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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.

    Comments Off on Briefing Topic 2 – Inequalities

    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
    1 Comment

    This is the 7th week that the SHA has published a Blog tracing the progress of the Coronavirus pandemic globally but more specifically across the UK. Over this time we have drawn attention to the slow response in the UK; the lack of preparedness for PPE supply and distribution; the delay in scaling up the testing capacity and system of contact tracing; a too early move away from trying to control the epidemic and poor anticipation of the needs of the social care sector.

    However we need to start to look at how we can reverse the situation we find ourselves in being one of the worst affected countries in the world. Our deaths in the UK now exceed 20,000 and we have been following Italy and Spain’s trajectory. It is true that while the lockdown came too late – London should have gone first – it has had an impact on suppressing the first wave and the NHS has stood proud and able to cope thanks to the unflagging commitment from all staff. It is good that Parliament has been reconvened so proper scrutiny can be given to government decisions on public health as well as the economy. We look to the new Shadow Team to pursue this energetically.

    It is no surprise that Trump’s USA is a lesson of the damage disinvesting in the Centers for Disease Control and Prevention (CDC) has had. It has led to poor emergency preparation and poor leadership at handling the pandemic at a federal level. From a SHA perspective an example of the superiority too of a nationalised health system as compared with a private health care model in the USA. Compare how it looked in New York City during their peak and the relative calm in London on the 8th April. From his rehabilitation home at Chequers it was concerning that one of the first phone calls PM Boris Johnson allegedly made was to Mr Trump. They share many characteristics but let’s hope that we do not end up second only to the USA in the international table of deaths/100,000 population and tie ourselves too closely with the ‘Make America Great Again’ nationalist neo-conservative movement.

    1. Scientific advice

    One of the characteristics of this pandemic has been the UK Government Ministers repeated claim that they have been making decisions on the best scientific advice. This claim has mystified some commentators who feel that the decisions being made by Ministers has not been in line with WHO advice (test, test, test) and not consistent with comparable EU countries who seem to have managed the pandemic more successfully (Germany and Denmark). We have never said that we cannot compare data published in Germany and Denmark before now!

    Sometimes Governments make bad calls during an emergency and wanting to keep the membership of SAGE secret was one such. There has been mounting concern about the provenance of some of the advice leading to Ministerial decisions. For example the early misunderstandings about ‘herd immunity’ and the fear that the nudge behavioural psychologists were having undue influence leading to the crucial delay in lockdown. Some of these scientists work in government units, which is not good for an independent perspective.

    The mixed messages about the modellers and their estimates of the likely deaths (20,000 to 500,000) which also surfaced before one modeller was allegedly responsible for pushing (thankfully) the belated decision on the lockdown.

    Many public health trained people have begun to wonder who on SAGE had any practical public health experience in communicable disease control? These concerns were prompted by the sudden abandonment of testing and contact tracing, the lack of airport or seaport health regulations used by other countries such as Australia and New Zealand (Australian deaths so far 80 for a population of 25m and NZ 18 for a population of 5m).

    Recently we have also been bemused by the inability to recognise how homemade cloth facemasks might play a part in easing lockdown. While there might be a relative lack of ‘gold standard’ evidence there is ‘face validity’ that a mask will stop most droplets and this will be important as we are finding so many people are infected for days before showing the classic symptoms and signs of fever and cough. Homemade cloth masks would not compete with NHS and Social Care supplies and these do seem to have been part of the strategy that countries that have been more successful at containment than the UK. We suspect that in time the recommendation to wear a cloth mask when going outside your home will become a recommendation!

    After the initial planeload of British nationals from Wuhan, who had been appropriately quarantined, there are no measures in place at all at our airports. The explanation about incubation period does not hold if people are quarantined for 14 days. The precision of temperature measurements should be seen as part of a screening regime, which would include risk assessment of country of origin, symptoms reported on a questionnaire or observed as well as temperature measurement. It is obvious that if a passenger causes concern the less accurate thermal imaging technique can be augmented by other more reliable ways of taking a temperature! It does not seem right that such measures are discounted for the UK and we are one of the worst performers while other countries with competent public health professionals take it seriously. It is estimated that nearly 200,000 people arrived from China to the UK between January and March 2020 with no checks at all apart from general Covid advice. Empty hotels would have been suitable for quarantining people at risk of having the virus. This matters as it is a very contagious virus and can spread before symptoms appear. Such symptoms can also be minimal and hard to detect.

    Now that the membership of SAGE has been leaked we can see that one of the Deputy CMOs is the only person who has had any ‘on the ground’ experience of communicable disease control in communities. This is important when we start to consider how we can get out of lockdown by using the new testing capacity optimally, contact trace effectively and introduce control measures locally. This will require Public Health England (PHE) to begin to strengthen its relationship with local Directors of Public Health (DsPH) located in Local Government. These DsPH can provide local leadership and work with Environmental Health Officers (EHOs) who to date have not been drawn into the pandemic management system.

    The presence of Dom C in SAGE meetings raises concerns. Of course civil servant officials have always attended the meetings to ensure that they are properly organised, agendas circulated and minutes recorded. It is quite a different thing to have an influential Prime Ministerial adviser like Dom C attend the meeting and no doubt interject during discussions and help shape the advice. That should be the Chief Scientific adviser’s (Prof Vallance) job and his role to brief the PM. The trust in SAGE has been damaged by the disclosure of membership, the lack of jobbing public health input as well as the presence and influence of these special advisers (SPADs).

    1. Easing lockdown

    One of the problems in the management of the pandemic in the UK has been the centralised London perspective, which has dominated the options and led to a one-size fits all approach. We have said before in these Blogs that Greater London was our Wuhan (similar population sizes). We should have shut London down much earlier and stopped the nonsense of those crowded tube trains and buses. We have seen from the Ministerial briefings that London has had an almost classic epidemic curve – rising steeply and then levelling off and declining. The devolved nations and English regions have lagged behind. Scotland and Wales got their first cases about 4 weeks after London and the South East. Regions such as the SW region in England, Northern Scotland and the Islands, rural Wales and parts of the North of England have been slow to have cases and even now have had few cases and few deaths. These areas did not need to be locked down at the same time as London and the South East and could have instituted regional testing and contact tracing which would have helped flatten the curve and protect the NHS.  Such a strategy would have built up experience of doing this which we now have realised we need to do to get out of lockdown. However we have an asymmetric situation with the regions showing gradual and flat epidemic curves, which will be prolonged and frustrate a UK alone approach.

    The challenge of easing lockdown will be quite different in metropolitan urban areas with heavily used public transport and metro trains and a more dense housing with fewer green spaces. The picture in more rural areas and small towns is quite different. There is a serious need to engage with local government more appropriately, pull back from central control and set out a framework as has been started in Scotland and Wales which local government partners can start to address via their Local Resilience Fora (LRFs) and emergency control structures.

    There does still need to be a UK wide COBR approach but the strategy needs to be more nuanced to set out the UK framework and allow devolved nations who are a similar size to New Zealand and Denmark and English regions to plan locally sensitive approaches drawing on expert advice from Public Health organisations such as Public Health Wales, Scotland and PHE. Metropolitan areas such as London, Birmingham and Manchester will also want to be able to adapt measures to fit their local complexities. This will be particularly important as we start a system of community testing, contact tracing and control measures. National testing standards and quality will apply and any mobile apps that are developed will need to be agreed at a national level with all the safeguards on privacy and information governance.

    Children have been remarkably resilient to this virus and it seems that back to school is something worth considering as an early venture as long as schoolteacher’s health is safeguarded by not exposing ‘vulnerable’ teachers, and implementing systems to make physical distancing more feasible. It is urgent to look at international best practice and be flexible in our approach.

    Pubs and restaurants will be further down the list as will mass sporting events but widening the retail sector and getting some workplaces back should be planned. Again travel to work should only be necessary for some workplaces and physical distancing, masks and health and safety regulations will need to be updated to suit each work environment before permission to reopen is given. All these steps require enhanced local public health capacity.

    1. Recovery planning

    An important part of emergency planning frameworks is the need immediately an emergency is recognised to begin the ‘recovery planning’. This will depend on the characteristics of each emergency. In the case of Covid-19 we will need to look at the build up of elective care, especially surgical waiting lists. It will also need to urgently review those people with long-term non-Covid conditions who may have had their continuing medical care disrupted. There will also be those casualties of the pandemic who have been traumatised by the pandemic and have mental health issues, burnout, faced economic hardship and PTSD. People who have had Covid-19 and survived a period in ICU and ventilation will also need weeks and sometimes months to recover. So all this adds up to a load for the NHS and associated services to address.

    As we have seen the economy has taken a big hit and many businesses have found themselves having to close down or reduce their workforce/suspend manufacturing output. It is unclear how we measure what has happened to our economic base but we have seen the growth in unemployment, the rise in welfare applications and the stories of those caught out with a sudden loss of employment and income. We know that 12 years after the 2008 financial crash that the legacy remains. This is far bigger so we need to begin to agree how the economy can be rebooted safely while protecting those vulnerable populations and safeguarding the children returning to school or workers to the factory floor. Trade Unions must be key partners of this economic recovery planning challenge.

    The other aspect of a recovery plan is to take advantage of good things we have experienced such as the reduction of air pollution with a reduction of car use and aviation and other transport. The global satellite pictures of Beijing, Delhi and Milan tell the story that life can be better if we reduce our carbon footprint. Working from home, the benefit of fast broadband should all lead to a reappraisal of environmental and other life changes. The growth in cycling and physical activity in green spaces should also be built on.

    Finally the pandemic has once again thrown a light on inequalities with the risks of occupational exposure (bus drivers), risks in hospital environments (porters, receptionists to nurses and doctors) and retail shops (shop assistants/cashiers). Many manual workers have had to go out to work still and in the process through travel and the work environment been at higher risk. Those who live in over crowded households have been at greater risk with fewer opportunities to self-isolate. Many of those in poorer urban housing estates have also been exposed to risk and found safely going to shops, medical centres or exercise much more difficult. We know about the health inequalities gradient and when this pandemic is analysed fully these social economic and environmental determinants will show through. It is pretty clear that BAME communities have been more susceptible to the virus and while this may have some biological features such as cardiovascular/metabolic risks it will also be socioeconomic, cultural and reflect occupational exposure.

    So recovery plans need to be set out to ensure that we do not revert to business as usual but grasp the opportunities that there are to build a better future after the C-19 pandemic. The Beveridge Committee was established relatively early during WW2 and the report was published in 1942 setting out the vision of an NHS and State Education for example. We have an opportunity to push for similar progressive changes after Covid-19.

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

    2 Comments

    The Socialist Health Association (SHA) published its first Blog on the COVID-19 pandemic last week (Blog 1 – 17th March 2020). A lot has happened over the past week and we will address some of these developments using the lens of socialism and health.

    1. Global crisis

    This is a pandemic, which first showed its potential in Wuhan in China in early December 2019. The Chinese government were reluctant to disclose the SARS- like virus to the WHO and wider world to start with and we heard about the courageous whistle blower Dr Li Wenliang, an ophthalmologist in Wuhan, who was denounced and subsequently died from the virus. The Chinese government recognised the risk of a new SARS like virus and called in the WHO and announced the situation to the wider world on the 31st December 2019.

    The starter pistols went off in China and their neighbouring countries and the risk of a global pandemic was communicated worldwide. The WHO embedded expert staff in China to train staff, guide the control measures and validate findings. Dr Li Wenliang who had contracted the virus, sadly died in early February and has now been exonerated by the State. Thanks to the Chinese authorities and their clinical and public health staff we have been able to learn about their control measures and the clinical findings and outcomes in scientific publications. This is a major achievement for science and evidence for public health control measures but….

    Countries in the Far East had been sensitised by the original SARS-CoV outbreak, which originated in China in November 2002. The Chinese government at that time had been defensive and had not involved the WHO early enough or with sufficient openness. The virus spread to Hong Kong and then to many countries showing the ease of transmission particularly via air travel. The SARS pandemic was thankfully relatively limited leading to global spread but ‘only’ 8,000 confirmed cases and 774 deaths. This new Coronavirus COVID-19 has been met by robust public health control measures in South Korea, Taiwan, Hong Kong, Japan and Singapore. They have all shown that with early and extensive controls on travel, testing, isolating and quarantining that you can limit the spread and the subsequent toll on health services and fatalities. You will notice the widespread use of checkpoints where people are asked about contact with cases, any symptoms eg dry cough and then testing their temperature at arms length. All this is undertaken by non healthcare staff. Likely cases are referred on to diagnostic pods. In the West we do not seem to have put much focus on this at a population level – identifying possible cases, testing them and isolating positives.

    To look at the global data the WHO and the John Hopkins University websites are good. For a coherent analysis globally the Tomas Peoyu’s review  ‘Coronavirus: The Hammer and the dance’ is a good independent source as is the game changing Imperial College groups review paper for the UK Scientific Advisory Group for Emergencies (SAGE). This was published in full by the Observer newspaper on the 23rd March. That China, with a population of 1.4bn people, have controlled the epidemic with 81,000 cases and 3,260 deaths is an extraordinary achievement. Deaths from COVID-19 in Italy now exceed this total.

    The take away message is that we should have acted sooner following the New Year’s Eve news from Wuhan and learned and acted on the lessons of the successful public health control measures undertaken in China and the Far East countries, who are not all authoritarian Communist countries! Public Health is global and instead of Trump referring to the ‘Chinese’ virus he and our government should have acted earlier and more systematically than we have seen.

    Europe is the new epicentre of the spread and Italy, Spain and France particularly badly affected at this point in time. The health services in Italy have been better staffed than the NHS in terms of doctors/1000 population (Italy 4 v UK 2.8) as well as ITU hospital beds/100,000 (Italy 12.5 v UK 6.6). As we said in Blog 1 governments cannot conjure up medical specialists and nurses at whim so we will suffer from historically low medical staffing. The limited investment in ITU capacity, despite the 2009 H1N1 pandemic which showed the weakness in our system, is going to harm us. It was great to see NHS Wales stopping elective surgical admissions early on and getting on with training staff and creating new high dependency beds in their hospitals. In England elective surgery is due to cease in mid April! We need to ramp up our surge capacity as we have maybe 2 weeks at best before the big wave hits us. The UK government must lift their heads from the computer model and take note of best practice from other countries and implement lockdown and ramp up HDU/ITU capacity.

    In Blog 1 we mentioned that global health inequalities will continue to manifest themselves as the pandemic plays out and spare a thought for the Syrian refugee camps, people in Gaza, war torn Yemen and Sub Saharan Africa as the virus spreads down the African continent. Use gloves, wash your hands and self isolate in a shanty town? So let us not forget the Low Middle Income Countries (LMICs) with their weak health systems, low economic level, weak infrastructure and poor governance. International banking organisations, UNHCR, UNICEF, WHO and national government aid organisations such as DFID need to be resourced and activated to reach out to these countries and their people.

    1. The public health system

    We are lucky to have an established public health system in the UK and it is responding well to this crisis. However we can detect the impact of the last 10 years of Tory Party austerity which has underfunded the public health specialist services such as Public Health England (PHE) and the equivalents in the devolved nations, public health in local government and public health embedded in laboratories and the NHS. PHE has been a world leader in developing the PCR test on nasal and throat samples as well as developing/testing the novel antibody blood test to demonstrate an immune response to the virus. The jury is out as to what has led to the lack of capacity for testing for C-19 as the UK, while undertaking a moderate number of tests, has not been able to sustain community based testing to help guide decisions about quarantining key workers and get intelligence about the level of community spread. Compare our rates of testing with South Korea!

    We are lucky to have an infectious disease public health trained CMO leading the UK wide response who has had experience working in Africa. Decisions made at COBRA and announced by the Prime Minister are not simply based ‘on the science’ and no doubt there have been arguments on both sides. The CSO reports that SAGE has been subject to heated debate as you would expect but the message about herd immunity and stating to the Select Committee that 20,000 excess deaths was at this stage thought to be a good result was misjudged. The hand of Dominic Cummings is also emerging as an influencer on how Downing Street responds. Remember at present China with its 1.4bn population has reported 3,260 deaths. They used classic public health methods of identifying cases and isolating them and stopping community transmission as much as possible. Herd immunity and precision timing of control measures has not been used.

    The public must remain focused on basic hygiene measures – self isolating, washing of hands, social distancing and not be misled about how fast a vaccine can be developed, clinically tested and manufactured at scale. Similarly hopes/expectations should not be placed on novel treatments although research and trials do need supporting. The CSO, who comes from a background in Big Pharma research, must be seen to reflect the advice of SAGE in an objective way and resist the many difficult political and business pressures that surround the process. His experience with GSK should mean that he knows about the timescales for bringing a novel vaccine or new drugs safely to market.

    1. Local government and social care

    Local government (LAs) has been subject to year on year cuts and cost constraints since 2010, which have undermined their capability for the role now expected of them. The budget did not address this fundamental issue and we fully expect that in the crisis, central government will pass on the majority of local actions agreed at COBRA to them. During the national and international crisis LAs must be provided with the financial resources they need to build community hubs to support care in the community during this difficult time. The government need to support social care.

    COVID-19 is particularly dangerous to our older population and those with underlying health conditions. This means that the government needs to work energetically with the social care sector to ensure that the public health control measures are applied effectively but sensitively to this vulnerable population. The health protection measures which have been announced is an understandable attempt to protect vulnerable people but it will require community mobilisation to support these folk.

    Contingency plans need to be in place to support care and nursing homes when cases are identified and to ensure that they can call on medical and specialist nursing advice to manage cases who are judged not to require hospitalisation. They will also need to be prepared to take back people able to be discharged from acute hospital care to maintain capacity in the acute sector.

    Apart from older people in need there are also many people with long term conditions needing home based support services, which will become stressed during this crisis. There will be nursing and care staff sickness and already fragile support systems are at risk. As the retail sector starts to shut down and there is competition for scarce resources we need to be building in supply pathways for community based people with health and social care needs. Primary health care will need to find smart ways of providing medical and nursing support.

    1. The NHS

    In January and February when the gravity of the COVID pandemic was manifesting itself many of us were struck by the confident assertion that the NHS was well prepared. We know that the emergency plans will have been dusted down and the stockpile warehouses checked out. However, it now seems that there have not been the stress tests that you might have expected such as the supply and distribution of PPE equipment to both hospitals and community settings. The planning for COVID-19 testing also seems to have badly underestimated the need and we have been denied more accurate measures of community spread as well as the confirmation or otherwise of a definite case of COVID-19. This deficiency risks scarce NHS staff being quarantined at home for non COVID-19 symptoms.

    The 2009 H1N1 flu pandemic highlighted the need for critical care networks and more capacity in ITU provision with clear plans for surge capacity creating High Dependency Units (HDUs) including ability to use ventilators. The step-up and step-down facilities need bed capacity and adequate staffing. In addition, there is a need for clarity on referral pathways and ambulance transfer capability for those requiring even more specialised care such as Extracorporeal Membrane Oxygenation (ECMO). The short window we now have needs to be used to sort some of these systems out and sadly the supply of critical equipment such as ventilators has not been addressed over the past 2 months. The Prime Minister at this point calls on F1 manufacturers to step in – we wasted 2 months.

    News of the private sector being drawn into the whole system is obviously good for adding beds, staff and equipment. The contracts need to be scrutinised in a more competent way than the Brexit cross channel ferries due diligence was, to ensure that the State and financially starved NHS is not disadvantaged. We prefer to see these changes as requisitioning private hospitals and contractors into the NHS. 

    1. Maintaining people’s standard of living

    We consider that the Chancellor has made some major steps toward ensuring that workers have some guarantees of sufficient income to maintain their health and wellbeing during this crisis. Clearly more work needs to be done to demonstrate that the self-employed and those on zero hours contracts are not more disadvantaged. The spotlight has shown that the levels of universal credit are quite inadequate to meet needs so now is the time to either introduce universal basic income or beef up the social security packages to provide a living wage. We also need to ensure that the homeless and rootless, those on the streets with chronic mental illness or substance misuse are catered for and we welcome the news that Sadiq Khan has requisitioned some hotels to provide hostel space. It has been good to see that the Trade Unions and TUC have been drawn into negotiations rather than ignored.

    In political terms we saw in 2008 that the State could nationalise high street banks. Now we see that the State can go much further and take over the commanding heights of the economy! Imagine if these announcements had been made, not by Rishi Sunak, but by John McDonnell! The media would have been in meltdown about the socialist take over!

    1. Conclusion

    At this stage of the pandemic we note with regret that the UK government did not act sooner to prepare for what is coming both in terms of public health measures as well as preparing the NHS and Local Government. It seems to the SHA that the government is playing catch up rather than being on the front foot. Many of the decisions have been rather late but we welcome the commitment to support the public health system, listen to independent voices in the scientific world through SAGE and to invest in the NHS. The country as a whole recognises the serious danger we are in and will help orchestrate the support and solidarity in the NHS and wider community. Perhaps a government of national unity should be created as we hear much of the WW2 experience. We need to have trust in the government to ensure that the people themselves benefit from these huge investment decisions.

    24th March 2020

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