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    The Camden New Journal (CNJ) have published the sixth article about the NHS written by Susanna Mitchell and Roy Trevelion. You can see it on the CNJ website under ‘Forum’ published on 16 July 2020 here. Or you can read it below:

    Neglect and inadequate excuses lie at the heart of the government’s failures, argue Susanna Mitchell & Roy Trevelion

    It is understood that there will be a public inquiry into the UK’s handling of the coronavirus pandemic.

    This should begin now, and not when the current crisis is over. Criticisms will be focused on the government’s disastrous response:

    Its initial adoption of a “herd immunity” strategy.

    Its failure to provide health care workers and others in front-line positions with adequate personal protective equipment (PPE).

    The shambolic state of its belated testing and tracking operations, including the collapse of its much-heralded app.

    Its reliance on private contractors with no relevant experience to supply services and equipment that they were subsequently unable to deliver.

    Critically, it will be claimed that all the measures taken were put in place far too late. With the result that the UK now has the highest death toll in Europe. The proportion of care-home deaths is 13 times greater than that of Germany.

    All these accusations are currently being met with the excuse that the Covid-19 pandemic was unprecedented. The government claims it has worked to its utmost capacity to control and manage the outbreak.

    But this narrow focus on what was done once the virus had established itself in the country is completely inadequate.

    Rather, any inquiry must examine the long-standing reasons why the country was unable to deal with the situation in a more efficient way. Unless this is done, the necessary steps to improve our handling of future pandemics cannot begin.

    For a start, the argument that government was taken by surprise by a global viral attack is false.

    To the contrary, a research project called Exercise Cygnus was set up in 2016 to examine the question of preparedness for exactly this eventuality.

    Its report was delivered in July 2017 to all major government departments, NHS England, and the devolved administrations of Scotland, Wales and Northern Ireland.

    The report concluded that “…the UK’s preparedness and response, in terms of its plans, policies and capability” were insufficient to cope with such a situation.

    It recommended NHS England should conduct further work to prepare “surge capacity” in the health service and that money should be ring-fenced to provide extra capacity and support in the NHS.

    It also stated that the social care system needed to be able to expand if it were to cope with a “worst-case scenario pandemic”.

    These warnings, however, were effectively ignored.

    One government source is reported as saying that the results of the research were “too terrifying” to be revealed.

    And a senior academic directly involved in Cygnus and the current pandemic remarked: “These exercises are supposed to prepare government for something like this – but it appears they were aware of the problem but didn’t do much about it… basically [there is] a lack of attention to what would be needed to prevent a disease like this from overwhelming the system.

    “All the flexibility has been pared away so it’s difficult to react quickly. Nothing is ready to go.”

    But the reason that the system was too inflexible and unprepared lies squarely with the government’s actions during the last decade.

    The Health and Social Care Act of 2012 ruinously fragmented the system.

    The austerity and privatisation of these polices have lethally weakened both the NHS and the social care services.

    As a result, the NHS is under-staffed, under-equipped and critically short of beds, while the social care service is crippled by underfunding almost to the point of collapse. It is therefore vital that we do not allow any inquiry to be limited to an examination of recent mistakes.

    The government’s bungled handling of the present crisis was virtually inevitable within a public health system depleted and rendered inadequate by their long-term policies.

    No post mortem can achieve a productive conclusion unless it is understood that these policies were the root cause of the shambles.

    If we are to avoid another catastrophe, these policies must be radically changed with the minimum of delay, and public health put back into public hands.

    • Susanna Mitchell and Roy Trevelion are members of the Socialist Health Association.

    Other articles written by Susanna Mitchell and Roy Trevelion are:

    Don’t allow the price of drugs to soar: Drug pricing is still a critical issue for the NHS http://camdennewjournal.com/article/dont-allow-the-price-of-drugs-to-soar?sp=1&sq=Susanna%2520Mitchell

    Beware false prophets: Don’t be fooled by the Johnson government’s promise of new money. It masks a move to further privatise the NHS
    http://camdennewjournal.com/article/nhs-beware-false-prophets?sp=1&sq=Susanna%2520Mitchell

    Brexit and the spectre of NHS US sell-off: Americanised healthcare in the UK – after our exit from the EU – would only benefit global corporations
    http://camdennewjournal.com/article/brexit-and-spectre-of-nhs-us-sell-off?sp=1&sq=Susanna%2520Mitchell

    Deep cuts operation threatens the NHS: The sneaking privatisation of the NHS will lead to the closure of hospitals and the loss of jobs
    http://camdennewjournal.com/article/deep-cuts-operation-threatens-nhs-2?sp=1&sq=Susanna%2520Mitchell

    Phone app that could destroy our GP system: A private company being promoted by government to recruit patients to its doctor service spells ruin for the whole-person integrated care we need from our NHS
    http://camdennewjournal.com/article/phone-app-gp?sp=1&sq=Susanna%2520Mitchell

     

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    • FBU members to be consulted on offer with union recommending money be paid immediately to staff
    • FBU to launch campaign for better pay with option of industrial action on table

    The Fire Brigades Union (FBU) has condemned a 2% pay offer from employers labelling it ‘insulting’ to frontline firefighters and control staff.

    Employers have offered firefighters and control staff a 2% pay uplift, below teachers, doctors, dentists, police, and prison officers. The offer is on par with judges, senior civil servants, and the armed forces.

    The FBU has slammed fire service employers and chief fire officers for failing to value the work of their staff and criticised government ministers for failing to step in and ensure firefighters are properly rewarded in this year’s pay round – especially in light of the extra work taken on in dealing with the COVID-19 crisis.

    After a meeting of the FBU’s Executive Council today (Wednesday 29 July) it has been recommended that the money be immediately paid to staff as it “will be better in the pockets of firefighters and control staff than sitting in employer reserves”.

    The FBU’s pay offer will now go out to consultation for 28 days, during which firefighters and control staff will discuss the offer at union meetings in workplaces across the UK. The FBU will talk to members about their options to campaign for better pay over the next year, including industrial action.

    Firefighters have taken on an additional 14 areas of work to respond to the coronavirus pandemic.

    An agreement reached on 26 March has allowed firefighters to drive ambulances, deliver vital supplies to the elderly and vulnerable, and move the bodies of the deceased.

    Since then, a number of further activities have been agreed, including assembling personal protective equipment (PPE) and training care home staff in infection, prevention and control.

    Despite this, fire service employers have offered the same pay settlement as last year, when pay rates for firefighters and control staff were increased by 2%.

    After a decade of pay restraint, firefighters are around £4,000 worse off than in 2010.

    Matt Wrack, FBU general secretary, said:

    “Firefighters and control staff were due a pay offer on 1 July. Nearly a month past that deadline, fire service employers have made an offer – there is absolutely no excuse for making our members wait like this.

    “Sadly, the offer reflects the fact that employers simply do not value the vital and life-saving work our members undertake every day, nor the extraordinary lengths many have gone to in aiding the coronavirus response. Government ministers could have stepped in to ensure our members would be properly rewarded in this year’s pay round, but they chose to stand idly by.

    “The Chief Fire Officers who advise employers during pay negotiations must also bear some responsibility for the desperate situation facing our service and those who work in it. Throughout the past decade they have done absolutely nothing to challenge the brutal austerity policies of central government which have continued to rob our service of investment and resources.

    “This pay offer does not address the needs of FBU members whose wages have still not recovered from years of pay restraint, however firefighters and control staff desperately need an improvement in their living standards and this money will be better in their pockets than sitting in employer reserves.

    “We will now consult firefighters and control staff on the offer and discuss campaigning options around issues of pay and conditions over the coming year, including various forms of industrial action.”

    Joe Karp-Sawey, FBU communications officer

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    Unite NHS members will be at the forefront of a march to Downing Street tomorrow (Wednesday 29 July) to show their anger at being overlooked in the latest round of public sector pay rises – despite more than 500 NHS and social care staff dying from Covid-19.
    The Unite branch at Guy’s and St Thomas Hospital will be marching to Downing Street at 18.00 tomorrow from St Thomas Hospital, Westminster Bridge Road, SE1 7EH to protest at the government’s decision to put off a pay rise for NHS staff until April next year – when the three year pay deal comes to an end. The march will be attended and supported by NHS staff across London.
    Last week, chancellor Rishi Sunak awarded up to a 3.1 per cent pay rise for 900,000 public sector workers, including doctors, teachers and police officers. Unite accused the chancellor of having ‘a selective memory’ when it comes to public sector pay, rewarding some, but ignoring hundreds of thousands of others.
    Unite national officer for health Colenzo Jarrett-Thorpe said: “Nursing staff and other allied health professionals have reacted with anger to being overlooked when pay rises were given to many in the public sector last week and the government not hearing the health trade unions’ call to bring their pay rise forward from April 2021.
    “This sense of anger was heightened, especially in light of their work and sacrifices during the global pandemic which has taken the lives of more than 500 NHS and social care staff across the UK.
    “We are facing a perfect storm for recruitment and retention in the NHS – in a decade of Tory austerity, NHS staff have seen their pay cut by 20 per cent in real terms and many are considering leaving the health service; at the same time, there are about 40,000 nursing vacancies in England alone.
    “This crisis is also being exacerbated by the scrapping of the student bursary, which is putting off many who may have considered becoming one of the next generation of nurses.
    “What we have seen in the last few months is generous praise, warm words, and lots of Thursday evening clapping by ministers; yet we got a flavour of the government’s true feelings with Rishi Sunak’s lack of a pay announcement for NHS staff last week, with no statement dealing with our call to move the pay of NHS workers forward.
    “The public expects – and ministers should deliver – a substantial pay increase for NHS staff that reflects their real worth to the NHS and society more generally. NHS workers shouldn’t have to wait till April 2021.”
    Unite branch secretary at Guy’s and St Thomas Hospital Mark Boothroyd said: “We have called this demonstration to express the anger that so many of our members feel at the government’s derisory treatment of NHS staff.
    “After all our sacrifice during the pandemic, to exclude us from the pay deal and make us wait till April 2021 is a slap in the face, and our members are going to Downing Street to tell Boris Johnson this directly.”

     

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    This is our twentieth weekly blog the series where we have commented on the course of the pandemic and the political context and implications from its impact on our country. The SHA has submitted our series of blogs to the All Party Parliamentary Group (APPG), Chaired by Layla Moran (LD, Oxford West and Abingdon), who are taking evidence to learn lessons from our handling of COVID-19 in time for the high risk winter ‘flu season’. The Labour MP Clive Lewis is on the group

    This is an edited version of the seven main points we have submitted:

    1. Austerity (2010-2020)

    This pandemic arrived when the public sector – NHS, Social Care, Local Government and the Public Health system had been weakened by disinvestment over 10 years. This was manifest by cuts to the Public Health England budgets, to the Local Authority public health grants and lack of capital and revenue into the NHS. In workforce terms there was staff shortages in Health and Social Care staffing exceeding 100,000.

    1. Emergency Planning but no investment in stocks (Cygnus 2016)

    The publication of the 2016 Operation Cygnus exercise has exposed the lack of follow on investment by the Conservative government which led to problems of PPE supplies, essential equipment such as ventilators and in ITU capacity. The 2016 exercise was a large-scale event with over 900 participants and occurred during Jeremy Hunt’s tenure as Secretary of State. There needed to be better preparation too on issues such as border controls as we note 190,000 people from China travelled through Heathrow between January-March 2020. Pandemics have been at the top of the UK risk register for years and the question is why were preparations not undertaken and stockpiles shown to be insufficient and sometimes time expired.

    1. Poor political leadership (PM and SoS Health)

    During the pandemic there has been a lack of clarity on what the overall strategy is and inconsistency in decision-making. The New Zealand government for example went for elimination, locked down early, controlled their borders and took the public with them successfully. We have had an over centralised approach from the Prime Minister and SoS for Health such as the NHS Test and Trace scheme and creating the Joint Biosecurity Unit. Contact tracing and engaging the Local Directors of Public Health was stopped on the 12th March and only in the past few weeks have their vital role been acknowledged. Ministers have been overpromising such as the digital apps, the antibody tests, the vaccine trials and novel drug treatments. Each time the phrases such as World Beating and Game Changers have been used prematurely. The Ministerial promises on numbers of tests has been shown to have become a target without an accompanying strategy and the statistics open to question from the UKSA.

    1. Social care

    From the early scientific reports from Wuhan it was clear that COVID-19 was particularly dangerous to older people who have a high mortality rate. A public health perspective would raise this risk factor and plan to protect institutions where older people live. Because of the distressing TV footage from Lombardy (Italy) the government’s main aim was to Protect the NHS. This was laudable and indeed the NHS stood up and had no call on the Nightingale Hospitals, which had a huge investment. The negative side of this mantra was that social care was ignored. As we have seen 40% of care homes have had outbreaks and about a third of COVID related mortality is from this sector. There have been serious ethical questions about policies in Care Homes as well as discharge procedures from the NHS that need teasing out. The private social care sector with 5,500 providers and 11,300 homes is in bad need of reform. Some of the financial transactions of the bigger groups such as HC One need investigation, especially the use of off shore investors who charge high interest on their loans. The SHA believes that the time is right to ‘rescue social care’ taking steps such as employing staff and moving towards a National Care Service.

    1. Inequalities

    It was said at the beginning of the pandemic in the UK that the virus did not respect social class as it affected Prince and Pauper. Prince Charles certainly got infected as did the Prime Minister. However we have seen that COVID-19 has exploited the inequalities in our society by differentially killing people who live in our more deprived communities as shown by ONS data. In addition to deprivation we have seen the additional risk in people of BAME background. The combination of deprivation and BAME populations put local authorities such as Newham, Hackney and Brent in London as having been affected badly. The ONS have also shown that BAME has an additional risk to the extent of being double for people of BAME heritage even taking statistical account for deprivation scores. Occupational risk has also been highlighted in the context of BAME status with the NHS having 40% of doctors of BAME heritage who accounted for 90% of NHS medical deaths. The equivalent proportions are 20% NHS nurses and BAME accounting for 75% deaths. The government tried to bury the Fenton Disparities report and we believe that this is further evidence of institutional racism.

    1. Privatisation

    The SHA is strongly committed to a publicly funded and provided NHS and are concerned about the Privatisation that we have witnessed over the last 10 years. We are concerned about the risks in the arrangement with Private Hospitals, the development of the Lighthouse Laboratories running parallel to NHS ones and the use of digital providers. In addition we feel that there needs to be a review of how contracts were given to private providers in the areas of Testing & Tracing, PPE supplies, Vaccine development and the digital applications. There are concerns about fraud and we note that some companies in the recent past have been convicted of fraud, following investigations by the Serious Fraud Office yet still received large contracts during the pandemic.

    1. Recovery Planning

    During the pandemic many of us have noticed the benefit of reduced traffic in terms of noise and air pollution. Different work patterns such as working from home has also had some benefits. The risk of overcrowded and poor housing has been manifest as well as how migrant workers are treated and housed. Green spaces and more active travel has been welcomed and the need for universal access to fast broadband as well as the digital divide between social class families. With the government having run up a £300bn deficit and who continue to mismanage the pandemic we worry about future jobs and economic prosperity. There is an opportunity to build a different society and having a green deal as part of that. The outcome of the APPG review should on the one hand be critical of the political leadership we have endured but also point to a new way forward that has elements of building a fairer society, creating a National Care Service, funding the NHS and Public Health system in the context of the global climate emergency and the opportunities for a green deal.

    Lets hope that the APPG can do a rapid review so we can learn lessons and not have to wait for years. The Grenfell Tower Inquiry remember was launched by Theresa May in June 2017, and we still await its key findings and justice for those whose lives were destroyed by the fire. The Prime Minister has been pointing the fingers of blame on others for our poor performance with COVID-19 but has accepted that mistakes were made and that an inquiry will be held in the future.

    However often these are mechanisms to kick an issue into the long grass (Bloody Sunday Inquiry) and even when completed can be delayed or not published in full such as the inquiry into Russian interference in our democratic processes. So let’s support the APPG inquiry and the Independent SAGE group who provide balance to the discredited way that scientific advice has been presented. As one commentator has pointed out there are similarities to the John Gummer moment when in 1990 he fed his 4yr old daughter a burger on camera during the BSE crisis. The public inquiry into the BSE scandal called for greater transparency in the production and use of scientific advice. During this crisis we have seen confusion whether on herd immunity, timing of lockdown, test and trace, border and travel controls and the use of facemasks.

    NHS and NIHR

    For the SHA we have been pleased with how the NHS has stood up to the challenge and not fallen over despite the huge strain that has been put under. Despite the expenditure on the Nightingale Hospitals and generous contracts with Private Hospitals these have not made a significant difference. These arrangements certainly helped to provide security in case the NHS intensive care facilities became overwhelmed and allowed some elective diagnostics and cancer care to be undertaken in cold hospital sites. However the lesson from this is the superiority of a national health system with mutual aid and a coherent public service approach to the challenge compared to those countries with privatised health care. The social care sector on the other hand, despite some examples of excellence, is a fragmented and broken system. The pandemic has shown the urgent need to ensure staff have adequate training, are paid against nationally agreed terms and conditions and we create an adequately resourced National Care Service as outlined in our policy of ‘Rescuing Social Care.

    Another area where a national approach has paid off is the leadership provided by the National Institute of Health Research (NIHR) which helps to integrate National R&D funding priorities and work alongside the Research Councils (MRC/ESRC) and Charitable Research funding such as from the Wellcome Trust and heart/cancer research funders. These strategic research networks use university researchers and NHS services to enable clinical trials to be undertaken and engage with patients and the public. It is through this mechanism that the UK has been able to contribute disproportionately to our knowledge about treatment for COVID-19 and in developing and testing novel vaccines.

    For example the Recovery trial programme has used these mechanisms to enlist patients across the UK in clinical trials. The dexamethasone (steroid) trial showed a reduction in deaths by a third in severely ill patients and is now used worldwide. On the other hand Donald Trump and Brazil’s Jair Bolsanaro’s hydroxychloroquine has been shown to be ineffective and this evidence will have saved unnecessary treatment and expense across the world.  Such randomised controlled trials are difficult to undertake at scale in fragmented and privatised health systems. The vaccine development and trials have also been built on pre-existing research groups linked to our Universities and Medical Schools. Finally while Hancock’s phone app hit the dust in the Isle of Wight, Professor Tim Spector’s COVID-19 symptom app has managed to enlist 4m users across the country providing useful data about symptoms and incidence of positive tests in real time. This is all from his Kings College London research base reaching out to collaborators in Europe. Ireland has launched the Apple and Google app created with the Irish software company NearForm successfully and it is thought that Northern Ireland is on the way to a similar launch within weeks too!

    A wealth tax?

    In earlier blogs we have drawn attention to the huge debt that the government have run up and we are already seeing the emerging economic damage to the economy and people’s livelihoods when the furloughing scheme is withdrawn in October. Already people are talking about up to 4m unemployed this winter and what this will mean in terms of the economy and funding public services like local government, education and health. The UK’s public finances are on an ‘unsustainable path’ says the Office for Budget Responsibility.

    There is a lot of chatter about the value of a wealth tax and there are some variations to the theme. It is estimated that there is £5.1 trillion of wealth linked to home equity. It is also said that the unearned gains on property are a better target for new taxes than workers earned income. Following this through a think tank has proposed – a property tax paid when a property is sold or an estate if the owner has died. A calculation could be made by taxing at 10% on the difference between the price paid for the property and the price at which it was sold. The % tax could be progressive and increase when the sum exceeds £1m for example. Assuming property rise in value by only 1% per annum this tax would raise £421bn over 25 years. If this sounds like an inheritance tax – that is true but for years now such taxes have become a voluntary tax for those with access to offshore funds and savvy accountants. In the USA, inheritances account for about 40% of household wealth. Fewer than 2 in 1000 estates paid the Federal estate tax even before Trump cut it in 2018. Trusts and other tax havens abound. Apparently Trump’s own Treasury Secretary has placed assets worth $32.9m into his ‘Dynasty Trust 1’

    Inherited wealth has been referred to in earlier blogs in relation to the Duke of Westminster family wealth. Another study which shows how this type of wealth transfer passes down the generations comes from Italy where in 2011 a study of high earners found many of the same families appeared as in the Florence of 1427!

    Populism and COVID

    In our blogs we have pointed to the fact that those countries, in different continents, which have had a bad pandemic experience are ones such as the UK, USA, Brazil, India and Russia. What unites them is a leadership of right wing populists. A recent study has started to analyse why this occurs and what the shared characteristics are:

    1. The leaders blame others – the Chinese virus/immigrants
    2. Deny scientific evidence – use ineffective drugs/resist face masks
    3. Denigrate organisations that promote evidence – CDC/PHE/WHO
    4. Claim to stand for the common people against an out of touch elite.

    What the authors found was that these leaders were successfully undermining an effective response to the pandemic. Sadly there is a risk that populist leaders perversely benefit from suffering and ill health.

    Taking lessons from history and the contemporary global situation we need to continue to speak out against these political forces and advocate for a better fairer recovery.

    27.7.2020

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

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    In this week’s Blog we will have a look at the lessons learnt so far with the first City lockdown in Leicester and see what this tells us about the UK Government’s handling of the COVID-19 pandemic, raise issues again about their competence, outline why the social determinants of heath matter and assess the risks involved in privatisation of the NHS testing centres and public health functions.

    Local lockdown

    Leicester has been directed by central government (Hancock in the House of Commons on the 30th June) to remain in lockdown this weekend when other parts of England were being urged by the Prime Minister to be brave, to bustle in the High Streets to help ramp up an economy which is waiting to be turbo charged. The government announced in Westminster on June 18th that there was a local outbreak causing concern in Leicester. This news broadcast in the media saw the local Mayor of Leicester and their local Director of Public Health (DPH) in a bemused state. They had been left in the dark because the central government and their privatised drive through/hometesting  service led by Deloittes/SERCO had not shared the so called Pillar 2 data with them. They did not receive Pillar 2 test data for the next 10 days!

    Outbreak plans

    Local Directors of Public Health (DsPH) across England had been required by central government a month earlier to produce Local Outbreak Control Plans by the 30th June. According to the PM they were meant to be in the lead to ‘Whack the Moles’ in his typically colourful and inappropriate language. Whacking moles apparently means manage local outbreaks of COVID-19. Anybody who has actually tried to Whack a Mole on their lawn or at a seaside arcade will know that this is almost impossible and usually the mole hole appears again nearby the following day.

    Local DsPH have been receiving from Public Health England (PHE) regular daily data about local NHS hospital laboratory testing from the Pillar 1 sources. In Leicester this was no cause for concern as there had been a decline since the peak in positive cases in April.  That explains why the Mayor and DPH were bemused. Each week there are now summary bundles of data incorporating both sources sent by PHE but not in a way that local teams can analyse for information of interest such as workplace/occupation/household information. Belatedly, postcode data is now shared which had been hidden before! One of the first requirements in outbreak management is to collect information about possible and confirmed cases with an infection in time, place and person. This information needs to include demographic information such as age and gender, address, GP practice and other data pertinent to the outbreak such as place of work/occupation and travel history. Lack of workplace data has made identifying meat packing plants in outbreaks such as near Kirklees more difficult and another example where the local DPH and the Local Authority were wrong footed by the Minister.

    Public Health England review

    On the 29th June PHE published a review  ‘COVID-19: exceedances in Leicester’. This excellent review showed that the cumulative number of tests in Leicester from Pillar 1 was 1028 tests whereas the number of Pillar 2 was 2188 which is twice as many! The rate per 10,000 people in the Pillar 1 samples was a relatively low rate of 29 while Pillar 2 showed a rate of 62/10,000. The combined positive rate of 90/10,000 is more than twice the rate in the East Midlands and England as a whole. It was on the basis of this Pillar 2 data that the government became alarmed.

    It is just incredible that the government have contracted Deloittes/SERCO to undertake something that they had no prior experience in and to allow a situation to develop when the test results from home testing and drive through centres was not being shared with those charged with controlling local outbreaks.

    The political incompetence was manifest to an extraordinary level when Nadine Dorries, Minister for Mental Health, confirmed to a Parliamentary enquiry that “the contract with Deloittes does not require the company to report positive cases to Public Health England and Local Authorities’.

    It seems as if the point of counting numbers of tests undertaken each day was to simply verify that home tests had been posted and swabs had been taken in the drive-through sites so that Matt Hancock could boast at the Downing Street briefings that the number of tests was increasing.. But we are trying to control COVID-19 and Save Lives. Sharing test results with those charged with controlling local outbreaks must be a fundamental requirement.

    Deprivation and health

    In earlier BLOGs we have highlighted that COVID-19 has disproportionately affected those who live in more deprived areasand additionally has impacted even more on BAME people. Studies have shown that relative poverty, poor and cramped housing, multigenerational households and homes with multi-occupants are all at higher risk of getting the infection and being severely ill. Other factors have been occupation – people on zero hours contracts, low pay and in jobs where you are unable to work from home and indeed need to travel to work on public transport. Many of these essential but low paid jobs are public- or client-facing which confers a higher risk of acquiring the infection.

    All these factors seem to be in play in Leicester. The wards with the highest number of cases have a high % of BAME residents (70% in some wards). One local cultural group are Gujeratis with English as a second language. Another factor that is emerging is the small-scale garment producing factories. It is estimated that up to 80% of the city’s garment output goes to internet suppliers such as Boohoo.

    The garment industry

    Two years ago a Financial Times reporter, Sarah O’Connor, investigated Leicester’s clothing industry. She described a bizarre micro-economy where £4-£4.50 an hour was the going rate for sewing machinists and £3 an hour for packers. These tiny sweatshops are crammed into crumbling old buildings and undercut the legally compliant factories using more expensive machines and paying fairer wages. As she points out (Financial Times 5th July) this Victorian sector is embedded into the 21st century economy and the workforce is largely un-unionised. The big buyers are the online ‘fast fashion’ retailers, which have thrived thanks to the speed and adaptability of their UK suppliers.  Boohoo sources 40% of its clothing in the UK and has prospered during lockdown by switching to leisurewear for the housebound while rivals have shipments left in containers.

    Mahmud Kamani with Kane founded Boohoo in 2006 and it has made him a billionaire. It is said that other competitors such as Missguided and Asos have been put off by concerns about some of Leicester’s factories – including claims over conditions of modern slavery, illegally low wages, VAT fraud and inadequate safety measures. A researcher went into the garment factories earlier this year and is quoted as saying

    I’ve been inside garment factories in Bangladesh, China and Sri Lanka and I can honestly say that what I saw in the middle of the UK was worse than anything I’ve witnessed overseas’.

    Occupational risks, overcrowded housing and poverty have been shown to be risks to contract the virus and become severely ill with it. BAME communities have additional risks over and above these as we have discussed before in relation to the Fenton Disparities report, which was blocked by Ministers who were not keen on the findings of racism in our society and institutions.

    Health and Safety

    In Leicester the Health and Safety Executive has contacted 17 textile businesses, is actively investigating three and taking legal enforcement action against one. In business terms the UK’s low paid sector are an estimated 30% less productive on average than the same sectors in Europe. As unemployment rises in the months ahead it will be vital to focus on jobs as the Labour leadership have stated. However quality should be paramount and the government apparently wants ‘to close the yawning gap between the best and the rest’.

    The Prime Minister has recently promised ‘a government that is powerful and determined and that puts its arms around people’. These arms did not do much for care homes during the first wave of COVID-19 and looking to the future of jobs and economic development the fate of Leicester’s clothing workers will be another test of whether he and his government meant it.

    Incompetent government.

    The pandemic has exposed the UK but particularly people in England to staggering levels of government incompetence. There are other countries too that have this burden and Trump in the USA and Bolsonaro in Brazil spring to mind. They seem confident that the virus won’t hit their citizens and it certainly won’t hit the chosen ones.

    Psychologists say that people like this appear confident because as leaders they know nothing about the complexity of governing. They refer to this as the Dunning-Kruger effect:

    incompetent people don’t realise their incompetence’.

    5.7.2020

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

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    So here we are in Week 16 of our SHA Blog about how the Johnson government is mishandling and mismanaging – except where it comes to the interests of the profit-making private sector – the COVID-19 pandemic; and why the UK is “world beating” – in terms of the highest death rate from COVID in Europe!

    Test and Trace

    The “teething problems” with the centrally designed, and privately contracted, NHS Test and Trace scheme, continues. It is a privatised system organised through the likes of Deloitte, (Deloitte is one of the Big Four accounting organisations in the world, whose business is in financial consultancy.) These private firms put the NHS logo in their own “branding” to try to build public belief, and confidence, that what they are doing is part of the NHS, and in the public’s interest, when it is a private system making lots of money for private investors: in the way that suits them best, rather than the most efficient way it could be done.  .

    It has had a huge investment of taxpayers’ money to employ 20,000 under-used telephone operators who are poorly trained in the complex field of contact tracing.  The Independent SAGE group reports that one contact tracer told them that ‘out of 200 tracers at my agency we have only had 4 contacts to call over the past 4 weeks’. Speaking to worried people and trying to elicit information about their contacts within a system which has not been able to build trust is a genuine challenge. The familiar GP practice or the local hospital and local authority – in which people really do have confidence – have in this “NHS Test and Trace scheme” had to take a back seat. (Readers will recall from previous blogs that the Independent SAGE group was set up in May to provide scientific advice independent of political pressure, after it was reported that Johnson’s “special advisor” Dominic Cummings had attended, and was believed to have influenced, the Government’s “official” Scientific Advisory Group on Emergencies. )

    Early problems have been identified in the initial design of diagnostic testing. No NHS number for instance, no occupation or place of work recorded, no ethnicity data and test results not being shared with the GP. The Lighthouse labs set up in Milton Keynes, Alderley Park Cheshire, Cambridge and Glasgow are collaborations between pharmaceutical industries (GlaxoSmithKline (GSK) and AstraZeneca), Universities in Cambridge and Glasgow, Boots, Amazon and the Royal Mail alongside the Wellcome Trust. (AstraZeneca owns Alderley Park).

    They were set up to meet the escalating government targets to get testing up to 100K (Hancock) and then to 200K (Johnson) without Ministers being clear about the strategy for testing and ensuring that results got back quickly to people and local players such as GPs and the local Public Health teams who could act. If the objective was just to get tests sent out in the mail or undertaken by Army squaddies in car parks across the country, in order to get the numbers up for the Downing Street briefings, then there was no need to worry about useful information about workplace/occupation? It is not the consortium of laboratories’ fault, as they are contributing to a national emergency, but the political leadership, which has not taken enough notice of public health professionals who have provided laboratory services and integrated themselves with NHS and local public health teams over decades. Public Health England are faced with the nightmare of quality assuring data sent to them from these laboratories.

    Workplaces

    One reason to worry is that incomplete information can lead to a delay in identifying a workplace outbreak. Returning the test result information started at Local Authority level which is not enough information on which to act. After some pressure the local teams have started to get postcode data. However noting a rise in individual cases scattered across West Yorkshire did not help public health officials pin down the common link: which was that they all worked at the Kober Meat Factory in Cleckheaton! These public health systems need to be designed by people who know about public health surveillance, outbreak management and contact tracing. It works best if the tests are undertaken locally, results go back to GPs and local Public Health teams with sufficient information to associate cases with industries, schools, places of worship, community events or food/drink outlets. This is the level of data that would help the public health team in Leicester who are under scrutiny with ‘knowledgeable’ politicians such as Home Secretary Priti Patel declaring the need for a local lockdown in the city. Speed is of the essence, too, as we know that COVID-19 is being transmitted when people do not have symptoms and is most contagious in the first few days of the illness.

    We have known from international data that meat-processing plants are high risk environments for transmission. This is clearly something to do with the damp, cool working environment, which is noisy and so workers have to shout to each other and are often in close proximity. Toilet facilities and rest areas are likely to be cramped and how often they are being cleaned an issue. Furthermore – as we have learnt from Hospital and Care Home outbreaks – how staff get to work will be important to know, too: for example, if they are bussed in together or car sharing, both of those involve being with other people in enclosed spaces.

    As in abattoirs here in the UK and in other parts of the world, jobs like this are usually undertaken by migrant workers. These workers usually live in cramped dormitory type multi-occupation residences. Low paid often migrant workers, who are poorly unionised, are particularly vulnerable to the COVID-19 contagion whether they work in US meat packing factories or in Germany or indeed in Anglesey (Wales). The 2 Sisters plant in Llangefni for instance has had over 200 workers with positive test results.

    The Tonnies meat processing factory in Germany has had more than 1500 of its workers infected and 7000 people have had to be quarantined as a result of the outbreak. This has had a ripple out effect with schools and kindergartens, which had only recently reopened, having to close again. Unsurprisingly there are stories of the factory being reluctant to share details of the staff, many of whom are Romanian or Bulgarian and speak little German.

    Contact tracing

    The importance of testing and rapid reporting of cases to local agencies was highlighted in a recent South Korean example, where a previously well -controlled situation was threatened by the finding that a series of nightclubs had been linked through one very energetic person. Tracers had to follow up 1700 contacts and be able to control the on-going chain of transmission! While South Korea, unlike the UK, has had a mobile phone app to assist contact tracing, they still depend on the local tracers to use shoe leather rather than computer software to really understand the local patch and the complex community relationships.

    The Independent SAGE group is producing useful analyses and information for us all and has been promulgating the WHO Five elements to test and trace, namely:

    FTTIS – Find, Test, Trace, Isolate and Support.

    All of these are important and the recent example in Beijing shows again how a rapid local lockdown response was used to implement FTTIS and they appear to have managed to contain the outbreak to one part of this megacity of over 20m people.

    Social distancing

    The Independent SAGE has also recently taken a line critical of the government position on social distancing. They say that the risk of transmission in the UK remains too high to reduce the social distancing guidance. They oppose the move from a 2m guidance to 1m plus and say that it risks multiple local outbreaks, or in the worse case a second wave. The pattern of continuing waves of infection has been seen in the USA, where social distancing has been poorly enforced, and in other countries where a significant second wave has occurred such as Iran.

    The Government is rightly worried about the economic impact of the lockdown and pandemic, but they are sending out mixed messages on social distancing which has led to chaotic scenes on Bournemouth beach, urban celebrations in Liverpool and street parties in many cities. In the USA it has identified the 20-44 year olds as being a group who are testing positive more frequently and we need to send the message out loud and clear that although they may not die from COVID-19 at the rate older people and those with underlying conditions, they are at risk of long term damage to their health and will transmit the virus to other more at-risk people in their families or local communities.

    The Prime Minister always wants to be communicating good news, and needs to beware that the call for more ‘bustle’ on the high streets and ramping up/turbo charging the economy carries big risks of new local outbreaks that will ensure that the Sombrero curve of infection is not flattened, but that we are condemned to live with on-going flare ups across the country.

    Ex Chancellor Kenneth Clarke tweeted recently, in the light of the situation in the UK and the flip flopping on air travel restrictions, that:

    The UK government’s public health policy now seems to be ‘go abroad on holiday, you’ll be safer there!”

    29.6.2020

    Posted by Jean Hardiman Smith on behalf of the Officers and Vice Chairs of theSHA

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    The Fire Brigades Union (FBU) has vowed to fight “unthinkable” proposals to cut the budget for the London Fire Brigade by £25m over two years, as part of the Mayor of London’s £500m saving plans.

    The FBU has condemned the “huge damage to the fire service” left over from Boris Johnson’s time as Mayor of London. Central government have so far refused to bail out the GLA’s budget shortfall accrued during the coronavirus pandemic.

    The union has criticised Mayor Sadiq Kahn for “passing on Tory cuts to the very emergency services that keep people safe” and has vowed to hold him to his commitment to protect frontline services.

    David Shek, FBU executive council member for London, said:

    “London is the epicentre of the UK’s building safety crisis and there is no safe way to manage funding cuts of this magnitude. A £25 million cut to London Fire Brigade’s funding is unthinkable and we will fight it to the bitter end.

    “We have just marked the third anniversary of the Grenfell Tower fire and in the years since have dealt with a number of fires in buildings with similar combustible materials. The dangers of cutting the fire and rescue service right now are blatantly obvious.

    “The Mayor has committed to protected frontline emergency services and we will hold him to that. We will not accept any reduction in frontline services – whether that be crewing reductions, shift changes, or a recruitment freeze. Make no mistake – any reduction in fire cover will put lives at risk.”

    Matt Wrack, FBU general secretary, said:

     “The scale of these cuts is devastating and is a gross insult to firefighters in London who have gone above and beyond to support their communities during the COVID-19 pandemic. The public will not support these cuts, and we intend to fight them.

    “Sadiq Khan made a commitment to protect vital frontline services and he must do that. The government should support regions facing financial difficulties as a result of COVID-19 but there is no excuse for a Labour Mayor to be passing on Tory cuts to the very emergency services that keep people safe across the capital.

    “Boris Johnson did huge damage to the fire and rescue service as London Mayor by pushing through the biggest cuts in history. These cuts impacted the response on the night of the Grenfell Tower fire and the London Fire Brigade has still not fully recovered. To be considering more spending cuts is downright reckless and would show contempt for the public’s safety.

    “This pandemic has demonstrated the value of the fire and rescue service and we should actually be talking about new investment to make the service better and safer. The government must step up to provide whatever financial support is necessary or the prime minister’s talk of ending austerity will ring hollow across London. If that support is not forthcoming, the Mayor must pledge to scrap these dangerous cuts.

    Joe Karp-Sawey, FBU communications officer

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    We are now into the 15th weekly blog during the pandemic and confidence in the government is plummeting as the weeks roll on. The UK stands out as the sick man of Europe according to the Economist with the highest excess deaths per million population and with the OECD forecasting the UK as having the highest % decrease in GDP for 2020 compared to a year ago

    Channel 4 broadcast a speech by Prince Charles on Monday (June 22nd), saying how grateful the Nation was to the Windrush Generation who came to staff the NHS and other public services after WW2. Viewers have been horrified by the programmes on TV showing how badly they had been treated under the Hostile Environment policy of Theresa May, and how disproportionately they are currently suffering from Covid-19..

    In this week’s blog we will touch on familiar themes such as the slow rebirth of local test and trace/outbreak control plans, the failure of the world beating NHSX app on the Isle of Wight, the scandal of government contracts for PPE purchases and the revelation that there was indeed a Fenton report on BAME deaths that was withheld.

    BAME

    As protests about Black Lives Matter continue across the country and the world, our Ministers are on a learning curve about the historic slavery/civil rights context of ‘taking the knee’, and that Marcus Rashford is a famous black Man U footballer and English international. The PM and his Cabinet Ministers continually display how out of touch they are.

    Having looked at the Fenton Part 2 report “ ‘Beyond the data: Understanding the impact of COVID-19 on BAME groups’ most people will nod quietly at the eminently sensible recommendations he made which were based on a rapid review of the literature, his group engaging with 4,000 people across the country with direct experience of racism and suggestions about what is to be done. These stakeholders expressed deep dismay, anger, loss and fear in their communities about the emerging findings that BAME groups are being harder hit by COVID-19 than others. This exacerbates existing social, economic and health inequalities.

    Professor Fenton’s report recommends that there be improved ethnicity data collection, more participatory community research, improved access to services, culturally competent risk assessments, education and prevention campaigns. He calls for pandemic recovery plans that are designed to reduce health inequalities caused by the wider determinants of health to create long term sustainable change.  The SHA heartily supports these recommendations and, along with David Lammy MP, demand that the government implements findings from previous BAME related reviews that date as far back as the Stephen Lawrence inquiry in 1999.

    We know that inequalities reflect racism and structural factors in society outside health. The Runneymede Trust looked at Pensioners’ Income for the Financial Years 2017-18 and found that Black pensioner families receive almost £200 less a week than white British pensioner families. Black households were the least likely to receive personal pensions. They also found that Black African and Bangladeshi households have approximately 10p for every £1 of white British savings and assets. The figures show that for every £1 a white British family has, Black Caribbean households have about 20p and Black African and Bangladeshi households about 10p. Its not just COVID!

    Test and Trace

    Remember that the Government called a halt to the local test and contact tracing that was happening in early March, claiming that there was too much community transmission for it to have an impact and there were not sufficient local resources to manage the surge? The real reason it has emerged was that there was insufficient test capacity to sustain both NHS hospital testing and testing in care homes and the community. That fateful decision meant that local test and trace schemes were stood down, and did not follow the pandemic by analysing local surveillance and build-local systems. A few weeks ago, quite suddenly, the government recognised the role that such local test and trace schemes might have as the pandemic continued, and demanded that local Directors of Public Health prepare new Local Outbreak Control Plans by the end of June. Thankfully they appointed a CEO from Leeds Council to advise them and quite properly he has been working with the Local Government Association (LGA) and the Association of Directors of Public Health (ADsPH). At long last local plans are emerging and demands increasing for timely access to test results. Some government investment has been extracted from Deloittes and other consultants and safely invested in local government teams.

    As we have touched on before, the government has been too centralised in its approach and the national testing sites have been ‘out sourced’ to firms in the private sector, such as  SERCO, with Deloittes hovering, and also creaming off profit while mismanaging things. This means that there is undue delay in getting test results back to local teams and the initial contact tracing is being handled by inexperienced call handlers at a distance from the person involved. Remember that COVID-19 has shown us that it affects older people, people in care homes, people of BAME heritage and those from the most disadvantaged communities in the UK, disproportionately badly . I wonder what advice scientists might have given about the most effective way of reaching the most at risk people? Surely by now we know that, despite apps and complicated ventilators, health care is still a people business.  Skilled and empathetic care workers matter. Meanwhile GPs and primary care are bystanders to this world beating system and local public health teams are frustrated at step one of outbreak control, namely information about who has relevant symptoms and whether they have tested positive.

    The app!

    The app the app my kingdom for an app!’ It is alleged that people have heard the scream from the SoS who has a boyish interest and naïve faith in apps and other digital technologies. The ‘world beating’ app being developed in the exceptionally clever UK and tested on the Isle of Wight has bitten the dust. Stories are now emerging about the errors and misjudgements that there have been on the way. Developers of successful apps, such as that of Prof Tim Spector of Kings College London which now has 3.5m users, tells us that the NHSX treated his research teams as the enemy. They told him that far from collaborating, their world beating all singing and dancing app would make his redundant. In case we think this is just Tim Spector we hear that Ian Gass of Agitate tried to tell the NHSX in March that its app design, which tried to use Bluetooth signals was flawed. He describes this weird almost paranoid state, where the government says publicly that they’re asking for help, but then rejects it when it is offered.

    PPE contracts

    With the PPE supplies debacle we also heard the refrain that the government was inviting local UK companies to help produce PPE for the NHS and Social Care. Company boss after company boss reported trying and failing to make contact with government commissioners. It seems that it is only the insiders who get the contracts. Some previously small companies like PestFix are under scrutiny having won contracts with a value of £110m. This amount is nearly a third of the £342m public sector contracts signed for COVID-related PPE.

    We are pleased that Meg Hillier MP, Chair of the Public Accounts Committee is taking evidence on these contracts. MPs have said rightly that the pandemic crisis should not be an excuse for failing to achieve value for money.

    And finally

    We started this blog with a reference to a report in the right wing leaning Economist magazine. It is extraordinary that their leader in the June 20th-26th edition under the banner heading ‘Not Britain’s finest hour’ should say:

    The painful conclusion is that Britain has the wrong sort of government for a pandemic – and in Boris Johnson, the wrong sort of prime minister…

    ….beating the coronavirus calls for attention to detail, consistency and implementation…..

    The pandemic has many lessons for the government, which the inevitable public inquiry will surely clarify. Here is one for voters: when choosing a person or party to vote for, do not under-estimate the importance of ordinary, decent competence.”

    Hear hear.

    22.6.2020

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

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    So we are into our 14th weekly blog tracking our way through the COVID-19 pandemic. There are many issues which we have raised before which remain relevant over the past week. The most notable are the continuing blunders by the Johnson government, intent on appearing to have a strategy and being in control. The podium politics continue with premature announcements blurted out as intent, without having checked out their feasibility with professional advisers. The schools debacle was always couched in terms of recalcitrant Trade Unions rather than the fact that our school buildings have lacked investment over decades, class sizes are high and teacher staffing relatively low. This means that you cannot reduce class sizes to enable social distancing in the buildings you have available! A simple estimate of size of buildings, number of children and staffing levels would have demonstrated that this was always going to be a challenge before taking account of the risks of transmission to teachers and back via children and staff to people’s homes. The embarrassing retreat could have been avoided and the stress on schools reduced by consulting those that know how the system runs. Meanwhile schools are open to vulnerable children and greater efforts can be made to get them back in the school setting.

    A similar fiasco has emerged in health when, suddenly and belatedly worried about outbreaks in hospitals and nursing homes, the government decides to direct all NHS staff in patient/public facing roles to wear surgical facemasks and all visitors to wear facemasks. Imagine the planning this requires and the supplies that will be needed to sustain it! PPE and the scarcity of medical facemasks has been a story throughout the pandemic. But there was no consultation with the NHS before the announcement on a Friday evening.

    As for Test, Trace and Isolate (TTI) this has had a ‘wobbly’ start, as rather than trusting in local Directors of Public Health (DsPH) to build local teams that local laboratories can report to quickly, they have sidestepped the service and asked private contractors, with no prior experience, to set up a telephone answering/contact tracer service. Training has been very basic and it is not delivering the timely communication needed to ensure cases isolate themselves and their contacts traced urgently by local staff. In the ‘post-Cummings stay alert era’ it is already emerging that people may have less commitment to listen to government guidance, and when the lockdown is easing will be reluctant to stay off work and name their contacts who may be in a similar position.

    BAME and Inequalities

    Two issues, which we have raised before, are the need to address racism in our society and its link to general inequalities. The Black Lives Matter movement is trying to ensure that the government does not whitewash this issue and hide behind statistical methods which try to discount the fact that BAME communities are over represented in disadvantaged groups and have additional pressures on them that arise from racism in society, in key organisations and in the individuals they interact with.

    We have seen an extraordinary example of institutional racism over the process of publication of the Public Health England (PHE) report on Disparities in risks and outcomes of COVID-19.

    This report was commissioned by the government, ‘from the podium’ in Downing Street, when confronted by the announcements of deaths related to COVID-19 where BAME people have been heavily over represented. The NHS employs many BAME staff but did not expect to hear that while 44% of NHS doctors are from BAME groups they accounted for 90% of deaths of doctors. BAME nurses are 20% of the workforce but account for 75% of deaths. So Ministers appointed Prof Fenton a senior Public Health Director in PHE to lead the review. This provided some comfort to the BAME communities, as Fenton is an articulate and experienced black health professional able to access the views of BAME communities to deepen our understanding of what was happening to lead to these extraordinary outcomes.

    In the event publication of the report, which had been delivered by Fenton and PHE as promised by the end of May, had been delayed. Professor Fenton had been booked to lead a webinar for the Local Government Association (LGA) on Tuesday 2nd June fully expecting to be able to refer to his report. He seemed unaware that the report would not be published by the Government, without it being clear that this was the Fenton Report, until a couple of hours later, and even then without it being clear that the publication was the Fenton Report. What has subsequently emerged is that the section of his report that starts to address the pathways that lead to these huge differences in health outcome had been taken out of the report without consultation. This was hugely disappointing to the many hundreds of individuals and organisations who had contacted him and the review team during their rapid review process. The LGA webinar had been hosted by colleagues in Birmingham, and both the local Director of Public Health for Birmingham and the Chair of the Health and Wellbeing Board, Cllr Hamilton, were clearly engaged in providing insight and proposals as to how to start to address the challenges.

    Of course we do not yet fully understand the shenanigans that have gone on but suspect that someone else was asked to edit the report and effectively take out all the challenging political bits and resort to a dry re-publication of some of the statistics which we knew about and which had led to the inquiry itself! This new epidemiological input seemed determined to try and account for as much as possible of the higher mortality by apparently neutral factors such as co-morbidities, occupational risk, living in cities and relative deprivation. Such findings had been submitted by a SAGE report at the end of April, which had not been peer reviewed or published. This attempt to explain away the disparities seriously misses the point about racism and how it works through cumulative lifetime risks. Treating Prof Fenton in this way exhibits a form of institutional racism that no doubt the Ministers, and the experts drawn into stripping the report of its insights into how racism works, do not grasp.

    Despite taking account of sex, age, deprivation and region in England people of Bangladeshi ethnicity had twice the risk of death than people of White British ethnicity. People of Chinese, Indian, Pakistani, Other Asian, Caribbean and Other Black ethnicity had between 10 and 50% higher risk of death when compared to White British. By stripping out other factors an attempt has been made to soften the data impact and bin the feedback from local communities based on their life experience and the specific experience with COVID-19.

    Other countries have shown that there is an overrepresentation of black people amongst hospitalised patients. The US Center for Disease Control and Prevention (CDC) report, for example, that: in New York City death rates from COVID-19 among black/African American people was, 92/100,000 and Hispanic/Latino people 74. These rates are substantially higher than the 45/100,000 for the white population and 34 for Asians.

    Back in the UK, if you look outside the health sphere you see similar data in the criminal justice system. The BAME population make up 14% of the population yet 51% of inmates of the youth justice system. Stop and search records show that black people have 38 searches /1000 population compared to 4 for the white population. They are also more likely to be arrested with 35/1000 for the black population compared to 10 for the white population. The black population are five times more likely to be restrained and twice as likely to die in custody. Looking specifically at the black population rather than BAME groups as a whole they account for 3.3% of the population and 12% of the prison population. Black people make up 1.2% of police officers while 93% are of white ethnicity (Sunday Times, 14th June).

    This information has been well known to the black populations of most of our cities since well before the 1981 riots in Brixton, Toxteth, Moss Side, Handsworth and Chapeltown, let alone the Black Lives Matter protests of 2000.

    Inequalities

    The Office of National Statistics (ONS) still manage to produce reports that have not been politically edited in the way that Fenton’s was, and they have published a review on inequalities and COVID-19. This shows that the most deprived areas of England have more than twice the rate of death from COVID-19 than the least deprived. In the period from the 1st March until the 31st May the death rates were 128/100,000 for the most deprived compared to 58.8 for the least deprived. This inequality continues to be proportionately high and is mirrored in Wales too where they measure multiple deprivation differently (WIMD) yet still show a contrast between 109/100,000 for the more deprived populations compared to 57.5 in the least deprived. Both nations show a gradient across the groups, which is the important point that Marmot and others have made that inequality is not just something that influences the socially excluded groups but adversely affects the whole society from top to bottom.

    The SHA has consistently argued that we need to seriously address the social determinants of health and wellbeing. We also recognise the work that Marmot has done globally with the message that where we live, learn, work and play affects our health. The conditions in which people live, learn, work, and play contribute to their health. These conditions over time lead to different levels of health risks, needs and outcomes among people in certain racial and ethnic minority groups.

    The Centers for Disease Control and Prevention (CDC) in America use this approach to set out how these determinants might be tackled despite the fact that the Trump administration is deaf and blind to their advice!

    The international response to the George Floyd murder on the street in Minneapolis must be built on to turn these daily injustices around. The Black Lives Matter campaign needs support.

    As Labour’s David Lammy MP says:

    We can’t just look back in 5 years and remember George Floyd as a hashtag. We have to find a way to transform this righteous anger into meaningful reform’.

    15th June 2020

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

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    On the third anniversary of the Grenfell Tower fire, the Fire Brigades Union (FBU) has said firefighters will not accept another year of inaction on building safety.

    The FBU has called for an end to “a politics that values profit over people”, condemning “endless promises, excuses, and platitudes” from government.

    Matt Wrack, FBU general secretary, said:

    “Firefighters do all that they can to protect human life and the loss of 72 people at Grenfell was deeply traumatic for them as well as for all those others directly affected by the fire. Today, a community and their firefighters grieve. But we will not accept another year of inaction.

    “Three years on, we have heard endless promises, excuses, and platitudes from government, but the reality on the ground has not changed.

    “Half a million of people are trapped in unsafe homes and across the country another Grenfell could happen tomorrow, potentially where fire services are not as well resourced. Every day that the government fails to tackle the building safety crisis is another day that residents’ lives are being put at risk.

    “While the world has faced up to the coronavirus pandemic, the inquiry into the Grenfell atrocity has been put on hold, giving the companies and politicians responsible more time still to avoid scrutiny.

    “It was decades of deregulation, privatisation, and austerity that allowed Grenfell to take place, with a politics that values profit over people. When the economy restarts, we must not fall prey to the failed arguments of the past that led to this horrendous loss of life. “

    Joe Karp-Sawey, FBU communications officer

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

    The impact of the pandemic on inequalities more generally and the implications for policy and plans going forward

    Key messages

    • The pandemic has hit us when we have already seen health inequities widen
      • 10 years of austerity have disproportionately affected the least affluent and the most vulnerable
      • Life expectancy has plateaued and inequalities in mortality have widened in recent years. The gap in healthy life expectancy at birth is about 19 years for both males and females.
      • Spending constraints between 2010 and 2014 were associated with an estimated 45,000 more deaths than expected: those aged >60 and in care homes accounted for the majority
      • There has been a systematic attack on the social safety net. Services have been cut disproportionately in more deprived areas with a clear North South divide, and there are higher rates of poverty in the Devolved Administrations who have limited powers to mitigate the impact of poverty. Child poverty has increased to over 4 million children
    • The COVID19 pandemic is having major impacts on health, through direct and indirect effects, summarised the in diagram below

    Source: Douglas et all, BMJ April 2020

    • The pandemic strategies are not clear across the UK and do not adequately recognise the unequal direct and indirect impacts.
      • The epidemic is at different stages in different communities and has caused more deaths in dense urban and more deprived areas.
      • It can be seen as multiple outbreaks. These are affecting the most vulnerable people inequitably, such as those in institutional settings, prisons and migrant detention facilities, homes with multiple occupancy, and households that are overcrowded or contain multiple generations.
      • A policy of managing the virus rather than aiming for suppression, may result in repeated surges, local outbreaks and lockdowns which could exacerbate the impact on health and further widen health inequities
      • The centralisation of data and decision-making has meant that approaches cannot be matched to the needs that only the regional and local level will know well enough and in real time
    • There is a consensus that the COVID19 pandemic has a major potential to widen health inequities,
      • As can be seen from the diagram above, the health impacts are likely to have differential effects on different groups of people, in particular:
        • Those most vulnerable to the infection: such as older people, BAME people, those living in enclosed settings
        • Those on low incomes or living with financial insecurity
        • Vulnerable families: for example, those at risk of domestic violence, those who are poorly housed, children at risk of abuse or neglect
        • Those at risk of social isolation
        • Vulnerable groups: for example, the homeless, people with disabilities, undocumented migrants
        • High vulnerability and institutional settings where outbreaks can occur rapidly.
        • This pandemic has made us focus on older people, and the young are paying a high price for protecting the old. Impacts on the young will have more long-lasting impacts on health inequities
        • Inadequate public health expenditure and ‘shrinking the state’ disproportionately affect poorer people including our BAME communities. More ‘austerity’ to ‘pay for’ the pandemic is not an option as austerity widens the health inequalities that lead to disproportionate mortality due to direct and indirect impacts of COIVD19
    • Deprivation: people living in more deprived areas are more likely to die from COVID19
      •  ONS analyses have shown that the age-standardised mortality rate of deaths involving COVID-19 in the most deprived areas of England was 55.1 deaths per 100,000 population compared with 25.3 deaths per 100,000 population in the least deprived areas. In Wales, the most deprived areas had a mortality rate for deaths involving COVID-19 of 44.6 deaths per 100,000 population, almost twice as high as the least deprived area of 23.2 deaths per 100,000 population.
      • The Kings College Symptoms tracker found that COVID-19 prevalence and severity became rapidly distributed across the UK within a month of the WHO declaration of the pandemic, with significant evidence of urban hot-spots, which tend to be more deprived areas.
      • The openSAFELY cohort study used national primary care electronic health record data linked to in-hospital COVID-19 death data, which is the largest cohort study in the world, examining 17 million primary care records. This showed a gradient from least deprived to most deprived, adjusted for age, sex and risk factors, so that people living in the most deprived quintile have a risk of 1.75 that of people in the least deprived

    Hazard ratio for in hospital COVID19 death (adjusted for age/sex/risk factors

    IMD quintile of deprivation
    • Unequal impacts
      • People living in more deprived areas are more likely to be exposed to COVID19:
        • Population density and overcrowding: urban poverty
        • Occupational exposure: more likely to be key workers and less likely to be able to work from home
        • Vulnerable groups e.g. homeless, refugees and asylum seekers, substance misusers
      • People living in more deprived areas are more likely to die when they get sick with COVID19:
        • They develop multiple co-morbidities at younger age (people in the most deprived areas get sick 10 years younger than the most affluent)
        • Equity of access to quality health and social care mitigates this, but has become eroded as austerity has hit services in the poorest areas most
        • They are more likely to also be from BAME groups
    • We have evidence on what works to reduce inequities in health
      • We know what causes inequities in health outcomes. The WHO Commission on Social Determinants of Health in states that inequities are caused by the conditions in which we are born, grown, work and live. There is now a large body of evidence from expert reports on health inequalities from academic as well as government sponsored reviews (Black and Acheson) for the past 40 years.
      • We know what works to tackle inequities in health: this can be usefully summarised by Sir Michael Marmot’s six policy areas for action:
        • Give every child the best start in life
        • Enable all children, young people and adults to maximise their capabilities and have control over their lives
        • Create fair employment and good work for all
        • Ensure healthy standard of living for all
        • Create and develop healthy and sustainable places and communities
        • Strengthen the role and impact of ill-health prevention
      • No strategy: the UK government has not prioritised health inequalities, and England has had no health inequalities strategy since 2010, although devolved nations have policies within the constraints of their powers.
      • But we have assets: We have seen how individuals and communities are resilient, and this has been amply demonstrated in their amazing response to this public health crisis. We should be following Prof Sir Michael Marmot’s advice: “Our vision is of creating conditions for individuals to take control of their own lives. For some communities this will mean removing structural barriers to participation, for others facilitating and developing capacity and capability through personal and community development”

    Conclusions:

    1. There are already major inequities in health outcomes in the UK, and these have been getting worse
    2. COIVD19 is disproportionately killing the less affluent and those in vulnerable groups
    3. There is a very high risk that the indirect impact of COVID19 will worsen health inequities through well-known mechanisms.
      • Greater vulnerabilities: for example, the higher prevalence of co-morbidities and complex multi-morbidities, ethnicity, disability
      • Higher exposure: for example, through occupations, overcrowding, enclosed settings, multi-occupancy households
      • Less access to resources to protect against economic and financial impacts
      • Less access to quality public services

    Actions

    • Commit to a long-term inequalities’ strategy with a multi-faceted approach building on previous Labour success 1997-2010. This should be even more ambitious, to tackle the commercial/ structural determinants of health, and to create healthy communities and places: it should reduce reliance on less effective individual behaviour change strategies, and include the intersectionality of disadvantage
    • Decentralise data and decision-making for COVID19 to better allow resources and control measures to be matched to need
    • Focus on elimination of transmission of COVID19 high risk settings, for example social care and health service facilities, prisons and migrant detention facilities, homes with multiple occupancy, and overcrowded or intergenerational households
    • Redistribute wealth: Maintain social protection measures as long as required and then in the longer term: implement Universal Basic Income and a Green New Deal with an economy based on need not profit. Ensure proportionate universal allocation of resources o Prioritise children: ensure safeguarding/ tackle domestic violence/ prevent unwanted pregnancies/ action to ensure healthy pregnancy outcomes/ push for childhood vaccinations programs to continue/ get children back to school as safely as possible
    • The NHS and social care should be always provided by need and not ability to pay: the state is a protective factor against unequal exposures to health determinants, as a provider, enabler and employer
    • Build and nurture the grassroots movements that have blossomed during the pandemic, and establish community oriented primary care to empower communities to create healthy communities

    Sources

    • Watkins J, Wulaningsih W, Da Zhou C, et al Effects of health and social care spending constraints on mortality in England: a time trend analysis BMJ Open 2017;7:e017722. doi: 10.1136/bmjopen-2017-017722
    • https://bmjopen.bmj.eom/content/7/11/e017722

    Posted by Brian Fisher on behalf of the Policy Team.

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    Summary

    The current National Health and Care System has shown the fact that a system can run on the basis of an ethic of altruism and public service, not profit.

    The hospitals have always held primacy in our system, and reorganisations have tried to rebalance the system in favour of community health and primary care.

    Public Health has been weakened by the 2012 Act and enjoyed more prominence during the period of Primary Care Trusts when it was integrated with Primary Care. This situation needs to be restored

    Health and Care need to be integrated regionally and the paper argues for Combined Authorities to be given overall control.

     

    No, the title was not a typo. There is more to healthcare than the NHS which we all know and love. Health Care includes Public Health, Social Care, Pharmacy and Dentistry, and they all need to work together. The present crisis has shown this. This is something which many experts in the field have acknowledged for years; doing something about it has proved elusive and difficult. This present crisis has shown not only the heroic dedication and commitment of the staff, but also the gaps and problems which need to be rectified, so perhaps this is the time to try and do it.

    In this paper I have tried to set out some sort of roadmap of the problems we need to tackle. That is why I have called the objective a National Health System, rather than the current NHS, but have preserved the iconic brand which is known all over the world. I once met mountaineers in a foreign land who praised the NHS.

    I am not an academic. I have taught about how the Health System works, but more practically I have been a councillor, worked for the NHS, served on a Clinical Commissioning Group and now Health Education England. I wrote a book about how the NHS should be organised with Sunderland University, and I will draw on bits of that in this paper, but my knowledge comes mainly from my practical experience. (“What Sort of NHS do We Want?”, Searching Finance, 2012)

    How we arrived at the present position

    There is much ignorance amongst the public as to how the NHS actually works. It is certainly very fragmented, but still able to respond as a national system, which has been shown by the present crisis. Many fondly think there was a “golden age” back in the 1950’s when the NHS was first established.  Aneurin Bevan boasted of a national system where the “sound of a bedpan dropped in Tredegar would reverberate around the Palace of Westminster”.

    We all know establishing the NHS was a political struggle and what emerged was a messy compromise. The immediate problem was sorting out hospitals which needed investment after the war. I can remember seeing pictures of my Grandmother, who was a hospital almoner, lining up the nurses to go out with the collection tins. Hospitals seem to have dominated ever since although they deal with a minority of the people who use the system. There are more patient contacts with GPs, carers, Public Health programmes ,  and Social Workers. Local Government had played an important role in health before 1948, and Directors of Public Health were important people. Much of what we would now call primary care was still run by local authorities up until the major reorganisation of 1974.  Strong central control was the way things worked in 1948, a legacy of the war – the NCB, British Railways, The National Grid and even the New Towns. The new NHS was no different.

    Initially Governments thought that a strong NHS would improve health and once the backlog of bad health had been dealt with, costs would reduce. This of course did not happen, so managing the NHS became a constant struggle between improving the service and keeping a lid on costs. In 1974 all health services came under Regional Health Authorities and this remained until the next major reorganisations at the end of Thatcher’s period in power. This was when the concept of the “market” was introduced into the NHS.

    At that time the model of the big top-down organisation was being challenged both in the public and private sphere. Although big organisations were still centrally controlled from the top, they wanted more flexibility locally to restructure and adapt to changing conditions at the bottom. Even the army now operates like this. The idea was that those who planned a service would commission it from who could provide it best. Commissioning meant what the service was going to be had to be evaluated and planned. The NHS had to think exactly want it wanted and the best, and most cost-effective way, of achieving it. This does not necessarily mean using the private sector. Other NHS and not for profit organisations are often involved. But it was never a free-for-all. The NHS was still in charge. Resulting from the Thatcher reforms there was a privatisation of many ancillary services such as cleaning, maintenance and catering. For clinical services there was still a preference to commission NHS and not for profit organisations. One consequence of these changes was that local authorities outsourced much of their social care provision, mainly for economic reasons.

    The Labour Governments after 1997 modified the model, introducing both Foundation Hospitals and Primary Care Trusts. In my opinion the PCTs were a very progressive reform, and one for which the Blair Governments, Frank Dobson and Alan Milburn received very little credit. They brought together Public and Community Health and allowed a high degree of local government involvement since they covered the same areas as local authorities and usually had councillors on their boards. Under the Blair Government resources were diverted to PCTS, and also prioritised deprived areas such as Easington in County Durham. There was a real push to reduce health inequalities. In my experience the PCTs also put a considerable amount of resource and effort into engaging with the public. In some ways this was a “golden age” for engagement, compared to the much less robust arrangements which replaced them.

    The Black Report in 1979 pointed out that despite large investment in the NHS, health inequalities persisted.  Professor Townsend, one of the main authors, mentioned Easington in a later report and visited Peterlee to explain his ideas. The dominance of the Hospitals in the system had led to a neglect of both social care and the promotion of health in the community. To reduce inequalities meant placing far more emphasis on how people lived, the conditions in which they lived and looking after them in the community when they were frail or unwell. Successive reports re-emphasised what the Black Report had said.

    The Primary Care Trusts were an attempt to redress the power balance with the hospitals. More resources were given to community and public health, which were now integrated. GPs had a major role. The PCTs were coterminous (horrible NHS word) with local authorities, and the Director of Public Health was now appointed jointly between the local authority and the PCT.  Cooperation was much easier. Many PCTs had councillors on their boards. The PCTs now had more power to negotiate with the hospitals to get better deals, and work with them. At this stage commissioning was mainly for other public sector and voluntary organisations. The NHS was the “preferred provider”.  The PCTs made considerable progress in improving public health, such as the reduction of smoking and teenage pregnancies, and set up many community initiatives.

    In my opinion the PCTs were a very progressive reform, and one for which the Blair Governments, Frank Dobson and Alan Milburn received very little credit. They brought together Public and Community Health and allowed a high degree of local government involvement since they covered the same areas as local authorities and usually had councillors on their boards. Under the Blair Government resources were diverted to PCTs, and deprived areas were prioritised. There was a real push to reduce health inequalities. In my experience the PCTs also put a considerable amount of resource and effort into engaging with the public. In some ways this was a “golden age” for engagement, compared to the much less robust arrangements which replaced them.

    I think I should make a few remarks about commissioning.  Many on the left regard it as synonymous with privatisation. This simply is not so.  As explained above the NHS is not monolithic and contains many different sections and specialities. Some of commissioning is straightforward – estimating the number of routine, predictable operations required in a year, like hip replacements. Then it is about negotiating the best deal with a provider.  But some is more complex, such as public and community health which requires constructing alliances between different organisations. Using a private provider is not a necessary part of this at all.

    All this was changed by the infamous Social Care Act of 2012 which established the Clinical Commissioning Groups. It compelled contracts to be put out for public tender, so private providers could apply, and often threatened to sue if they thought they had not been fairly considered.

    Councillors were not allowed to be involved, and their only oversight was through Scrutiny Committees. Public Health was handed back to local authorities. A strong national agency, Public Health England was created to exercise many of the responsibilities which PCTs had previously done including disaster planning and campaigns to reduce smoking and other habits deemed to be harmful to health. I will say more about the consequences of that later.

    The CCGs were a result of lobbying by a minority of GPs who wanted to commission directly without the NHS bureaucracy and pressure from private providers who wanted a bigger slice of the action. The Government thought they could use them to reduce costs. The whole enterprise was ill thought out and very disruptive. It is a useful lesson in the sort of “creative destruction” advocated by the likes of Dominic Cummings. The idea being that somehow once the bureaucratic shackles of the NHS and local government had been thrown off, GPs would somehow emerge as the heroes of the NHS and challenge the dominance of the Trusts. I can remember attending seminars before the new act was implemented where it was even advocated that two GPs could form a commissioning group. How they would work out the necessary plans and calculations was not thought about. I can remember a seminar about the changes entitled “Breaking Though”.

    In reality it was only a minority of GPs who wanted to run the NHS.  Most of them simply wanted to get on with their jobs which were demanding enough. Much of the pressure came from private providers, aided and abetted by members of the government anxious to reduce costs and eliminate, as they saw it, unnecessary bureaucracy.  Andrew Lansley, in many other ways a fairly level-headed man, seemed carried away by it all, and David Cameron and Nick Clegg did not really understand it. The only contribution by the Liberals was to ensure lay representation on the new CCGs. The reorganisation was described by one critic as “visible from space” and disrupted the NHS for several years.  Patterns of cooperation between agencies, carefully established over time were either disrupted or had to be carried on “under the radar” in the new competitive model. A new bureaucracy had to be established from the PCT staff to perform commissioning.

    One hospital (Hinchinbrooke) was taken over by a private company which could not cope and had to hand it back to the NHS.  Many private providers attempted to run the new 111 services, but now most of them are organised by Ambulance Trusts.

    The idea behind the 2012 Act was that there would be a free market. The CCGs would commission the most efficient service, public or private.  Collaboration, whether between hospitals and other parts of the NHS was not, in theory, allowed. Private providers could take the NHS to court if they thought the NHS had an unfair advantage. In practice, however, the national NHS kept a firm grip on things. There is always the need in the NHS to pool risk.  If there is an outbreak or crisis in one area the whole system has to pitch in.

    The 2012 Act led to an extremely costly and disruptive reorganisation. Many health professionals soon realised that it did not work. In reality the bureaucracy expanded, and much energy had to be expended negotiating between different parts of the NHS. The majority view was that if the NHS was going to cope, two things were necessary. Firstly, more resources needed to be directed to promoting good health, and thus reducing those diseases which were caused, or exacerbated, by a bad lifestyle, such as diabetes. Secondly an ageing population meant more people would need care in the community, rather than treatment in hospital. If they did not receive this care, then they would end up in hospital, as so called “bed blockers”.  Hopefully if policies to address these objectives could be put into place it would reduce unnecessary hospital admissions.

    Local health professionals have tried to negotiate arrangements for CCGs, Hospitals and Local Authorities to work together.  These were originally called Strategic Transformation Partnerships, abut have now morphed into Integrated Care Systems.

    Simon Stevens, Chief Executive of the NHS, said in the Five Year Forward View

    “The government will not impose how the NHS and local government deliver this. The ways local areas integrate will be different, and some parts of the country are already demonstrating different approaches, which reflect models the government supports, including: Accountable Care Organisations such as the one being formed in Northumberland, to create a single partnership responsible for meeting all health and social care needs; devolution deals with places such as Greater Manchester which is joining up health and social care across a large urban area; and Lead Commissioners such as the NHS in North East Lincolnshire which is spending all health and social care funding under a single local plan.”(Implementing the five Year Forward View 2017)

    More detailed plans for ICSs have been set out last year

    The NHS Long-Term Plan set the ambition that every part of the country should be an integrated care system by 2021. It encourages all organisations in each health and care system to join forces, so they are better able to improve the health of their populations and offer well-coordinated efficient services to those who need them.(The NHS, Designing Integrated Care Systems in England 2019)

    It is important to notice the word “Systems”. These ideas rely on different organisations working together. They do not pool budgets, and have no one accountable management, just committees who liaise.

    The trouble is all this is against the 2012 Act. Manchester eventually commissioned other NHS organisations to deliver its community health services, but was threatened with court cases from private providers. All that would have wasted a considerable amount of public money.

    The Conservative election manifesto recognised the system was not working in 2017 and proposed changes to the rules.  All this has since been forgotten about with the dominance of Brexit but will eventually have to be addressed.

    Some on the left see the ICS’ as some sort of conspiracy, implying that there is a secret plan to fragment the NHS and then sell off parts of it. Simon Stevens is often portrayed as being some sort of ogre who is using his American experience to somehow smuggle American health companies into this country.  Remember that health is largely organised on state lines in America, and the insurers who pay for much of it want single organisations whom they can work with. I think the reality is somewhat different. Many think Simon Stevens is a shrewd operator who managed to secure additional funding for the NHS.

    Ever since I have been involved with the NHS there have been efforts to join up health and social care at a community level, and to challenge the dominance of the hospital Trusts.  In the early 2000’s the former Sedgefield Borough Council worked with their Primary Care Trust and Durham County Council to effectively integrate services by putting social workers, district nurses and housing officers in the same room, and Easington PCT considered integrated care initiatives.  The Sedgefield initiative worked at a grassroots level because it did not involve redesigning systems.  As soon as you tried to set up a new structure people retreated into their bunkers.

    It is much easier to set up an integrated system in theory than in practice. One senior insider I spoke to recently said that negotiations to set up an integrated care system locally were not getting very far because of vested interests. Different organisations have different hierarchies and systems of accountability.  They are also keen to hang onto their budgets.  It looks like a solution will only be reached if the NHS imposes it, and they do not have much spare energy for that at the moment.

    I remember the days before local government was reorganised in Northumberland and Durham, and District and County Councils were merged into the present unitary ones. The Government asked councils to work out ways of working together. There were interminable liaison meetings between the different councils which got precisely nowhere, each one wanting to preserve its own interests. Eventually the Government imposed a solution.

    Insiders also tell me there is very little interest from councils in the new arrangements.  Although in practice working relationships between the local authority and the NHS in most areas are good, some councillors appear to prefer the scrutiny role than actually being responsible for the service.

    So overall I think the problem is not so much a conspiracy to carve up the NHS as some on the left seem to think, but rather getting our fragmented system to work together for the benefit of all of us.

     

    Where we are now

    Most people on the left believe in a publicly run health service, free at the point of use. They also value the dedication of the staff and think they should be better rewarded.

    Socialists also dislike privatisation.  There is a difference between having to use the private sector if nothing else is available and the obligation to put services out to tender regardless of whether they are functioning properly as happens now. Efforts to integrate services are also hampered if parts are privately owned, as private providers may not disclose their information and not cooperate. (I remember my efforts on the CCG to get Capita to produce its accounts to the Audit Committee for a service they provided.)

    Privatisation often results in poor staff conditions and pay.  I think nearly all Labour Party members would wish a future Labour Government to repeal the 2012 act and restore the NHS as the preferred provider.

    That is the easy part.  Now we get to the difficult issues of how we organise an integrated service in the future and ensure it is accountable. Let me stress now that I do not want another major reorganisation. Our NHS staff do not deserve that. Rather we must think about how what we have now can be made to work better.

    I have not said much about Social Care, either personal, which is delivered at home, or residential in care homes. It is widely accepted that the situation is at crisis point. The paper by Professor Paul Corrigan is an excellent starting point. A recent briefing by the Nuffield Trust emphasised the dimensions of it. (Nuffield Trust, Election Briefing Nov 2019.)  Here are a few statistics:

    We believe the scale of the workforce challenge has so far been underestimated: our new calculations show that just providing a basic package of care of one hour per day to older people with high needs would require approximately 50,000 additional home care workers now. To provide up to two hours would need around 90,000 extra workers. ( Then there is the question of where they would come from if Brexit is implemented)

     

    A decade of austerity has seen government funding for local authorities halve in real terms between 2010–11 and 2017–18,* which has led to councils tightening the eligibility criteria for care. It is known that there were 20,000 fewer older people receiving long-term social care services in 2017/18 than in 2015/16, but this is likely to understate the problem – estimates of unmet need go as high as 1.5 million.

    Constraints on public sector finances in recent years have meant that fees paid by councils to the organisations that provide home and residential care have been cut repeatedly. The predominant approach used for buying services from providers incentivises organisations to provide a bare minimum of services and nothing more. Some 75% of councils report that these organisations have either closed or handed back contracts in the last 6 months, creating enormous disruption and discontinuity for those receiving care.

    The problems of Care Homes have been highlighted by the current pandemic. There are roughly 11,300 care homes in the UK who look after 410,000 residents. Most of their income comes from fees paid by residents or their families, with a minority provided by local authorities.  In practice the private fees subsidise the public ones which are often insufficient to cover the costs of the residents. Sally Copley of the Alzheimers Society says “The whole system hasn’t been working properly for some time”.  Many staff are on zero hours contracts and staff shortages are endemic as Professor Corrigan pointed out. Staff are paid far less than they are worth and do not receive adequate training nor professional recognition.

    We all have formative experiences which make us socialists. One of mine was in a care home where a member of my family was a resident. I knew two married members of staff well. Both were dedicated to their work and the residents.  They were always cheerful.  I can remember them saying with great enthusiasm how they had saved up enough to take their young family to Great Yarmouth for a week in the summer.  Their work deserved far more reward than that. I though “something has to be done about this”.

    A proper care system would assess people on the basis of clinical need, not ability to pay.  At the moment there is continuing health care, provided by the NHS, which is free,  for those thought to have health issues, but domiciliary and residential care largely has to be paid for by the clients or their families except for the minority who benefit from a stringent means test. Dementia is not classified as a medical condition.  Many people feel this system is unfair. A senior commissioner I spoke to said she would rather commission “care” which would be provided by professionals trained by the NHS, rather than try and distinguish between continuing health care and social care.

    At the last election the Labour Party promised free personal care for those over 65, as in Scotland.  As the Nuffield Report points out this does not include assistance with cleaning and general supervision.

    One of the best assessments of the cost of integrating health and social care was done by Kate Barker and associates for the Kings Fund in 2014.  They looked carefully at what social care involves, and how it could be paid for. There are different levels of social care, and they conclude that the same principles should apply as to the NHS.  Afflictions can strike anyone, rich or poor, so care funding should come from the public purse. The costs of care and treatment should be publicly funded, although this might not include the actual “hotel charges” for residential care. The authors suggest various ways to raise the extra funding, such as means testing free TV licences, and requiring those (usually better off) who continue to work after the retirement age to pay national insurance.  There would of course be a need for those on higher incomes to pay more tax, possibly after the age of 40, and the Government should consider a wealth tax which in reality for most would be a tax on your home. There are various avoidance schemes and tax loopholes for the wealthy which could be closed.

    There would probably be agreement amongst socialists that health and social care should be integrated and paid for out of taxation, but it is no good thinking only the rich would have to pay.  Everyone would have to pay something.

    Finally, there is the issue of Public Health. Transferring it to local government has not been a success. The budget, supposedly ring fenced, has been diverted to other local government departments because of the squeeze on local authority finance, and last year some of the poorest authorities took a very big hit. Durham lost almost 40% of its public health funding. Yet even in its diminished state, The Centre for Health Economics at York has estimated that expenditure on Public Health is four times more effective in promoting health than that spent on the NHS. Simple common sense tells us that keeping people healthy is better than curing them once they are ill.

    Several distinguished epidemiologists, including Professor Allyson Pollock at Newcastle, have argued that the marginalisation of Public Health locally has severely reduced the country’s ability to deal with the coronavirus epidemic. Back in PCT days Public Health had the resources and plans to deal with disasters, often pooling risk with others.  Now that has been transferred to Public Health England, leaving local authority public health departments to deal mainly with schemes to keep people fit. Worthy enough, but nothing like the resources they used to have.   A regional public health response might have led to better testing and efforts to contain the virus. The Government’s response has been “one size fits all”. Restoration of the importance of Public Health and its reintegration with the NHS should be a major aim of policy.

     

    Policy Objectives

    Our policy objectives will be ambitious. We might need a five year, or even ten year forward view to coin a phrase.

    We seek an integrated National Health System, encompassing the National Health Service, Social Care, Public Health, with links to Pharmacy, which has a role in primary care, and Dentistry, which is not a totally public service although the NHS controls the training. But we do not want a major reorganisation again. Our dedicated health and care staff do not deserve that. What we want to do is give the present system more resources and steer it in the right direction. Repealing the 2012 Act would be a priority.

    We must ensure that particularly in social care staff are paid a decent wage and given proper access to training. The present system which relies on the minimum wage and zero-hour contracts must end.

    The first thing we know is that all this will cost more than it does now, although integration may produce some savings. A future Labour Government has to be honest about this. It is no good promising a few rich people will pay, as the public simply will not believe it. It is a good principle that everyone should contribute to something which is part of national solidarity, so all feel that it is theirs, but contributions have to be proportionate to the ability to pay.  A proper revaluation of properties, which is akin to a wealth tax, would raise money through the community charge to make a substantial contribution to social care.  An increase in National Insurance, earmarked for the NHS should be considered, provided that it became more progressive.

    Then we come to the whole issue of Governance.  Despite showing little enthusiasm, local government needs to be involved in the whole strategic planning of the NHS. But they must not see it as simply concerning their own territory, so to speak. The present structure of Foundation Trusts should stay, but Public Health and Commissioning Services should be reintegrated into Primary Care Trusts, in my opinion one of the most successful NHS organisations in its long history of restructuring. The PCTs would have oversight of Pharmacy and Dentistry. Many of the responsibilities transferred to Public Health England should be restored to the PCTs. Their boards should contain both professional and local government representation.

    There is a need for a regional dimension in all this.  When the Northumbria Trust reorganised its A&E provision to build a super emergency only hospital at Cramlington it did not consider the effect on major hospitals in Newcastle like the RVI. Patients in Hexham, for example would find it easier to go there than to Cramlington. This is just one example of where a regional perspective would have been useful.

    Local authorities’ power over social care providers need to be strengthened. At present there is a real mixture of providers, commercial companies, charities, cooperatives and individuals who provide personal care as a small business. There is a strong argument for integrating the private sector, which is virtually bankrupt anyway, into area trusts responsible to local authorities. Standards and remuneration need to be strengthened.

    Trying to merge different organisations would be very difficult and disruptive. The result could be some unwieldy bureaucracy which would be difficult to manage and slow to react to changing needs and priorities. Accountability should be pushed upwards. We need to have some sort of accountable umbrella which ensures that hospital trusts, PCTs (coterminous with local authorities) and Social Care, which is regulated by local authorities, all work together. There will always be oversight from NHS England, NHS Improvement, and the Care Quality Commission, but these bodies are mainly regulatory.  There needs to be a more local system of Governance and Oversight.

    Nationally the country is moving to a system of Combined Authorities which at present oversee economic development and transport.  Manchester has also had community health added to its powers. A combined authority does not take powers away from local authorities.It has power and oversight over services provided by other organisations. Its membership is delegated from existing councils, with a mayor if that is agreed. It would seem logical for a combined authority to exercise oversight over the Foundation Trusts, PCTs and Local Authority Care in its area and produce a plan to ensure they work together. The CCGs now cooperate to cover larger areas in any case. That way we preserve flexibility within the system without adding another layer of bureaucracy,and move towards the integrated National Health System we want.

    I want to end by stating that as socialists we owe a great deal to the NHS and Care Services. They are an example, much admired elsewhere, of how a publicly run system can be successful, and that duty and altruism more important motivators of human conduct as making a profit.  It is our duty to ensure it is funded and run properly.

    David Taylor-Gooby, author on the NHS and member of the Socialist Health Association

    May 2020
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