virus that causes COVID) that allows it to attach to and infect our cells. The vaccines also prime immune cells called T cells to protect against severe COVID if we do contract the virus.

Because immunity acquired after two doses wanes in the months afterwards, many countries have elected to administer booster vaccines to maintain immune protection, particularly in vulnerable groups.

Several studies have suggested that following COVID vaccination, antibody levels may be lower in people with obesity than in the general population.

Read more: Severe COVID in young people can mostly be explained by obesity – new study

Earlier in the pandemic, we assembled a team of researchers from the University of Cambridge and the University of Edinburgh to investigate the effect of obesity on vaccine effectiveness over time.

Using a data platform called EAVE II, the University of Edinburgh team, led by Aziz Sheikh, examined real-time healthcare data for 5.4 million people across Scotland. In particular, they looked at hospitalisations and deaths from COVID among 3.5 million adults who had received two vaccine doses (either Pfizer or AstraZeneca).

They found that people with severe obesity, defined as a body mass index (BMI) over 40, had a 76% increased risk of hospitalisation and death from COVID after vaccination compared to those with a BMI in the normal range. The risk was also moderately increased in people who were obese (a BMI between 30 and 40) and those who were underweight (a BMI lower than 18.5).

The risk of severe disease from breakthrough infections after the second vaccine also began to increase more quickly among people with severe obesity (from around ten weeks post-vaccination) and among people with obesity (from around 15 weeks) compared with people of a normal weight (from around 20 weeks).

Investigating further

Our team conducted experiments to characterise the immune response to a third dose, or booster, of mRNA COVID vaccines (those made by Pfizer and Moderna) in people with severe obesity.

We studied 28 people with severe obesity attending Addenbrooke’s Hospital in Cambridge, and measured antibody levels and function as well as the number of immune cells in their blood post-vaccination. We compared the results to those from 41 people of a normal weight.

Although antibody levels were similar in samples from all participants before booster vaccination, the ability of antibodies to work efficiently to fight the virus, known as “neutralisation capacity”, was reduced among people with severe obesity. In 55% of people with severe obesity we either couldn’t detect or quantify neutralisation capacity, compared to 12% of people with normal BMI.

This might mean COVID vaccines induce lower quality antibodies in people with obesity. It’s possible the antibodies are not able to bind to the virus with the same strength as in people of a normal weight.

Read more: How much immunity do we get from a COVID infection? Large study offers new clues

After a booster, antibody function in people with obesity was restored to the same level as those of normal weight. However, using detailed measurements of B cells, which are responsible for antibody production and immune memory, we found that these immune cells developed differently in the first couple of weeks after vaccination in people with obesity.

By repeating measurements of immune responses over time, we could see antibody levels and function declined more rapidly after the third dose in people with severe obesity.

What does this mean?

There were some limitations in both parts of the study. For example, BMI data was only collected once in EAVE II and therefore we cannot exclude changes in BMI over time. Also, the number of people included in our in-depth immunology study was relatively modest.

Nonetheless, immunity from COVID vaccines doesn’t seem to be as robust or long-lasting in people with obesity. With severe obesity affecting 3% of the UK population and 9% of the US population, these findings have important implications.

First, COVID boosters may be particularly important for this group. Our study also highlights the need for more targeted interventions to protect people with obesity from severe COVID.

Evidence shows weight loss of at least 5% can reduce the risk of type 2 diabetes and other metabolic complications of obesity. Interventions that can lead to a sustained reduction in weight (such as lifestyle modification, weight loss drugs, and bariatric surgery) could similarly improve COVID outcomes.

Weight loss may likewise improve vaccine responses, but we need more research to investigate.

Agatha A. van der Klaauw received funding from ZonMW (2007, The Netherlands), Wellcome Trust (2012, UK) and UKRI (2021, UK).

I. Sadaf Farooqi is supported by Wellcome (207462/Z/17/Z), Botnar Fondation, the Bernard Wolfe Health Neuroscience Endowment and a NIHR Senior Investigator Award. I. Sadaf Farooqi has consulted for Eli Lilly, Novo Nordisk and Rhythm Pharmaceuticals on weight loss drugs.

James E. D. Thaventhiran does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

Read More