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    Through the decade of austerity, the Welsh Government is to be commended for its efforts to maintain the sustainability of our social services, in contrast to other parts of the UK. Socialist Health Association – Cymru (SHAC-C) welcomes the initiatives to promote greater joint working with other key agencies such as the NHS, housing, and education. The cap on the costs of domiciliary care and the increased thresholds for residential care provides Welsh residents with a more generous provision than elsewhere.

    We also welcome the proposals to improve the status of the social care workforce through its increased professionalisation and to seek remuneration solutions through the Social Care Forum. The initiatives to reduce the prevalence of zero hours contracts and to enhance the choice of the care workforce should help to bring some stability to the sector.

    Innovative initiatives such as the Children’s Commissioning Consortium Cymru has provided a strategic response of humanely addressing some of the most difficult challenges in Children’s Services provision.

    During the Covid-19 pandemic the Welsh Government recognised the vital role of its public sector partners as being pivotal in its response rather that embark on a wasteful and incompetent embracing of the private sector. It acted quickly to learn important early lessons by intervening to provide care home providers with personal protective equipment and to institute a regular programme of staff testing.

    In this period of crisis, partnership working across organisational boundaries happened to an unprecedented extent. It showed what is possible – with proper leadership and the political will to make things happen. These achievements were on a par with those inspired by the “Spirit of 45” which followed WW 2.

    SHA Cymru fully supports the Welsh Government’s £500 bonus payment to our frontline social care staff. It is a pity that the UK Government did not have the generosity of spirit to reciprocate.

    Despite these commendable policy initiatives, SHA Cymru feels the consultation underestimates the scale of the challenges that the social care sector faces. The present substantially privatised provider model is in crisis at all levels from children’s services to services for older people. It is not at all clear what are the continuing advantages of this model. There is an underlying premise that it is possible to achieve the necessary improvements in quality through commissioners purchasing and procuring services from non-public services bodies.

    Social care should not be a market. The approach of ‘switching suppliers’ may work for consumers of electricity, but it doesn’t work for social care. It does not matter who provides your electricity, the product is the same and it is just a matter of price. It does matter who provides your social care. Who delivers the care can determine what care is given.

    The NHS was conceived as a national service, designed to meet the health needs of both individuals and communities. Provision was rationally planned and provided. Individuals accessed it when needed. Their needs were not assessed and then the market searched for the product. This is very much the “for profit” and insurance model where you justify your claim in line with means testing and eligibility criteria.

    In the past a combination of pro-market ideology and determination to drive down costs was the rationale for the current model. As time has gone on it is becoming increasingly obvious that there is a price to be paid for this dogma – in terms of quality of care, workforce retention and training as well overall sector stability. SHA Cymru welcomes the view arising from the two-year review of A Healthier Wales that further work will be done to…” rebalance social care and address the barriers which have made it difficult for the public sector and not-for-profit organisations to be major providers of care.”

    We accept that there will be an element of disruption if there was a precipitate switch to a public service model of care. However, we believe that this can be done in stages e.g., i) establishing national terms of service for care staff ii) national fee structures iii) taking domiciliary care services in-house and remodelling others into mutual/social enterprises iv) provision of new all-life housing as an alternative to residential care in advance of any wholescale transfer of residential care provision.

    This consultation document recognises that the market is not working. Its responses are substantially proposals to re-shape the market. SHA Cymru asks if it is time to consider alternatives to the market itself. We believe this, in line with a substantial investment, is the only way to address all key problems that this consultation is trying to address. The inherent tension between the use of the for-profit sector to deliver public services is threatening the quality of care for service users and is undermining the attainment of the employment environment which the consultation wishes to achieve. In the event of market failure, it is the public sector that must pick up the pieces.

    SHA Cymru supports the establishment of a National Care Service. This is the first step in addressing many of the consequences of the present fragmented provision model. This national model would have many of the features of the NHS which are so valued by people in Wales, but we do not support the “take over” of social care by NHS.

    Social care is a service which not only interfaces with health care, but it also interfaces with many other sectors including education, housing, the world of work and training, the welfare system as well as culture and recreation. Social care and its workforce have a different range of values and professional standards which do not readily fit with the mainstream medical model.

    A National Care Service must promote a more uniform set of standards of across Wales while recognising the diversity of our population and the diversity of its needs. These standards would include what citizens can expect from social care as well promoting a working environment that values the staff which will deliver the service.

    Such a service must be free at the point of use. The present means testing system is long out of date as it catches more and more people on relatively modest means into its clutches following the growth in home ownership since the 1980s. There is a strong view that those who pay for care also contribute a premium to make up for the inadequate levels of public funding and the consequences of a decade of brutal austerity.

    A reformed social care sector must be about more than structures and organisational boundaries. This is where the consultation document is weakest. The present market model of provision, linked to a decade of austerity, shapes what type of care is provided. Fewer people are being deemed eligible for more complex packages of care. Those who do not reach the threshold are obliged to fall back on their own resources and the resilience of their families, friends, and their communities where the root of the problem often lies in the first place. This is often falsely described as reducing unnecessary dependency and promoting the resilience of the care seeker.

    As social care is only fully accessed by people with increased complexities of care this place greater demands on service providers who are invariably operating on stand-still levels of resources.

    The service needs to be more citizen and user directed where co-production of provision is the heart of the assessment and delivery process. However, SHA Cymru has serious concerns about initiatives such as “direct payments” which have their own add-on costs, and which often operate on the fringes of poorly or self-regulated market.

    SHA Cymru strongly believes that obtaining any advantages and benefits of user directed care are entirely consistent with a public sector or mutual/social enterprise model of care. However, it will require resources and a culture in which the service user is the key architect of the service provided. In this new approach the work of social workers and other Allied Health Care professionals will be to facilitate and empower citizens rather than being constrained by eligibility and financial barriers on what can be provided. We need to move beyond a service in which the citizen receives what is defined by a range of eligibility criteria and means testing to one that is based on a holistic assessment of their needs.




    SOCIALIST HEALTH ASSOCIATION CYMRU
    Response to individual Questions.

    Summary of the consultation questions The Welsh Government welcome comments on all aspects of the proposals. We are particularly interested in responses to the questions. A summary of the questions is provided below.

    Question 1: Do you agree that complexity in the social care sector inhibits service improvement?

    Yes.
    The complexity and inefficiencies of the market exists at many levels.

    Service users.
    1. Services users are subject to a needs assessment which is often predicated on seeking ways to delegate caring duties to the applicant, their family, or friends.
    2. Financial constraints may curtail the delivery of a fully holistic care package.
    3. Applicants are subject to a financial assessment which can be difficult and obtrusive.
    4. The lack of staff continuity means that service users must deal with a series of different carers.

    Commissioning Process.
    1. There is a multiplicity of providers of social care, usually in the for-profit sector. This involves additional and unnecessary transactional costs. This is further complicated by additional costs when a “self-funder” must be reassessed having dropped below the various capital thresholds.
    2. There is continuing confusion between paying for “social care” and “continuing NHS care (which is free).

    Cross Organisation Boundaries.
    1. We welcome efforts to promote integrated joint working via Regional Partnership Boards and through funding streams such the Integrated Care and Transformation Funds. However, all these arrangements are not without their problems though they have made an important contribution to joint working.

    The lack of clear mechanisms to identify, allocate and share budgets is a significant obstacle to joint working.

    Joint working on the front line is facilitated by putting a “face to a name” and building trust. The relationships built during the present Covid-19 crisis bears this out. In “normal times” it unusual for front line workers in social care, housing, education, and the NHS to build up a relationship based on joint working – they do not know each other, they work for different organisations with different priorities, and they do not share a common workspace.

    Question 2: Do you agree that commissioning practices are disproportionately focussed on procurement?

    Yes. Except that the extremes, price will always trump quality.

    SHA Cymru strongly believes that the number of people who obtain services and what services are provided are curtailed by financial constraints rather than by full needs assessments. This also applies to unpaid carers.

    We accept that austerity is a major obstacle to commissioning for quality when resources are extremely limited, and need is increasing.

    Also, it is difficult to measure quality as opposed to measuring a failure of compliance which is set out in rules, standards, and regulations. There needs to be better ways of capturing the lived experience of the service-user, their carers, their parents, and their advocates.

    Question 3: Do you agree that the ability of RPBs to deliver on their responsibilities is limited by their design and structure?

    Regional Partnership Boards are a step in the right direction. The Welsh Government must do more to promote their importance and profile.

    However, most of the organisations that are involved still have a limited commitment and retain a strong territorial loyalty to their parent bodies. Competition for funding and resources is a major obstacle to joint working.

    The governance arrangements for the RPBs are totally opaque and SHA Cymru suspects that their existence is only known to a small number of people in the NHS, local government, Third Sector, and public bodies such as NRW.

    The RPB needs assessments and the strategic responses that they generate are not major priorities for most of the constituent bodies. They are more exercises in compliance that an engine for change and delivery.

    We believe that RPBs could enhance their role and effectiveness by being a catalyst and conduit of best practice within their region and elsewhere.

    Question 4: Do you agree a national framework that includes fee methodologies and standardised commissioning practices will reduce complexity and enable a greater focus on service quality?

    Question 4a: – What parts of the commissioning cycle should be reflected in the national framework?

    SHA Cymru supports a National Care Service in Wales in which citizens have a reasonable understanding of what they can expect from their social care service. However, this national service must reflect the diversity of need and culture in the various parts of the country.

    We support the creation of a national social care workforce for Wales rather than the infinite variety of current employment practices and standards. This will ensure a uniformly trained workforce with national terms of service. As staff pay is the single biggest cost in the sector this will remove a lot of the fog that surrounds fee setting now. This will simplify the commissioning process and reduce its inefficiencies.

    We also welcome the Welsh Government’s proposals for regular sector viability assessments. This will be an important mechanism to align capacity with need. However, we are disappointed that these proposals are not linked with policies to promote direct public sector provision where local needs are not being met.

    The commissioning process must seek to identify unmet and unfunded need. This will provide important information for future planning cycles.

    Question 5: Do you agree that all commissioned services provided or arranged through a care and support plan, or support plan for carers, should be based on the national framework?

    Yes. However, this does not mean a one size fits all provision delivered in any colour providing it is a bland white!

    In health and education people have a reasonable understanding of what to expect across Wales. There is no reason why the same should not apply in social care. Indeed, the co-payment element in social care makes this more important. We welcome the Welsh Government cap on the cost of domiciliary care and the increased thresholds for residential care.

    Care plans must be co-produced with the service user and their carers rather than provided within constraints and obfuscations of means testing and eligibility barriers.

    Question 5a- Proposals include NHS provision of funded nursing care, but do not include continuing health care; do you agree with this?

    Without understanding the historical context, the present system is totally incomprehensible to the average citizen. There is no sense that one person gets a “free NHS bath” while someone else has to pay for a “social care bath”. Equally there is no logic that a person with a chronic illness such as cancer gets a free service on the NHS while those with dementia must pay for most of their care via social services.

    These arrangements fly in the face of the Welsh Government’s commitment to user centred and integrated care.

    Question 5b- Are there other services which should be included in the national framework?

    As mentioned in our introduction we believe that in a National Care Service there should be national standards of care, national eligibility criteria for services, national means to promote co-production and citizen led services and national terms of service for staff.
    Question 6: Do you agree that the activities of some existing national groups should be consolidated through a national office?

    A National Care Service needs a strong sense of national purpose for social care. The concept of a “national office” fails to capture this vision. SHA Cymru believes that we need a national executive or directorate to drive forward many of the objectives outlined in the consultation document. The executive / directorate should have a clear mission to develop a quality, coherent service across all of Wales.

    In a National Care Service in Wales many of the present “bolt-ons” should be integrated into a single cohesive organisation. However, the specific specialisms of the individual services need to be recognised and provided for.

    Question 6a- If so, which ones?

    While we support an overall National Care Service, the regulatory and inspection roles should be independent and seen to be independent. We welcome the integration of NHS and Social Care complaints processes on an independent basis from the NHS and local government.

    Question 7: Do you agree that establishing RPBs as corporate legal entities capable of directly employing staff and holding budgets would strengthen their ability to fulfil their responsibilities?

    Yes. SHA Cymru would welcome the establishment of the RPBs as corporate legal entities. Now they exist as a gift provision by their component bodies. This deprives them of the status or capacity to plan the delivery of integrated services across organisation boundaries.

    There must be mechanisms to allocate resources to the RPBs for both their own administrative / management purposes and to have the means to fund integrated cross boundary services. We note the references in the consultation document to experiences in the other parts of the UK in relation to integrated working.

    We believe that there are valuable positive lessons from the Scottish experiences. On the other hand, we would advise caution about replicating the main English direction of travel – which is deeply contaminated by serious under-funding and commercialisation of services.

    Question 8: Do you agree that real-time population, outcome measures and market information should be used more frequently to analyse needs and service provision?

    Question 8a- Within the 5-year cycle, how can this best be achieved?

    The Financial Crisis of 2008, Brexit and the Covid Pandemic of 2020 show how vulnerable long-term planning is to unforeseen events. Any planning cycle must be flexible enough to adjust to such shocks.

    However, we also realise that strategic change cannot be delivered on short time scales. The NHS process of in-built short- and medium-term reviews within a long planning cycle has a lot to commend it.


    Question 9: Do you consider that further change is needed to address the challenges highlighted in the case for change?
    Question 9a- what should these be?

    The consultation document has presented itself with a range of almost irreconcilable ambitions.

    For the immediate future we are likely to face continuing austerity. We welcome the Welsh Government’s commitment to continue to lobby and use its good offices to urge the UK Government to deliver on its decade old, and much delayed, pledge of addressing the challenges of social care. If these efforts are not successful, many of the consultation paper’s objectives will not be achievable.

    A shift toward “commissioning for quality” is highly commendable, but the road to achieving this is littered with obstacles and potholes. The sector itself is in a highly fragile state bordering on unsustainably. At a very minimum, a quality service requires a valued, stable, and well-trained workforce. All these requisites are at the mercy of the variability that is inherent in a multi-provider for-profit model for care delivery.

    Unless there is a way of addressing current financial pressures then the present trend of ever higher eligibility criteria will mean fewer and fewer people will be in receipt of care. As need is inevitably going to increase it will mean that more and more of people will be left to live deal with their problems by whatever means they can muster.

    Question 10: What do you consider are the costs, and cost savings, of the proposals to introduce a national office and establish RPBs as corporate entities?

    See the answers to Q6 and Q7 above.

    Question 10a- Are there any particular or additional costs associated with the proposals you wish to raise?

    We accept that a quality social care service will cost money.

    We note the work that is being done on a social care levy and we wait to see its outcome. However, any market-based funding system will be subject to major shocks – we have seen three since 2008 – and we wonder how resilient they will be in the long run. Very few insurance based public services have been sufficiently resilient to survive without state interventions and guarantees.

    Welsh language

    Question 11: We would like to know your views on the effects that a national framework for commissioning social care with regionally organised services, delivered locally would have on the Welsh language, specifically on opportunities for people to use Welsh and on treating the Welsh language no less favourably than English. What effects do you think there would be? How could positive effects be increased, or negative effects be mitigated?

    It is essential that social care services should be delivered bi-lingually. This is crucial across all age groups from children’s services to services for vulnerable older adults. Equally the right for people with learning and physical disability to live their lives thought either Welsh or English must be fully recognised.

    The local needs assessments must take full account of the cultural values and diversity of the population it is assessing. Service providers must not regard responding to this diversity as an optional extra.
    Welsh and English have a particular standing in Wales. However, many other vulnerable people e.g., asylum seekers, refugees, migrant workers, and minority ethnic groups will have needs which a holistic service must strive to address.

    Question 12: Please also explain how you believe the proposed policy to develop a national framework for commissioning social care with regionally organised services, delivered locally could be formulated or changed so as to have positive effects or increased positive effects on opportunities for people to use the Welsh language and on treating the Welsh language no less favourably than the English language, and no adverse effects on opportunities for people to use the Welsh language and on treating the Welsh language no less favourably than the English language.

    If “quality” is to be the key barometer of performance, then a citizen focused service that is planned and delivered in line with local needs can only promote Wales as a bi-lingual country. Most social care providers are heavily dependent on local people for service provision. This workforce will be familiar with local cultural values and norms. A secure, valued, and well-trained workforce can only enhance the quality of life of the citizens under their care.


    https://gov.wales/improving-social-care-arrangements-and-partnership-working

    Comments Off on REBALANCING SOCIAL CARE IN WALES — Response to Welsh Government White Paper on Social Care.

    NHSE/I consultation on

    “Integrating care: Next steps to building strong and effective
    integrated care systems across England”

    Response to the consultation by

    Professor Allyson Pollock and Peter Roderick, Population Health Sciences Institute, Newcastle University; and David Price, independent researcher

    8 January 2021

    1. Overview

    Publication of the next steps document during the covid-19 pandemic comes at a remarkable moment. Significant shortcomings have been exposed in the NHS[1], in the systems for communicable disease control and public health,[2] in the procurement system[3] and in the social care system.[4] The lack of hospital and ICU capacity have been major drivers of national lockdowns in March 2020 and January 2021 and the causes of severe winter pressures in previous years.

    At the same time, the pandemic has demonstrated the obstacles created by market bureaucracy and heavy-handed and centralised market regulation which have developed over decades in the NHS.

    The document hints at positive effects of the pandemic (paragraph 2.1) and refers in general terms to some of them (e.g., 2.72), which have played a part in “increas[ing] the appetite for statutory ‘clarity’ for ICSs and the organisations within them.” (3.8). It also recognises “the persistent complexity and fragmentation” which is rightly complained about (1.3).

    This is largely the product of reforms premised on competitive relations and contracting among health bodies. Finally a new anti-competition consensus appears to have emerged in NHS reform[5] which has found its way, though problematically, into the document.

    But as David Lock QC has said in 2019: “The big picture is that you have a market system. If you do not want a market system and you want to run a public service, you need a different form of legal structure.” And this obvious truth raises fundamental questions, which the document seems to glimpse, but which it is unwilling to grasp.

    Why, for example, continue to insist on running health organisations as businesses if the aim is collaboration instead of competition? How should needs-assessment and population planning be undertaken if the aim is to secure comprehensive health and social care for geographic areas? Where should they be located and on which bodies does the statutory duty of universality fall? How can major political questions surrounding resource distribution be undertaken consensually outside established political processes? Equitable access and solidarity require risk-pooling and a community response.

    Rather than rising to the challenge of these questions in ways which could reliably “provide[] the right foundation for the NHS over the next decade” (page 31), the document puts forward substantial de-regulatory proposals which continue to ‘work-around’ the current statutory market­based framework and undermine risk-pooling, even when proposing legislative change; much essential detail is omitted.

    As they stand, the proposals seek to achieve integration by focussing on increasing freedoms of the various bodies involved in commissioning and contracting. They rely on general exhortations to counter deregulation. Laudable “fundamental purposes” inform an “aim” of “a progressively deepening relationship between the NHS and local authorities”. Three “important observations” which may or may not be aims relate to more local decision-making, more collaboration and economies of scale. A “triple aim” duty of unspecified strength relates to “better health for the whole population, better quality care for all patients and financially sustainable services for the taxpayer” (1.3, 1.8, 1.9, 3.3).

    The approach however leaves substantially unchanged the legal powers of the many incorporated bodies active in the health care market among which collaboration is expected but from which disintegration has spread. If the aim is “rebalancing the focus on competition” (3.3) a concrete administrative alternative is required. None is offered. Seeking to promote greater integration whilst retaining commercial autonomy will not work.

    In summary, the proposals:

    • leave in place the purchaser-provider split and commercial contracting;
    • continue the ability to give further contracts to private companies, including, it seems, integrated care provider contracts;
    • provide no response to the finding of the National Audit Office in 2017 that “The Departments have not yet established a robust evidence base to show that integration leads to better outcomes for patients”;
    • favour no controls on ICS membership;
    • give immense and barely-regulated power to monopoly providers and clinical networks
    • contain no controls on the composition of “provider collaboratives”, which could include, for example, large private hospitals;
    • are silent on public accountability mechanisms at a system level, and at the non-statutory “place” level;
    • repeal section 75 of the 2012 Act, revoke some of the ‘section 75 regulations’ and remove commissioning of NHS healthcare services from the Public Contracts Regulations 2015 – which are welcome – but are silent on the safeguards against corruption and conflicts of interest, and some of the section 75 regulations would seemingly be retained;
    • emphasise the importance of strategic needs assessment – which is also welcome – but do not require the assessment to frame provision or to qualify the power of providers and clinical networks;
    • do not appear to make ICSs responsible for all people in an area, and there are unresolved difficulties for integrating health and social care because of different funding bases for different populations;
    • are silent on whether individuals on GP lists will transfer to an ICS body, a provider or a provider collaborative;
    • are unclear on the fate of CCGs in Option 2;
    • contain no explanation of how capital investment strategies will operate, and whether charges on capital, including PFI charges, will change;
    • do not address the powers of NHS foundation trusts;
    • are unclear on how local authority public health funding will be protected;
    • are unclear on how social care funding will be protected, and how the currently different funding bases for health and social services will be addressed;
    • are silent about workforce planning;
    • envisage, but are unclear about, moving staff between organisations, and their terms and conditions.

    We discuss the details in the following two sections.

    1. ICSs during 2021/22 and before legislation

    The document seems to have two purposes: to further progress ICSs and the merger of CCGs ahead of legislation; and to explain changes to the NHSE/I’s legislative proposals published in September 2019.

    Our understanding of what an ICS will be and do, before legislation, is set out in the Box below.

    Box: What will an ICS be and do before legislation – as far as we can make out?

    1. An ICS will not have legal form and will consist of:
    • provider organisations as part of one or more undefined and self-determined “provider collaboratives” operating within and beyond the ICS playing “an active and strong leadership role” and being “a principal engine of transformation”(2.4, 2.31, 2.63); and
    • place-based partnerships”, defined by each ICS but seemingly comprising providers of primary care, community health and mental health services, social care and support, community diagnostics and urgent and emergency care – i.e., excluding secondary care, but including local authorities, Directors of Public Health and Healthwatch, and “may” include acute providers, ambulance trusts, the voluntary

    sector and other – undefined – partners (2.31, 1.16).

    1. It will receive a “single pot budget” which would comprise “current CCG commissioning budgets, primary care budgets, the majority of specialised commissioning spend, the budgets for certain other directly commissioned services, central support or sustainability funding and nationally-held transformation funding that is allocated to systems” (2.40), and will decide how that budget should be delegated to local “places” within the ICS.
    2. Providers will “agree proposals developed by [undefined and self-determined] clinical and operational networks” and will “implement resulting changes” including “implementing standard operating procedures to support agreed practice; designating services to ensure their sustainability; or wider service reconfiguration”; and will “shape the strategic health and care priorities for the populations they serve, and new opportunities – whether through lead provider models at place level or through fully-fledged integrated care provider contractual models – to determine how services are funded and delivered, and how different bodies involved in providing joined-up care work together” (2.11, 1.44).
    3. The ICS will undertake more strategic needs assessment and planning than CCGs can do, resulting in “the organisational form of C.’CGs…evolv|ing|” (2.62-2.63).
    4. The ICS will be subject to governance and public accountability arrangements that are said to be “clear but flexible”, but will not be statutory. (2.28-28, 2.19)

    We make a number of key points under the following headings:

    • Strategic needs assessment
    • The emphasis on strategic needs-based assessment and planning is welcome, yet there will be no single body which has the responsibility to carry it out and no legal mandating of it. This is likely to lead to buck-passing. Perhaps more importantly, it is also likely to lead to needs-based planning being overridden by increasingly powerful monopoly providers having pivotal influence over a single budget, and over its allocation both for non-secondary care services to undefined “places” with no statutory identity, and for secondary (and tertiary) care.
    • Moreover, it seems highly unlikely that services provided would be based on the needs assessment, because clinical networks are expected to carry out “clinical service strategy reviews on behalf of the ICS” and “develop proposals and recommendations” which providers will agree.

    Indeed, “[c]linical networks and provider collaborations will drive…service change” (2.26, 2.11, 2.72). No tie-in to the strategic needs assessment is proposed, let alone a requirement for it to frame provision.

    • Public health experts have traditionally performed the functions of needs assessment, facilitating service development and service planning. However, public health sits outside of health services and is further fragmented between local authorities and the Secretary of State (Public Health England, to be replaced by another non-statutory body, the National Institute for Health Protection) as a result of the 2012 Act.

    Clinical Support Units provide information and support for commercial contracting. They are not substitutes for public health, are not integrated into CCGs or local public health departments, and do not inform strategic needs assessment and service planning.

    • The single pot budget

    It appears – certainly before, and perhaps after, legislation – that ICSs will not be responsible for all people within an ICS area. That term – an ICS area – is conspicuously absent from the proposals. The CCG membership model (‘persons for whom they are responsible’) cannot be changed without legislation and so will presumably be ‘scaled-up’ to cover all the CCGs involved.

    We have previously expressed[6] concern about how Accountable Care Organisations would have been able to integrate health and social care services because their funding would have been for a different population (GP lists versus local authority), and would not have health service funding allocated for unregistered CCG residents who might be eligible for local authority social services. This concern still applies in relation to ICSs, including provider collaboratives and place-based partnerships, both with and without legislation, and with and without integrated provider care contracts.

    In addition, the bases upon which resources will be allocated to secondary (and tertiary) care and to place-based partnerships, and within those partnerships are entirely unclear. This is presumably deliberate. Already there has been a marked decrease in administrative accountability for spending, and multiple contracts and subcontracts – which will continue – make it increasingly impossible to ‘follow the money’, let alone to assess the costs of contract administration. Detailed financial reporting to NHSE/I is obviously essential and may be provided for, but public transparency in funding as between primary care, community and mental health services, and acute, secondary and specialist care, including sub-contracting, is also essential.

    • Provider collaboratives

    No control is proposed over the composition of these collaboratives. They could and presumably will consist of private as well as public providers, e.g., of mental health services, residential and nursing care, acute hospital care and pathology services. The potential inclusion, for example, of large private hospitals, which have been contracted during the pandemic, needs to be clarified immediately. No control is proposed over the granting of contracts to providers within these collaboratives, who may in fact be distant from and have no connection with the local community and be subject to commercially-driven mergers, acquisitions and closures that threaten patient care.[7]

    Full integrated care provider contracts can be awarded, though there is no reference to the House of Commons Health and Social Care Committee in June 2019 having “strongly recommend[ed] that legislation should rule out the option of non-statutory providers holding an ICP contract [in order to] allay fears that ICP contracts provide a vehicle for extending the scope of privatisation in the English NHS”. In September 2019, NHSE/I acknowledged this and stated that it supported the recommendation. If private companies are not likely to be awarded such contracts, then what is lost by legislating to that effect? And what prevented a clear statement to that effect being made in this document?

    Neither is there any reference to the HSC Committee’s recommendation that “ICP contracts should be piloted only in a small number of local areas and subject to careful evaluation”.

    • ICS membership

    There are two potential aspects in this regard.

    The document proposes for legislative change Option 2 that the ICS body should be able to appoint such members to the ICS body as it deems appropriate “allowing for maximum flexibility for systems to shape their membership to suit the needs of their populations” (3.19). It seems that this will be possible de facto before legislation, e.g., via the unspecified provider collaboratives. This risks giving private companies influence over the allocation of NHS funding: “they are there to make money from the NHS” in the words of Dr Graham Winyard – and should not be admitted as members. Yet the document is silent on this point.

    As for patients, the document is silent on whether individuals on GP lists will transfer to any provider (e.g. under an integrated care provider contract), or even to a provider collaborative – or, after legislation based on Option 2, to an ICS body; and, if so, how that would be achieved and whether individuals would have any choice in the matter. In addition, will individuals be able to move from one ICS to another? And what happens, for example, if an individual is on the list of a GP (or provider or provider collaborative) within the ICS, but lives in a local authority area within another ICS and requires social care?

    NHSE/I should clarify these issues as soon as possible.

    • Public accountability

    ICSs will be making major resource allocation decisions, which will often be controversial. Transparency and scrutiny will be critical. However, the document says nothing about how current public accountability requirements and mechanisms will work in an ICS context. These mechanisms are based mainly around CCGs and local authorities, but in reality these bodies will no longer be the decision-makers. Actual decision-making will be de-coupled from legal functions and the effectiveness of public accountability will be diminished in the process.

    • Competition and contracting

    Proposals to remove market competition, compulsory contracting and the commissioning of NHS healthcare services (only) from the Public Contracts Regulations 2015 – which are welcome – cannot happen without statutory change; the rights of private providers and the purchaser-provider split remain in place. The work-arounds continue.

    • Social care

    Adult social services are means-tested. Health services are not. Providers of social care and support are said to be included in place-based partnerships, but the allocation of resources to and within the partnerships is entirely unclear. There is no mention of any safeguards to prevent services which are currently free from being re-designated as social care and so subject to means-testing and possible charges.

    • Public health

    Local authority public health will fall within place-based partnerships. As for other services covered by these non-statutory partnerships, there is no mention of how protecting public health funding will be achieved in the face of the power of provider collaboratives and clinical networks operating at the level of the ICS and beyond. Representation by DPHs and other local authorities is unlikely to be enough.

    • Workforce planning

    The next steps document is silent about work force planning. Lack of doctors and staff is already a serious issue after years of fragmentation, lack of investment and, appallingly, absence of a strategy: the Kings Fund described it recently as “a workforce crisis”. NHSE/I need to be clear about how attempts to improve this critical function would operate in the ICS context.

    • Moving staff and their terms and conditions

    It is proposed that there should be “frictionless movement of staff across organisational boundaries” (bizarrely in the context of data and digital technology, page 20). This is capable of different meanings across a spectrum, but nothing more is said about this, nor on the terms and conditions of staff in the ICS context. Much more information should be provided.

    1. ICSs after legislation

    There is much less information on legislative changes in the next steps document than was contained in NHSE/I’s September 2019 document entitled The NHS’s recommendations to Government and Parliament for an NHS Bill. The next steps document lists some of those recommendations and states, oddly, “We believe these proposals still stand” (3.3, 3.4). This statement makes it unclear whether they continue to be proposals.

    The next steps document proposes two options for legislation.

    Option 1 would establish the ICS as a mandatory statutory ICS Board in the form of a joint committee of NHS commissioners, providers and local authorities with an Accountable Officer, and with one CCG only per ICS footprint which would be able to delegate “many of its population health functions to providers” (page 29).

    Option 2 would set up a new statutory ICS body as an NHS body by “repurposing” CCGs, taking on their commissioning functions, plus additional duties and powers, and having “the primary duty…to secure the effective provision of health services to meet the needs of the system population, working in collaboration with partner organisations”. It would have “flexibility to make arrangements with providers through contracts or by delegating responsibility for arranging specified services to one or more providers”. It would have a board of representatives of system partners (NHS providers, primary care and local government alongside a Chair, a Chief Executive and a Chief Financial Officer as a minimum) with the ability to appoint such other members as the ICS deems appropriate “for maximum flexibility for systems to shape their membership to suit the needs of their populations” (page 30).

    NHSE/I prefer Option 2.

    Most of the points we have made pre-legislation continue to apply. We expand on some of those and add to them as follows:

    • Major reorganisation

    It is striking that despite the apparent opportunity for primary legislation following the Queen’s Speech neither Option grapples with the fundamental questions posed in the Overview above, which flow from the anti-competitive consensus (if such there be). This might be because NHSE/I wish to avoid being seen to be proposing a major reorganisation. But this is exactly what is happening, even without legislation.

    In September 2019, NHSE/I stated:

    “The Select Committee [in July 2019] agreed that NHS commissioners and providers should be newly allowed to form joint decision-making committees on a voluntary basis, rather than the alternative of creating Integrated Care Systems (ICS) as new statutory bodies, which would necessitate a major NHS reorganisation.” (emphasis added)

    • Competition and contracting

    No legislative changes are proposed to the purchaser-provider split. Whilst repeal of procurement rules under section 75 of the 2012 Act and removal of commissioning of NHS healthcare services (only) from the Public Contracts Regulations 2015 are welcome, the document is silent on safeguards against corruption and conflicts of interest.

    It is also important to recall that in September 2019 NHSE/I stated that it would retain a number of the provisions of the NHS (Procurement, Patient Choice and Competition) (No.2) Regulations 2013 – commonly referred to as the ‘section 75 regulations’. Of particular worry, exacerbated by the covid- 19 pandemic, is retention of “the requirement to put in place arrangements to ensure that patients are offered a choice of alternative providers in certain circumstances where they will not receive treatment within maximum waiting times”. The possibility of the use of private providers in these circumstances, rather than increasing NHS capacity, is obvious.

    • Fate of CCGs

    NHSE/I still seem undecided about the fate of CCGs in Option 2. Under both Options, the document states that “current CCG functions would subsequently be absorbed to become core ICS business” (2.64). Yet the document only proposes, in relation to Option 2, to replace the CCG governing body and GP membership, but for some unknown reason does not state that CCGs will be abolished, which presumably they must be, under Option 2, with no replacement.

    • ICS membership

    The document proposes in Option 2 – though we are not clear why this is not a possibility in Option 1 nor de facto from now onwards (see section 2(4) above) – that the ICS body should be able to appoint such members as it deems appropriate. This would be a blatant undermining of the ICS as an NHS body.

    In addition, as stated above (section 2(4)), it is unclear whether individuals on GP lists would be transferred to the ICS body.

    • Missing proposals
    • Even though both Options propose primary legislation, the document contains no proposal for ICS- specific public accountability mechanisms, for abolishing the purchaser-provider split, or to give place-based partnerships a legal identity.

    • A fundamental omission is how capital investment strategies will operate and whether charges on capital will change. NHS Property Services is now charging market rent for property occupied by Trusts, CCGs and some GP premises. Foundation trusts have autonomy over the property they hold and investment decisions. However, the Private Finance Initiative has left a legacy of major debt in health services and in local authorities. There has been no public scrutiny of the impact of the covid- 19 pandemic on PFI contracts, on debt repayments and on renegotiation of the exorbitant rates of interest being paid out as part of the annual payments.

    • The powers of FTs are not addressed not least the ability to generate up to half their income from outside the NHS, at a time when public capacity is reducing and waiting lists, e.g., for surgery and cancer care, are growing. Nor is it made clear whether current contracts with large private hospital chains (SPIRE et al.) are long-term and whether they will be involved in provider collaboratives.

    • In September 2019, NHSE/I recommended abolishing the prospective repeal of the power to designate NHS trusts that was enacted in the 2012 Act but never brought into force, to support the creation of integrated care providers. The next steps document only mentions this in passing (3.3). It remains unclear if this still being proposed and, if it is, the circumstances in which it could be exercised.

    1. Conclusion

    These proposals are incoherent, de-regulatory and unclear, and are not equal to the existential threat that is posed by the current government to the NHS as a universal, comprehensive, publicly- provided service free at the point of delivery. This has been amply demonstrated by the government’s response to the covid-19 pandemic which has directed billions of pounds to private companies to provide services that should have been provided by the NHS, Public Health England and local authorities. The proposals allow this to continue and increase.

    Neither can the ambition of providing a sound foundation for the next decade be sensibly addressed without considering the inevitable but uncertain changes that will be necessary post-pandemic to the public health and social care systems, and to the functions of local authorities.

    The challenge now is much greater than it was in 2019, when the difficulties of getting major NHS legislation through the House of Commons was used as a reason/excuse for not proposing legislation equal to the task of taking the market out of NHS once and for all. We urge MPs who are committed to the NHS as a public service to support scrapping the 2012 Health and Social Care Act in its entirety and to support the NHS Reinstatement Bill which would put back the government’s duty to provide key services, delegated to Strategic Integrated Health Boards and Local Integrated Health Boards.

    END

    [1] E.g., lack staff, beds and other capacity following inadequate investment and the absence of a workforce planning strategy over many years; inadequate planning and personal protective equipment (PPE); marginalising GPs.

    [2] E.g., devaluing local authorities and the NHS by centralising and privatising tracking, tracing and testing; spending hundreds of millions of pounds on inaccurate lateral flow tests; by-passing the established system for notifying suspected cases.

    [3] E.g., spending billions of pounds on untendered contracts, including to companies with no track record.

    [4] E.g., shortages of staff and PPE; high excess deaths; inappropriate discharge of hospital patients to care homes.

    [5]  “These developments [of STPs and ICSs] represent an important shift in direction for NHS policy. The 2012 Act aimed to strengthen the role of competition in the NHS, consolidating a market-based approach to reform that has been in place since the establishment of the internal market in 1991. By 2019, however, competition rarely gets mentioned in NHS policy. Instead, the Five Year Forward View, STPs, and ICSs are based on the idea that collaboration – not competition – is essential to improve care and manage resources, including between commissioners and providers”. Health Foundation submission to the Health and Social Care Select Committee inquiry into legislative proposals in response to the NHS Long Term Plan, April 2019

    [6] Pollock AM, Roderick P. Why we should be concerned about accountable care organisations in England’s

    NHS. BMJ. 2018;360:k343. https://allysonpollock.com/?page id=11

    [7] E.g., Care Home Professional, Terra Firma close to £160m care home sale to Barchester Healthcare, 15 November 2019, https://www.carehomeprofessional.com/terra-firma-close-to-160m-ca re-home-sale-to- barchester-healthcare-report/

     

    ICS Next steps Consultation Response 08Jan21

    2 Comments
    The UK-CAB is the UK’s HIV treatment advocates network.
     
    A couple of weeks ago four UK-CAB members spoke to Dr Rageshri Dhairyawan from Barts Health NHS Trust. It was a chance for HIV positive people from BAME communities to voice their concerns about the coronavirus pandemic. The strong focus was on questions from people living with HIV and the communities they work in.

    Watch via YouTube: https://youtu.be/Cy7d7FD2ro0

    The recording is about 40 minutes long. It covers a wide range of questions in relation to COVID-19. Discussion covers inequalities in health care, sexual health, mental health, research, stigma and HIV treatment. 

     

    We hope this film provides an educational tool for doctors and the public. Please share it with people accessing your services, clients, partners, and friends and families. 


    Thank you to Adela, Jide, Juddy and Shamal for taking part and to Jo for chairing this session, and of course to Dr Rageshri for answering these important questions.
     
    And, here is Dr Ameen Kamlana in a very short interview with Sky News on how COVID-19 is disproportionately affecting people of colour.
    Comments Off on COVID-19: BAME communities living with HIV and a short interview with Dr Ameen Kamlana

    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.

    1 Comment
    Boris Johnson’s hardline stance not to waive the £400 NHS surcharge for overseas health and social care workers combating coronavirus was described as ‘mean-spirited and shabby’ today (Thursday 21 May) by Unite, Britain and Ireland’s largest trade union.
    Unite, which has 100,000 members in the health service, said the hypocrisy of the prime minister was given extra piquancy as he singled out two non-UK  nurses – one from New Zealand and the other from Portugal – for praise after he survived his fight with Covid-19.
    The NHS fee of £400-a-year for care workers applies to those from outside the European Economic Area, regardless whether they use the NHS or not. It is set to rise to £624 in October.
    There is also controversy over the £900m figure which the prime minister told MPs is raised by this charge. The Institute of Fiscal Studies put the sum at a tenth of that – £90 million.
    Unite national officer for health Colenzo Jarrett-Thorpe  said: “Of all people, Boris Johnson should appreciate the wonderful and dedicated work of NHS health and social care professions, including the two non-UK nurses he singled out for particular praise in his fight for survival against coronavirus.
    “Therefore, the fact he won’t waive this £400 fee for overseas health and social care workers is mean-spirited and shabby.
    “With this prime minister warm words of praise come cheap, but a small financial gesture for NHS migrant workers, many of them low-paid, is beyond his compass. His stance is hypocritical.
    “Tonight, we will have the Thursday ‘clap for carers by the people of the UK, many of them who voted for Boris Johnson as recently as last December – there is a big irony here. This charge should be waived immediate.”:
     
    Unite senior communications officer Shaun Noble
    Twitter: @unitetheunion Facebook: unitetheunion1 Web: unitetheunion.org
    Unite is Britain and Ireland’s largest union with members working across all sectors of the economy. The general secretary is Len McCluskey.

     

    1 Comment

    The nine-point blueprint by 16 health unions for reopening the NHS should act as ‘a rocket booster’ for ministers to tackle the lack of PPE and the shambolic testing regime, Unite, Britain and Ireland’s largest union, said today (Friday 15 May).

    Unite, which has 100,000 members in the health service, is one of the 16 unions that has contributed to the blueprint designed to make the NHS the safest possible environment for patients, staff and visitors as the lockdown is eased by the government, and out-patient clinics and operations resume.

    Unite said that the three key issues that needed to be addressed urgently were the continuing lack of PPE; the ‘messy’ testing regime which has seen samples sent to the USA; and the withdrawal of the threat that NHS staff could be subject to a public sector pay freeze highlighted in leaked Treasury documents.

    Unite national officer for health Colenzo Jarrett-Thorpe said: “This blueprint by the health unions should act as a rocket booster for ministers to really get to grips with key elements of the pandemic.

    “A continuing shortage of PPE is a dark stain on the government’s response to the coronavirus emergency. We have ambulance, biomedical scientist, nursing and speech and language therapist (SALT) members telling us that there are still shortages and, in some cases, when it does arrive it is out-of-date, ill-fitting or not up to standard.

    “We have feedback from our members that they are being leaned on by NHS bosses not to raise the PPE shortages – but Unite urges them to #staysafenot silent and to #telluswhatPPEyouneed.

    “And we will back you to the hilt in raising these legitimate concerns that are of the highest public interest.

    “The testing regime totters between the shambolic and the messy. There is little openness and transparency about how the government will hit its increased 200,000 daily test target.

    “We have thousands of healthcare science members who could be used to better effect and engaged more substantively, so we can avoid the situation where samples are sent to America for analysis.

    “It appears that the right hand does not know what the left hand is doing as the ‘test, track and trace’ initiative struggles to get off the ground in a meaningful way.

    “Finally, our members are furious at the leaked Treasury assessment that a public sector pay freeze could be on the cards to pay for the cost of the pandemic. If the Thursday ‘clap for carers’ means anything, it should be that there can be no return to the age of austerity.

    “More than 270 NHS and social care workers have died due to Covid-19 and hundreds of thousands more are risking their lives on a daily basis to care for others – yet this does not seem to stop Treasury mandarins drawing up heartless proposals to freeze public sector pay, which a recent Unite survey has shown the public does not want.”

    The unions’ blueprint includes fast, comprehensive and accessible testing, and the ongoing, ample supply of protective kit, as well as calls for staff to be paid properly for every hour worked.

    Notes

    The NHS unions are: British Association of Occupational Therapists, British Dental Association, British Dietetic Association, British Orthoptists Society, Chartered Society of Physiotherapists, College of Podiatry, Federation of Clinical Scientists, GMB, Healthcare Consultants and Specialists Association, Managers in Partnership, Prison Officers Association, Royal College of Midwives, Royal College of Nursing, Society of Radiographers, UNISON and Unite.

    The final text of the blueprint is here

    Unions have been asking the government to fund a consistent approach to overtime across the whole NHS. They are currently awaiting government sign off on a joint proposal from employers and unions.

    The 16 unions represent health workers covering the whole of the UK. There may be issues specific to Scotland, Wales and Northern Ireland that can be taken up with the employer/union structures of those administrations.

    Twitter: @unitetheunion Facebook: unitetheunion1 Web: unitetheunion.org

    Comments Off on Unions’ blueprint on NHS reopening is a ‘rocket booster’ for ministers to tackle PPE and testing crises, says Unite

                      DOCTORS IN UNITE

    The rising death rate from COVID-19 and the pressure of the pandemic on a weakened NHS have caused warranted anxiety. There were reports from Italy of rationing, when life saving equipment was simply unavailable for some sick patients, and difficult triage decisions had to be made by doctors. Many deaths in the UK are occurring among elderly residents of care homes, and unlike deaths in hospital, these have not been given prominence in daily reports.

    Press coverage has indicated that Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) agreements have been misused. Rather than an agreement on a one to one basis after full discussion and as part of advance care planning, marginalised groups such as the elderly and disabled have been asked for consent by letter. In some cases decisions have been made on their behalf.

    Such agreements should only apply to what happens in the event of the heart stopping during an illness, but they have been wrongly interpreted as consent to not having treatment for illness, or not being admitted to hospital.

    Professional bodies such as the British Medical Association are attempting to provide an ethical framework for health care staff faced with impossible decisions regarding rationing and who should take precedence. Not only has the government failed to provide guidance on this matter, perhaps because it undermines their narrative that the NHS is coping with the onslaught and will continue to do so. Their grotesque incompetence in failing to follow World Health Organisation advice has put front line workers in an unprecedented position: having to make decisions about who should and who should not receive care.

    The government, policymakers, managers and clinicians have a responsibility to patients. They must ensure that any system used to assess the escalation or de-escalation of care does not disadvantage any one group disproportionately. Treatment should be considered irrespective of a person’s background when it can help them survive, balanced against the risk of that treatment causing harm.

    A GP surgery in Wales sent letters to patients asking them to complete a DNACPR form, reportedly stating “several benefits” to its completion. The form explained that “your GP and more importantly your friends and family will know not to call 999” and that “scarce ambulance resources can be targeted to the young and fit who have a greater chance.”

    In an “ideal situation”, it continued, doctors would have had this conversation in person with vulnerable patients, but had written instead due to fears the doctors may be asymptomatic carriers of coronavirus. The practice later apologised to recipients of the letter.

    A GP surgery in Somerset also wrote letters to a support group for adults with autism, requesting they make plans to prevent their clients being resuscitated if they become critically ill. The letter was later withdrawn after criticism.

    The Guardian has reported that “elderly care home residents have been categorised ‘en masse’ as not requiring resuscitation”, and that “people in care homes in Hove, East Sussex and south Wales are among those who have had ‘do not attempt resuscitation’ notices applied to their care plans during the coronavirus outbreak without proper consultation with them or their families”.

    The Mirror also reported that adult patients and parents of children with chronic conditions were sent letters asking if they wanted to have DNACPR statements agreed in case of admission to hospital with coronavirus.

    A learning disability care provider described an unprecedented increase in the number of DNACPR letters it had received. In the Health Service Journal their spokesperson said “making an advance decision not to administer CPR if a person’s heart stops, solely because they have a learning disability, is not only illegal, it is an outrage.

    “We are seeing DNR orders that have not been discussed with the person themselves, the staff who support and care for them, or their families. This is very concerning as it may potentially lead to people being denied life-saving treatment that other patients would be granted”.

    NHS Trusts, GPs and clinical commissioning groups have been told by NHS England they must not send out blanket DNACPR forms.

    The British Medical Association, Royal College of Nursing and Resuscitation Council UK provide detailed guidance on decisions relating to cardiopulmonary resuscitation. CPR was introduced in the 1960s following recognition that some hearts could be restarted when they had stopped beating, often after a heart attack.

    The probability of CPR being successful in other situations is generally low. It involves compressing the chest, delivering high voltage electric shocks to the heart, attempts to ventilate the lungs and giving intravenous drugs. Injury to ribs and internal organs may occur and some patients survive only to spend long periods in intensive care without full recovery. This is why people talk about the risks and benefits of CPR.

    The heart and lungs stopping is a natural part of dying from any cause. When CPR is used in people who have been gravely ill it is very unlikely to work. Rather than a peaceful death, their lives could end in the context of aggressive but futile attempts to change an irreversible process.

    To prevent this happening patients can be asked well in advance about their wishes, with a full exploration of the issues involved. In normal circumstances, the decision to not attempt CPR is made after a discussion between patient and doctor. An understanding can be reached that because of frailty, and because the heart stopping is the final stage of an irreversible process of multiple organ failure, the potential benefits to the patients are outweighed by the risks of pain and indignity.

    Standardised DNACPR forms were introduced to attempt to ensure patients’ wishes were recorded and would be easily available to healthcare staff. They do not have to be signed by patients. The member of the healthcare team who has discussed CPR with the patient signs the form, as does the responsible senior clinician (this may well be the same person).

    Doctors are told by their professional organisations that “considering explicitly, and whenever possible making specific anticipatory decisions about, whether or not to attempt CPR is an important part of good-quality care for any person who is approaching the end of life and/or is at risk of cardiorespiratory arrest.

    “If cardiorespiratory arrest is not predicted or reasonably foreseeable in the current circumstances or treatment episode, it is not necessary to initiate discussion about CPR with patients.

    “For many people, anticipatory decisions about CPR are best made in the wider context of advance care planning, before a crisis necessitates a hurried decision in an emergency setting.”

    The purpose of advance care planning is to allow each individual to choose in advance what interventions, including CPR, they wish to receive in the event of deterioration in their health. For people with multiple conditions, or those who are severely unwell, the optimal time to undertake advance care planning is when they are relatively stable. Discussions are best had in their home or usual care environment where planning can be supported by the healthcare professionals who know them well. These may include doctors and nurses based in general practice, in the community, in hospices or in hospitals. Making a decision in advance ensures that there is time for all the appropriate people to be involved in a decision. It allows time for reflection and scrutiny.

    Decisions made may be written down, and described variously as a living will, personal directive, advance directive, medical directive, or advance decision. This is a legally enforceable document in which a person specifies what treatments or interventions they would not wish to undertake in the future if they are unable, due to illness, to give their opinion at that time.

    Nearly one in five people over 80 may need hospitalisation with COVID-19. An estimated 1.28% of people diagnosed with COVID-19 will die. Around half of patients ill enough to be admitted to ICU in the UK for ventilation have died. 95% of UK COVID-19 deaths have occurred in patients with underlying medical conditions.

    Consequently asking people most at risk to decide what they would like to happen in the event of them becoming unwell is sensible, and good medical practice.

    It is however important to distinguish this from a blanket application of DNACPR orders to particular groups. This is discriminatory and illegal. There must be full consultation with the individual concerned. A thorough face-to-face discussion with staff who know the patient well is required. This has clearly not happened in the examples cited in the press.

    Care workers may worry about breaking social isolation rules and potentially infecting patients at home visits. There are ways around this, including video consultations. Poor communication over such sensitive issues breeds mistrust.

    The risks and benefits of CPR may change in the context of coronavirus. In patients with COVID-19 pneumonia who then have a cardiac arrest, not only is there little likelihood of CPR restarting the heart, there is the potential for health personnel to become infected as a consequence of attempted resuscitation.

    Professional guidelines are however quite clear. “A decision not to attempt CPR applies only to CPR. All other appropriate treatment and care for that person should continue. It is important that this is widely understood by healthcare professionals and that it is made clear to patients and those close to them.

    This is essential as it is a common fear amongst members of the public that a ‘DNACPR’ decision will lead to withholding of other elements of treatment.”

    For example, if someone in a care home agrees to a DNACPR, it does not mean they cannot be admitted to hospital if appropriate, or that they cannot be considered for intensive care. It only means that if their heart stops, resuscitation would not be attempted.

    There is an anxiety about the availability of resources if the number of patients overwhelms the amount of life saving equipment available. The COVID-19 pandemic is a major challenge for a weakened NHS. The elderly, care home residents and those with disabilities are being marginalised. The government mantra of “stay at home, protect the NHS, save lives” led people with acute medical conditions to avoid medical attention when they needed it, and encouraged some ill with COVID-19 to stay out of hospital, dying at home when they may have survived.

    The idea of rationing life saving care is anathema to healthcare staff, but it may be on the horizon. In Italy, which has twice as many ventilators per 100,000 population as the UK, there were age cut-offs applied for admission to intensive care. Ventilator treatment was withdrawn from some patients expected to do badly in favour of younger patients with a better prognosis.

    If rationing does become a reality, front line teams will try and work in accordance with accepted ethical principles. This will unfortunately not provide perfect answers.

    Ethicist and barrister Daniel Sokol described the dilemma on April 7th. “It is no secret that intensive care unit (ICU) capacity may be overwhelmed if the pandemic worsens. Why then is there so little published guidance on ICU triage from the UK government and NHS Trusts? The Royal College of Physicians’ ethical guidance on covid-19, published on 2nd April 2020, stated that ‘any guidance should be accountable, inclusive, transparent, reasonable and responsive.’ The British Medical Association’s ethical guidance, published the next day, emphasised the need for decisions to be made ‘openly, transparently, by appropriate bodies and with full public participation’.”

    Sokol asked, “Where are the protocols setting out the triage criteria?” He suggested that senior officials in the government and NHS England may be reluctant to publish anything that might clash with the current messaging that the NHS is managing present demand and is likely to continue to cope. “The official message is that with continued communal efforts the NHS can be protected, ICU need not be overwhelmed, and tragic choices will be avoided. Publishing a document that contemplates an NHS in chaos and tragic choices aplenty sits awkwardly with that message”.

    He also wondered if fear of legal challenge was a factor. The National Institute for Health and Care Excellence was threatened with judicial review on publishing its COVID-19 guideline for clinical care. This advice was subsequently amended due to concerns about unlawful discrimination against people with long-term conditions including autism and learning disabilities.

    The 2019 National Security Risk Assessment also highlighted the potential for public outrage if health and care systems were seen to struggle, especially if provision of the remaining services was unevenly distributed.

    There are no ethical guidelines from the Department of Health or NHS England for front line staff and senior managers relating specifically to COVID-19, but the British Medical Association (BMA), Royal Colleges and specialist medical bodies have produced their own.

    The BMA suggests, “All patients should be given compassionate and dedicated medical care including symptom management and, where patients are dying, the best available end-of-life care. Nevertheless, it is legal and ethical to prioritise treatment among patients. This applies where there are more patients with needs than available resources can meet.”

    To help decide which patients to treat, they ask doctors to “follow your organisation’s guidelines and protocols, including relevant procedures for making complex ethical decisions. The speed of patient’s anticipated benefit will be critical. Other relevant factors include: severity of acute illness; presence and severity of co-morbidity; frailty or, where clinically relevant, age.

    “Managers and senior clinicians will set thresholds for admission to intensive care or the use of highly limited treatments such as mechanical ventilation or extracorporeal membrane oxygenation based on the above factors. Patients whose probability of dying, or requiring prolonged intensive support, exceeds this set threshold would not be considered for intensive treatment. They should still receive other forms of medical care. Prioritisation decisions must be based on the best available clinical evidence, including clinical triage advice from clinical bodies. These criteria must be applied to all presenting patients, not only those with COVID-19.”

    The Royal College of Physicians says, “Any decisions made to begin, withdraw or withhold care must also comply with the shared decision-making policies of the NHS. This means that these decisions should include the patient and their wishes (as much as is feasible for the given situation) and, if appropriate, the patient’s carers. This is true regardless of whether the patient has COVID-19.

    “Front-line staff, policymakers, management and government have a responsibility to patients to ensure that any system used to assess patients for escalation or de-escalation of care does not disadvantage any one group disproportionately. Treatment should be provided, irrespective of the individual’s background (e.g. disability) where it is considered that it will help the patient survive and not harm their long-term health and wellbeing.

    “Many front-line staff will already be caring for patients for whom any escalation of care, regardless of the current pandemic, would be inappropriate, and must be properly managed. We strongly encourage that all front-line staff have discussions with those relevant patients for whom an advance care plan is appropriate, so as to be clear in advance the wishes of their patients should their condition deteriorate during the pandemic.”

    There is an urgent need for national guidance from the Department of Health and NHS England on how to manage if resources run out. In the absence of such guidance, individual clinicians will be using the available evidence to assist in making extremely challenging decisions.

    This will not be an easy task, as illustrated by one Italian doctor speaking to the New York Times. “If you admit an 82-year-old with hypertension, in a situation where you have two or three patients waiting outside your I.C.U. who have many more chances of survival that you cannot admit because your I.C.U. is full, then it becomes really inappropriate, or I would say, immoral”.

    It is outrageous that UK medical staff may be put in this position due to the government’s incompetence.

    Dr John Puntis is the co-chair of Keep Our NHS Public

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    Firefighters across the UK could support the delivery of COVID-19 testing, including taking samples for antigen tests, in the latest agreement between the Fire Brigades Union (FBU), fire chiefs and fire service National Employers. After appropriate training, firefighters will be able to carry out swab tests on other fire and rescue personnel, their families, and the wider public if necessary.

    The update to the national agreement will now allow firefighters to drive ambulances to non-emergency outpatient appointments and to transport those in need of urgent care. Firefighters can also begin training non-emergency service personnel to drive ambulances to aid the coronavirus response.

    It follows an agreement last week between the union, fire service National Employers, and the National Fire Chiefs Council (NFCC), which has allowed firefighters to fit face masks and deliver vital PPE and medical supplies to NHS and care staff.

    Firefighters have already begun driving ambulances, delivering food and medicines to vulnerable people, and moving dead bodies in some areas, after an initial agreement was reached on 26 March.

    The FBU warned earlier this week that around 3,000 fire and rescue personnel were already in self-isolation due to coronavirus. The union says NHS and care staff are a priority but that testing must also be urgently made available to fire and rescue personnel.

    Matt Wrack, FBU general secretary, said:

    “While the government is lagging behind its own schedule to deliver testing, the number of tests that have long been promised may require assistance from outside of the NHS and we are here to help.

    “Firefighters are highly skilled and are able to take on new areas of work to assist in these extraordinary times – and this now includes carrying out antigen tests, driving ambulances to non-emergency incidents, and training other personnel to drive ambulances.

    “We’ve raised our concerns about the government’s mishandling of coronavirus testing and the impact it is already having on frontline services. Fire and rescue personnel are now able to assist in the national testing which is so urgently required.

    Joe Karp-Sawey, FBU communications officer

    1 Comment
    Unite national officer for health Colenzo Jarrett-Thorpe said: “Pressures on our ambulance members are unprecedented with the profession not currently being given the correct guidance as to whom they should take to hospital.
    “They are also not being given the correct level of personal protective equipment (PPE) if they suspect a patient has Covid-19.  Ambulance workers are putting their health, perhaps their lives, at risk, by not receiving the correct PPE and also by not receiving the correct fit test training to wear the PPE. 
    “On top of this, the lack of testing remains a stark and very serious issue – there are not enough tests to ensure ambulance staff are tested within the five-day window for testing.”
    “Unite is urgently calling for ambulance workers to be given clear guidance regarding triaging which patients should be taken to hospital and more action on PPE which needs to be supplied to paramedics, so they are able to do their essential duties.
    “Paramedics are terrified of making the wrong call and being sanctioned for this.
    “I think the public’s patience with ministers is wearing very thin as they continue to say that there is enough PPE in the system, when there are numerous reports from frontline staff that this is simply not the case.
    “It is humbling to see social media posts which show some NHS and social care staff risking their lives as they go to care for patients with coronavirus. The situation is even more dire in social care settings, as care staff do their utmost for the elderly with inadequate protective kit.
    “Unite has thousands of members who are part of the healthcare science workforce. These talented staff need to be engaged to provide the test that is required to ensure 100,000 people can be tested a day. 
    “Unite has over 100,000 members in the health and social care services and we will not rest until we ensure that all health and social care workers are secure in their individual roles in keeping us all safe and well – we are campaigning for that goal 24/7.
    “If these objectives are not met and NHS staff continue not to be protected, reluctantly NHS and social care staff could legitimately and lawfully decline to put themselves in further danger and risk of injury at work. Unite will defend NHS and social care staff.”

    Unite senior communications officer Shaun Noble

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    1. On PPE. From a Greater Manchester doctor working on a respiratory ward, unofficially renamed by staff the “Coronavirus Ward”, about protective equipment:

    “It’s not so much whether there’s enough, it’s what’s being brought in is really poor quality and advice about what constitutes PPE  is changing daily. Loads of my colleagues have already tested positive…… that’s one good thing my hospital is really on it with testing staff.”

    1. From a Unison rep in NHS Greater Manchester:

    “I am worried about members with diabetes, especially type 1. First of all they were listed in the ‘at risk’ group, not quite as at risk as the ‘vulnerable’ group, but who should still not be asked to work. Now they are being asked to go in. The responsibility has been put on them to observe the recommendations. They are sent on to wards where it is impossible to keep a 2m distance from patients, and PPE is still a problem.”

    And “there are not enough tests for the virus. But it would be possible to identify people with symptoms, and teams could be recruited to monitor symptoms and track contacts. However this is not happening.”

    1. Care workers are also on the Frontline. From a care worker in Scotland who visits patients in their homes. She was very upset because she was not allowed to shop at the time reserved for NHS staff “because she had the wrong uniform”. She has been working double shifts for a month, and will be doing so until July, and at the same time doing shopping for some of her patients, elderly people unable to get out of the house and whose adult children live too far away to help. This has been made more difficult by not being treated as a frontline worker, especially as there are limited occasions when she can do shopping, given her extra workload. She points out she is risking her life and those of her family members, but not being treated as “frontline”.

     

    1. Terror of the Unknown. From another Greater Manchester doctor, a retired consultant: “I have been retraining, but will be back at work full time on Monday. The main thing I noticed last week was the atmosphere of fear amongst the staff. Our hospital are pretty organised, it seems to me, with training and equipment, but not unexpectedly, there is terror of the unknown.”

     

    1. Ventilators and Tory Donors. Andrew Raynor of MEC Medical submitted an application to help the government on 16th March, but “nothing” happened. They are a worldwide supplier of oxygen therapy, suction, flow meters, electric suction, regulators and more. Raynor said the government had, instead, “ploughed loads of money into big consortiums to try and make a cheap, makeshift ventilator”. He did not have a problem with the government wanting to make a cheaper ventilator, but pointed out that his firm was already a ventilator manufacturer, and could “upscale quicker”.

    Instead, on 26 March, the BBC reported that the government had ordered 10,000 ventilators from the vacuum cleaner firm Dyson, which has no experience making the ventilators required. Dyson, working with medical technology firm, The Technology Partnership, has “hundreds of engineers working round the clock to design the ventilators from scratch.” The BBC commented that even if a suitable prototype was produced as a result, it still had to get regulatory approval, and move to production on a significant scale.

    As an anaesthetist commented to us: “simple ventilators allow you to dial in the tidal volume (the amount of air moved into or out of the lungs during each ventilation cycle), the respiratory rate” and the concentration of oxygen being breathed in. The ventilators deliver all the breaths and can be used during surgery or for transferring patients.” That is, for short term ventilation.

    But after several days on these ventilators, usually necessary for Covid-19 patients, “people develop wasting and loss of condition in the muscles responsible for breathing in. This means that patients need to be supported during this time, but support can be gradually reduced as they begin to recover muscle strength and can take progressively larger breaths. “They usually also need a temporary tracheostomy to reduce the amount of dead space, enabling lighter sedation and more effective breathing.”

    However, the Dyson ventilators are very basic and do not allow for weaning of the ventilator. “But he’ll make a lot of money, get a peerage, and make it look like Matt Hancock is doing something.”

    In contrast, “modern Intensive Care Unit ventilators are expensive and take ages to produce. Hancock just wanted a soundbite and a photo-opportunity. He passed over offers from established manufacturers to award contracts to big name companies like JCB and Dyson, with no experience of ventilator production, but owned by Tory donors.”

    Our informant compares the finger-prick antibody tests that Hancock has ordered. “They are totally unreliable, with low sensitivity and specificity, but home testing makes for a good, eye-catching headline, even if it’s a waste of time and money. Hancock is a joke; he is surrounded by sycophants and yes-men at the DHSC.”

    Obviously the production of much-needed ventilators is welcome. But the Government’s choice of manufacturers raises major questions about whether it has prioritised its friends and donors, rather than the specification of the ventilators needed.

    Blog from Vivien Walsh

    Comments Off on News From the Frontline

    20/03/2020

     

    OPEN LETTER TO THE PRIME MINISTER FROM THE SOCIALIST HEALTH ASSOCIATION

    Dear Mr Johnson,

    The pandemic has exposed the steady destruction of our public services and welfare state which has happened over the last 10 years.

    This is the most unprecedented health challenge in 100 years which is complex and difficult – but as voiced by many experts in the field, we have significant concerns about the way the UK government has hitherto been approaching this national emergency. We hope from now on this will be better co-ordinated. We support frontline staff at this worrying time.

    However the public is finally waking up to the fact that, as a result of government austerity and privatisation policies, we are ill-prepared – with too few ICU facilities, NHS beds, healthcare staff and equipment – to offer a safe and effective response to the virus. Those most at risk also have to use a threadbare social care system which is already bending under the strain.

    The UK should be in a relatively strong position on public health with a comprehensive service, considered one of the best in the world. However, Tory reforms in England destroyed the health authority structure below national level and has slashed budgets but at least Public Health England has a regional organisation and Local Government have Directors of Public Health. We wish to make some key points:

    1. You are placing staff at risk

    There is not enough personal protective equipment (PPE) for clinicians/frontline staff who are now personally at risk every time they go to into work.

    There is insufficient testing of staff who, having been put off work with minor illness and then return to the front line, do not know whether they have had the virus or not.

    1. You are placing patients at risk

    There are too few beds and too few trained intensive care staff and equipment such as respirators. The government appears to have acted too late. We should be requisitioning beds from the private sector, not paying them £2.4 million a day.

    Covid-19 testing has been wholly inadequate. It appears that a combination of inadequate preparation and misguided policy is responsible.

    1. You are placing communities at risk

    Undocumented people, for instance migrants and refugees, have long felt unable to use the NHS for fear of being referred to the police or the Home Office. This will increase risk. Legislate on charging and reporting undocumented migrants must at least be suspended.

    Those precariously employed, particularly gig economy workers, are still not financially protected and may be compelled to continue working inadvertently spreading infection.

    Thousands of excess deaths have occurred in the last few years as a result of the slowdown and reversal in life expectancy. Austerity policies have been a significant cause. It confirms international evidence that cutting the welfare state while at the same time introducing austerity, kills people.

    This pandemic is likely to add to that grotesque toll.

    1. You are placing the NHS at risk

    Government policy has split hospitals from general practices and from each other. It has created an industrial approach to care where staff and patients are increasingly seen as economic units. The newest redisorganisation has opened up the English NHS planning process to the private sector and to the US, especially if we have a trade deal. In addition, it has the potential to split the English NHS into 44 independent units – exactly what we do not want as we fight a global pandemic. If your government’s Long-Term Plan had already been fully implemented doing exactly that, we would not have been capable of a well-coordinated national response to the Covid-19 crisis.

    1. You are placing Social Care at risk

    Too little funding for Local Authorities has put social care on life support. Those most at risk receiving personal or residential care appear to receive the least advice and the least support to combat the virus. Those with Direct Payments, organising their own care with Local Authority funding, appear to be entirely on their own if their carers get ill.

    1. You are placing democracy at risk

    The most recent reorganisation of the NHS has made both formal and informal democracy more difficult. Just when we need all communities to collaborate and contribute to responding to this global challenge, NHS organisations have become more distant and poorly responsive.

    It has been frustrating and confusing to have changing government advice without any formal presentation of the data and evidence behind it. It was patronising and did not inspire confidence.

     

    WE EXPECT YOUR GOVERNMENT TO:

    • Treat us like adults – show us the evidence on which you base your decisions
    • Protect frontline staff right now with clinically appropriate protective gear and systematic testing. Bring testing in line with the WHO recommendations.
    • Protect the population of the UK by permanently increasing NHS staff in hospitals and primary care, increasing hospital beds, increasing respirators.
    • Roll back privatisation and austerity across public services.
    • Seize the opportunity of this pandemic to invest for the long-term in the welfare state, recognising that a thriving society requires a thriving state.
    • Suspend now legislation on the charging and reporting of undocumented migrants.
    • Invest permanently in social care, making it free at the point of use, fully funded through progressive taxation, promoting independence for all and delivered by a workforce with appropriate training, career structure, pay and conditions.
    • Protect those in precarious employment from financial meltdown from the pandemic. All those who should not be at work should have an living income.
    • Ensure that people across the UK have equitable access to the help they need, through their Devolved Administrations
    • Review the Long Term Plan

     

    Faced with this international emergency, we need to combine medical expertise – including support from abroad, with technical investment with practical solutions and community engagement along with emergency economic measures to fight this together.

     

    Chair SHA

    Dr Brian Fisher, London

    Vice-chairs SHA

    Dr Tony Jewell

    Tony Beddow, Swansea

    Norma Dudley, London

    Mark Ladbrooke, Oxford

    Secretary

    Jean Hardiman Smith, Ellesmere Port

    Treasurer

    Irene Leonard, Liverpool

    Co-Chair KONP

    Dr Tony O’Sullivan, London

     

    Co-signatories

    Dr John Carlisle, Sheffield.

    Terry Day, London

    Carol Ackroyd, London

    Corrie Louise Lowry, Wirral

    Caroline Bedale, Oldham

    Hazel Brodie, Dumfries

    David Taylor-Gooby, Newcastle

    Peter Mayer, Birmingham

    Dr Alex Scott-Samuel, Liverpool

    Dr Jane Roberts, London

    Dr Judith Varley, Birkenhead

    Vivien Giladi, London

    John Lipetz, London

    Jane Jones, Abergavenny

    Dr Kathrin Thomas, Llandudno

    Dr Louise Irvine, London

    Dr Jacky Davis, London

    Dr Coral Jones, London

    Dr Nick Mann, London

    Dr John Puntis, Leeds

    Brian Gibbons, Swansea

    Anya Cook, Newcastle,

    Alison E. Scouller, Cardiff

    Punita Goodfellow, Newcastle upon Tyne

    Parbinder Kaur, Smethwick

    Gurinder Singh Josan CBE,  Sandwell

    Jos Bell, London.

    Steve Fairfax Chair SHA NE, Newcastle upon Tyne

     

    The Socialist Health Association is a policy and campaigning campaigning membership organisation. We promote health and well-being and the eradication of inequalities through the application of socialist principles to society and government. We believe that these objectives can best be achieved through collective rather than individual action.

    4 Comments

    You may have seen the Panorama programmes about the shocking crisis in social care. If not, please see links to iPlayer at the end of this post.

    Below is a motion that I’ll present at my local Labour Party branch meeting on 9 July next week.

    The motion has been agreed by the Reclaim Social Care Group (RSCG) with the aim of getting it discussed and accepted as union policy at Labour Party Conference this year.  Although I’m not ‘registered’ disabled, I’m a member of Disabled People Against Cuts (DPAC).

    The RSCG is co-ordinated through the umbrella group, Health Campaigns Together (HCT). It includes representation from Socialist Health Association (SHA), and KONP (Keep Our NHS Public).  Also included in RSCG are the National Pensioners’ Convention (NPC), several unions including Unite and Unison branches, and a wide range of disabled people’s user-led groups, and writers and academics.

    Motion: Reclaim Social Care

    England’s social care system is broken. Local Authorities face £700m cuts in 2018-19. With £7 billion slashed since 2010, 26% fewer older people receive support, while demand grows.

    Most care is privatised, doesn’t reflect users’ needs and wishes; charges are high. Consequences include isolation, indignity, maltreatment. Disabled and elderly people face barriers to inclusion and independent living, thousands feel neglected.

    8 million unpaid, overworked family carers, including children and elderly relatives, provide vital support.

    Public money goes to shareholders and hedge funds as profits. Service users and families face instability as companies go bust.

    Staff wages, training and conditions are slashed. Staff turnover over 30%.

    This branch demands Labour legislates a duty on the SoS to provide a universal social care and support system based on a universal right to independent living: 

     

    • Free at point of use

     

    • Fully funded through progressive taxation

     

    • Subject to national standards based on article 19 of the United Nations Convention on the Rights of Persons with Disabilities addressing people’s aspirations and choices and with robust safeguarding procedures.

     

    • Publicly, democratically run services, designed and delivered locally, co-productively involving local authorities, the NHS and service users, disabled people and carers

     

    • Nationally agreed training, qualifications, career structure, pay and conditions.

     

    • Giving informal carers the rights and support they need.

     

    Labour to establish a taskforce involving user and carers organisations, trade unions, pensioners and disabled people’s organisations to develop proposals for a national independent living support service, free to all on the basis of need.

     

    (250 words)

    Notes for members

    SoS – Secretary of state

    Reclaiming Our Futures Alliance (ROFA).

    This is an alliance of Disabled People and their organisations in England who have joined together to defend disabled people’s rights and campaign for an inclusive society. ROFA fights for equality for disabled people in England and works with sister organisations across the UK in the tradition of the international disability movement. We base our work on the social model of disability, human and civil rights in line with the UN Convention on the Rights of Persons with Disabilities (CRPD).

    We oppose the discriminatory and disproportionate attacks on our rights by past and current Governments. Alliance member organisations have been at the forefront of campaigning against austerity and welfare reform and inequality.

    National independent living service

    The social care element of Disabled people’s right to independent living will be administered through a new national independent living service managed by central government, but delivered locally in co-production with Disabled people. It will be provided on the basis of need, not profit, and will not be means tested. It will be independent of, but sit alongside, the NHS and will be funded from direct taxation.

    The national independent living service will be responsible for supporting disabled people through the self-assessment/assessment process, reviews and administering payments to individual Disabled people. Individuals will not be obliged to manage their support payments themselves if they choose not to.

    The national independent living service will be located in a cross-government body which can ensure awareness of and take responsibility for implementation plans in all areas covered by the UNCRPD’s General Comment on Article 19 and by the twelve pillars of independent living, whether it be in transport, education, employment, housing, or social security. The cross-government body will also be responsible for ensuring that intersectional issues are adequately addressed.

    BBC Panorama – Social care 

    Part 1:  https://www.bbc.co.uk/iplayer/episode/m0005jpf/panorama-crisis-in-care-part-1-who-cares

    Part 2 – https://www.bbc.co.uk/iplayer/episode/m0005qqr/panorama-crisis-in-care-part-2-who-pays

    8 Comments