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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.

    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?

    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.

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    Posted by Jean Smith on behalf of Labour Trans Equality


    First some background. NHS England Commissions GIDS (The Gender Identity Development Service) at the Tavistock & Portman NHS Foundation Trust. GIDS accepts referrals of young people with the features of gender dysphoria up to the age of 18 in England and Wales. The service at Tavistock & Portman in London has a regional centre in Leeds and satellite clinics in Exeter, Bristol and Birmingham.

    As a result of representations, to the Care Quality Commission (CQC) including by the Children’s Commissioner, the CQC undertook a focused inspection of GIDS in October and November 2020.  This resulted in a rating of Inadequate for the service..

    The CQC report presents a sobering picture of a service under considerable pressure. It finds that at the time of the Inspection the service was working with 2093 young people with a further 4677 young people on the waiting list resulting in a waiting time of at least 2 years for access to the service.

    While these figures would be cause for concern for any NHS service it is what lies behind them in terms of safeguarding and the risk to these young people which is most important and worrying. It is worth quoting directly from the CQC report….

    “Many of the young people waiting for or receiving a service were vulnerable and at risk of self-harm. The size of the waiting list meant that staff were unable to proactively manage the risks to patients waiting for a first appointment”.

    This is currently the reality for thousands of young people and the background to the current debate about the desirability of providing access to “hormone blockers” to young people below the age of 16 and cross sex hormones for young people from the age of 16. A debate heightened by divergent views about the legitimacy and safety of such therapies which has crystallised leading up to the recent Bell v Tavistock Court Case and its outcome now subject to Appeal. The case hinged on the role of parental consent in the treatment of trans children and young people Its impact has been significant for access to treatment and will remain so pending a conclusive outcome to the Appeal. (See commentary on the case by Robin Moira White & Nicola Newbigin of Old Square Chambers)

    This debate about treatment at GIDS frankly rather misses the point. In reality the number of young people currently being prescribed “hormone blockers” and cross sex hormones  at GIDS is less than a hundred. The NHS England treatment protocol for prescription of hormone blockers and cross sex hormones is very strict and following the outcome of the court case has become more so.  Meanwhile as the CQC report makes crystal clear thousands of young people are at varying degrees of risk because they are unable to access the diagnostic and clinical support which they desperately need from GIDS because of the size of the waiting list and the capacity of GIDS to assist them.

    It follows surely that if we are truly concerned about the care and wellbeing of a significant cohort of young people many of whom are at risk  this is what we must be focusing on.

    So what is to be done ? Simply we must focus on the reality rather than be influenced by myth and misinformation about the use of these treatments. Fortunately two key initiatives are now underway. Prior to the CQC Inspection NHS EI had already commissioned Professor Hilary Cass formerly President of the Royal College of Paediatric and Child Health to conduct a review. (The terms of Reference can be viewed on the NHSEI web site)

    Also and in response to the CQC’s findings, NHS EI is currently preparing proposals for establishing local support structures for young people seeking access to GIDS details of which will be revealed shortly. Implementation of these proposals will require support and engagement from people working with young people locally and especially in primary care.

    Meanwhile SHA members can play an important role in ensuring that the discussion about the care and support of these young people focuses on the realities facing thousands of them, their families and their carers and what must be done.  When NHS EI comes forward with its proposals for addressing this problem we must hope and expect that it will receive a positive response from primary care and local mental health services.


    CQC Report

    Tavistock & Portman NHS Foundation Trust Gender Identity Service Inspection Report 20.01.21

    The Cass Review

    “Review of GID Services for Children & Adolescents”

    Click to access GIDS_independent_review_ToR.pdf

    Legal Commentary

    “What about Parental Consent in the Treatment of Trans Children and Young People”

    Nicola Newbigin & Tobin Moira White

    Click to access What-about-parental-consent-1.pdf


    Comments on this article can be sent to Labour Trans Equality at


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    Doctors in Unite statement in support of NEU: 3.1.21

    Doctors in Unite support the NEU in calling upon Government to move learning online in all primary schools including primary special schools in England for at least 2 weeks and in issuing advice to all their members informing them of their legal rights not to have to work in an unsafe environment.

    We supported the NEU on May 2020 and we support them now.

    Doctors in Unite are fully cognisant of the detriment to our young people that stems from missing their education and that the educational deficit falls disproportionately on the most disadvantaged in society. Research is urgently needed to quantify the extent of this disadvantage in order to begin to level the playing field. However, it is also a fact that COVID 19 causes more mortality and morbidity for the most vulnerable in society. Sending children to school is more likely to cause adverse outcomes in families and communities beset by poverty and poor housing, disproportionately those of BAME origin.

    We have consistently called for a robust, locally driven, community based Find, Test, Trace, Isolate and Support programme, coordinated by borough Public Health and Primary Care teams This has worked well in other countries but our Government has singularly failed to heed other’s experience and has continued to plough billions into the privately run, thoroughly discredited national test and trace system and the potentially dangerous Operation Moonshot. We contend that if Government had invested a fraction of this money into local public health and primary care teams, using this as an opportunity to rebuild decimated public health services, that schools would not be faced with mass closure. Additionally the Government could have funded infrastructure so that all children could have access to education at home but instead they chose to prioritise the business interests of their friends with August’s  “eat out to help out” scheme and had to be dragged into ensuring that vulnerable children did not starve by a national pouring of outrage led by Marcus Rashford.

    The blame for the situation we find ourselves in lies squarely with the Government and not with the teaching unions.

    We yet again call on the Government to rebuild local public health services, fund the NHS and Social Care properly and to heed the multiple reports that link poverty with ill health, the latest being the updated Marmot report:

    And this on iSAGE making schools safe:

    Dr Jackie Applebee, Chair Doctors in Unite.

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    Watching and reading the arguments Tory MPs put forward for voting against an extension of free school meals over the school holidays, there seems to be a common thread. Nearly all of them use the argument of dependency, that is relying on the state to provide for us rather than supporting ourselves through personal responsibility.

    These arguments are not new, “Booth and Rowntree found the greatest cause of poverty was not, as often believed, feckless shirking by the irresponsible lower classes, but low pay for full-time work, or inability to get regular work despite best efforts”. In other words dependency is invalid as an argument for poverty. The causes of poverty are well known. This research was conducted before 1914.

    What the Tories call dependency, Labour calls decency. Whatever defence the Conservative MPs type, say, shout or even belief is at odds with fundamental human rights. The right to water and food is part of our existence. The Tories commodify them through privatisation, e.g. the English water companies. Now, they are re-defining them – again – as dependency.

    The language of dependency is interesting yet alarming. From 1997 onwards, society was not focussed on this language, but on how to design policy around alleviating poverty. These alleviation measures while not focussing on the eradicating poverty, sadly, but they helped reduce child and pensioner poverty.

    Without the state focussing on alleviation and the eradication of poverty, we will go backwards in time rather forwards. I know, as I grew-up in poverty in the 1980s and received free school meals. I am very proud that Lewisham through the leadership of Damien Egan and Cllr Chris Barnham acted quickly in Lewisham to extend the free school meals entitlement over half-term.

    Finally, I suspect the dependency argument will continue to be spoken by Tory minsters and MPs. If they can use that past descriptor for free school meals then it won’t be long before it is extended to universal, free at the point of need, NHS healthcare. I have no doubt that a significant number of Tory MPs want us to follow the US system of healthcare. Such a system is the number one cause for bankruptcy among the American population.

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    This is the twelfth week of the SHA COVID-19 blog in which we have responded to emerging issues in the pandemic response, from a politics and health perspective. As it stands the UK has performed “like lions led by donkeys”. The NHS and care home staff, plus all the other essential workers in shops, delivering mail and answering phones have been heroic, risking their lives, working long hours and generally going well above and beyond the call of duty, supported by armies of volunteers, delivering food to neighbours, sewing protective clothing, organising suitably distanced entertainment, and generally rising to the occasion. While the Tory Government, led by Johnson “advised” by Cummings, on the other hand, has done very badly in comparison to the governments of some of our European neighbours as well as many countries further away in Asia and Australia/New Zealand.

    Germany and Greece 

    UK government advisers have told us that the UK could not easily be compared with Germany. This was a surprise to most people as Germany, France and the UK have over many years had comparable levels of social and economic development. We have drawn attention in earlier Blogs to Germany’s quick response to lockdown, how it closed its borders and uses test and trace widely with leadership in regional Public Health departments. The latest data shows that Germany, with a population of 83m people, has had 8,500 deaths which is a crude death rate of 10/100,000 population. This compares very favourably to the UK, with a population of 68m, which has had 38,400 deaths with a crude death rate of 58/100,000. The UK was slow to lockdown, has not closed its borders but promises to introduce quarantining in a weeks time and is struggling to introduce test, track and isolate having not developed its local public health capacity.

    So if we don’t compare well to Germany – what about relatively poor Greece which has in recent years been ridden with national debt? Greece locked down in early March, before many cases were identified and ahead of any COVID-19 related deaths. They enforced lockdown vigorously, closed schools and for their population of 11m, they have had 175 deaths at a population crude death rate of 1.6/100,000. They have now been opening up in comparative safety with shops on May 4th and shopping Malls on the 18th May along with Archaeological sites. They are now advertising for summer tourists to come from countries like Germany and Eastern Europe: but from the UK only if we get COVID under control!

    Test, trace and isolate

    The COVID-19 SARS virus has many troubling characteristics, such as its infectivity while people are not showing symptoms and its ability to cause serious systemic illness in adults and particularly older people. However it behaves much like other respiratory viruses; transmission can be blocked by isolating infected people, hand washing, cleaning surfaces and maintaining physical distance from others to prevent droplet/aerosol spread. Facemasks have also been shown to reduce spread from individuals hosting the virus in their nose and throat. These control measures are not ‘modern’ or technically complex – they are basic public health interventions to prevent infectious diseases spreading and they have been shown to work over many years. The government’s belated control measures, such as stay at home, isolate and maintain social distancing, use these infection control measures. They have worked as infection rates have reduced but are in danger of now being undermined.

    The testing process has been problematic, as we have said before, not least in the slow pace of increasing capacity. In order to try and catch up politicians have plucked large round numbers out of the sky, announced them at the Downing Street briefings without any explanation as to why that number and how it all fits together strategically.  They then commission inexperienced private sector consultancies and contractors to try and build a new system of testing de novo, which has also involved Army squaddies to deliver. This has led to serious organisational and quality problems, results taking too long to be useful, and not being fed back to the people who need to know other than the patient, namely GPs, local Public Health England teams and local Directors of Public Health. The big question has always been why did they not invest in the PHE system to scale up and at the same time invest in local NHS laboratories to tool up? Local NHS laboratories could have worked with university research labs and local private sector laboratories in the area to utilise machinery and skilled staff. This new capacity would have built on established NHS and Public Health systems and avoided the confusion and dysfunction. The answer is they decided to save the money! They chose to ignore the findings of Cygnus, which foretold all this, because they were intent on cutting the funding of the NHS to the bone and privatising everything that could be turned into a profit-making enterprise.

    Tracing contacts is a long standing public health function often done from sexual health and other NHS clinics but also in local authority-based Environmental Health departments, which are used to visiting premises where food is handled, and following up outbreaks of food poisoning and infectious diseases. GPs are also used to being part of the infectious disease control procedures with Sentinel Practices, set up to provide early warning of infectious diseases such as meningococcal meningitis and helping to track e.g. influenza incidence in the community. It should NOT have been left until LAST WEEK to start seriously engaging with local public health departments and their local microbiology laboratories and primary care! These local leaders and partners should have, as in Germany, been what the community control of the pandemic was built on. This did not need to wait for SERCO to set up a telephone answering service and train people on you tube videos with a malfunctioning (and in some areas totally non-functioning) IT system.

    Typically the Government made an announcement that Tracing was going to start before arrangements were in place, and local Directors of Public Health were left to make bids for investment after the starting gun had been fired! To this day the data that ‘comes down’ to local level is from the Office of National Statistics (ONS) and Public Health England (PHE) and is on a Local Authority population level. There is no postcode or other data that would help local surveillance and understanding where infected people live or indeed where deaths have already taken place.

    The NHS has data by GP practice and hospital, but again there remain issues about identifying where those individual patients reside, who have been hospitalised or, sadly, died. These data could be analysed but that job has not been undertaken and so Directors of Public Health do not have the “Information Dashboard” (or data visualisation software) they need to be credible local leaders in the testing, tracing and isolating work that needs to be done to monitor the local situation and intervene with control measures. Hopefully we are on the road to getting a more balanced approach with national standards and the introduction of a mobile app to support contact tracing. Why did the government not learn lessons from South Korea, Singapore and Germany where they have been successful?

    Independent SAGE

    SAGE is the Scientific Advisory Group on Emergencies which is supposed to be independent. The SHA is delighted that Sir David King has taken the initiative and established a credible Independent SAGE group. We are pleased to see that SHA President Professor Allyson Pollock has been invited to contribute as well as others known to be supportive of our approach such as Professor Gabrielle Scally a former regional Director of Public Health and public health adviser to Andy Burnham.

    The way that the Chief Medical Officer (CMO) and Chief Scientific Adviser (CSA) have been played into the Downing Street briefings has been problematic and the secrecy behind who was giving the government scientific and public health advice and what specifically that advice was has been exposed as unacceptable. The CSA has belatedly started to share the membership and minutes (suitably redacted of course) but this has only come about because of political pressure. The SHA were not alone in expressing horror that Dominic Cummings (Johnson’s senior special advisor or SPAD) and his sidekick Ben Warner were allowed to attend these meetings and in fact intervene in the debates! It is the job of the CSA to Chair the meetings of SAGE and discuss the advice for Government, and then summarise the advice for the politicians.

    The independent SAGE group has a very different outlook and its aims are to:

    1. Provide clear and transparent reasons for government policy
    2. Remove ambiguity – messages should be very precise about what behaviours are needed, how they should be carried out and in what circumstances.
    3. Develop detailed, personalised advice that can be tailored to specific groups of people and specific situations depending on their risk from infection.
    4. Messaging should emphasise collective action, promoting community cohesion and emphasising a sense of civic duty and a responsibility to protect others.
    5. Avoid any appearance of unfairness or inconsistency. Any easing from lockdown must be clearly communicated and explained to prevent loss of trust in the Government.

    By adopting this SAGE Scientific Pandemic Influenza Group on Behaviour (SPI-B) terms of reference it is hard for government to be critical! In response to recent government decisions on easing lockdown and opening primary schools further the independent SAGE group finds that:

    “We have already been critical of the recent change in the content of the messages from Government, from the clarity of ‘Stay at Home’ to the vagueness of ‘Stay Alert’ (breaching recommendations 1-3). Now there is a clear risk that the gain delivered from the long period of lockdown will be lost as a result of recent events, further breaching recommendations 4 and 5, with the potential that many take less seriously current and further public health messages from the Government.  The recommendation about collective action is especially important in rebuilding trust that has been eroded.  Working in close and respectful partnership with organisations across society including those representing disadvantaged communities and working people will be vital in this process”.

    The new group will also work in a more transparent way by engaging in:

    “an open debate on the topics on the agenda. This evidence session was live streamed on Youtube so the public can see the evidence presented and understand the debate within the scientific community on the most appropriate course of action for the UK government”.

    We will “provide a series of evidence-based recommendations for the UK government based on global best practice”.

    When should a School Reopen?

    The Independent SAGE group have published their report on school reopening after their public hearing:

    “We all found hearing directly from the public incredibly valuable, and have updated our report accordingly by:

    • Developing a risk assessment tool to help schools and families work together to make return as safe as possible
    • Emphasising further the importance of providing a full educational experience for children as soon as possible – including the many children who will not be returning to school soon. This should include educational opportunities for children over the summer holidays, through a combination of online learning, summer camps and open-air activities. Teachers cannot be the primary workforce for such activities and other options such as scout leaders, sport coaches and other roles should be explored.
    • Explaining further the risks of reopening for children, staff and communities based on our modelling and taking into account SAGE modelling released on 22nd May
    • Emphasising the need to support black and minority ethnic (BAME) and disadvantaged communities, whose members are at higher risk of severe illness and death from COVID19.

    The group went on to say that the decisions to reopen schools should be done on a case-by-case basis in partnership with local communities. They pointed out the risks of going too early while recognising the needs of children who remain at home and their right to education.


    What is the strategy, the science and where are we going?

    There is increasing concern that the government have lost the plot and are now making sudden decisions based on the Prime Minister’s wish to move the debate on from the appalling behaviour of Dominic Cummings his adviser. We have lost the step-by-step changes undertaken with care, built on the published science and giving time for organisations to adapt and respond to the new requirements. There is a pattern of behaviour – policy announcement incontinence – amongst Ministers asked to attend the Downing Street briefings. Announce on Sunday evening, flanked by advisers, and expect delivery to start on Monday morning!

    The English CMO seems locked into this format, which has disabled him from establishing a rapport with the public. His advice and the advice of other CMOs across the UK is meant to be independent professional advice on public health and health care. Similarly the CSA should be there to report on the SAGE findings and recommendations. There is no reason for them to both attend as sentinels at these briefings. Indeed it would be welcome for the CMO to illustrate his independence to have regular slots with the media to explain some of the findings and the rationale for his recommendations. He should have become a trusted adviser – the Nation’s Doctor – and steer clear of the shady political manoeuvring.

    There is increasing evidence too that SAGE scientists are getting restless that the finger of blame will be pointed at them – to become scapegoats when the blame game truly starts. That is why the secrecy around SAGE should not have been permitted and the role of the CSA should have been clearer – to transmit the advice to the government. The Independent SAGE group has shown how this can be done and how you can also engage the wider professional community and public voice in the discourse. The SHA has always advocated for co-production of health and wellbeing.

    The Prime Minister’s newspaper the Sunday Telegraph has today (31st May) applauded him for not sacking his adviser, admits that mistakes have been made but points the finger of blame quite unfairly on PHE. They declare that the ‘system needs structural change’ after the pandemic. The last period we had such changes were during austerity which cut back the NHS and Local Government and the implementation of the disastrous Andrew Lansley disorganisation.

    Scientists need also to beware as the government casts around to blame someone else and we have long been concerned about the claims that they have been ‘following the science’. Several senior SAGE advisers have had to break ranks to say that in their view the government is relaxing the lockdown in England too early. As we have said repeatedly the UK has not performed well in controlling the pandemic and we have had a terrible death toll. It will be shameful if politicians point to scientists, PHE and their own professional advisers as the cause of the dither and delay at the start and the poor decision making since on ‘game changers’ and digital apps. The chaotic introduction of private consultancies and contractors have hindered a joined up public health partnership response and wasted resources which could have been invested in re-building capacity in local government, PHE and the NHS.


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

    1 Comment

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

    The Westminster Government announced on May 10th that:

    “As a result of the huge efforts everyone has made to adhere to strict social distancing measures, the transmission rate of coronavirus has decreased. We therefore anticipate, with further progress, that we may be able, from the week commencing 1 June, to welcome back more children to early years, school, and further education settings. We will only do this provided that the five key tests set by the government justify the changes at the time, including that the rate of infection is decreasing. As a result, we are asking schools, colleges, and childcare providers to plan on this basis, ahead of confirmation that these tests are met”

    We believe that the 5 tests will not be fully met by June 1st and that this announcement was premature. This decision has been taken without transparency about the evidence that has been used on the direct and indirect health impacts. We now see French schools having to reclose.

    We also believe that the Government should have attempted to agree a consensus with Local Authorities and Teaching Unions before announcing a country wide directive around schools in general. The announcement has left schools without clear expectations, without a structure for managing this. We understand that many Local Authorities and schools will now have to seek the skills and information to figure this all out themselves. We believe that this uncertainly will lead to decisions that could adversely affect the health of children, teachers, families, and vulnerable people in their communities. We do not want a repeat of the mistakes in respect of care homes.

    In addition, it breaks the consensus across the four nations in the UK and shows little regard for regional variation or for impacts on inequities in health outcomes for everyone, and educational outcomes for children. Educational opportunities are a powerful determinant of long-term health outcomes.

    The SHA believes that the education sector has been systematically under-resourced and discouraged by this Government since 2010 under austerity, which leaves many schools with insufficient staff, increasing class sizes and inadequate environments that are less able to meet the stringent conditions to enable them to open as safely as possible in such a short timescale.

    We believe that the Government should have considered the following:

    1. How risks would be minimised, and benefits maximised:
      1. In the school environment, such as through safe distancing, handwashing, and other logistic measures to minimise transmission of COVID19, where staffing levels may not be sufficient and school buildings are not always suitable. Children use their bodies to learn.
      2. To children, in particular those in deprived neighbourhoods, in vulnerable groups, children from BAME families, and those with special needs. There is no clarity on alternative arrangements that could have been much more robust to safeguard, and to ensure their nutrition, learning and emotional needs. This should not rely on schools to provide these solutions now
      3. Allowing for the full autonomy of schools and their local authorities within their safeguarding obligations on an area basis
      4. To other groups, such as teachers, communities, and vulnerable groups, and weigh these against the benefits and risks to the wider society
    1. How harm would be minimised, and benefits maximised:
      1. To children who may be missing education which is likely to have a long-term impact on those from more deprived neighbourhoods and those who are less likely to have received equitable support at home
      2. To children who become infected, including asymptomatically and to their immediate household and contacts
      3. To the wider community, especially those that have had a high incidence of COVID19 and remain at high risk of further outbreaks and resurgences. These have disproportionately affected more deprived communities and those with a high proportion of BAME people
    2. How the overall public health response would support this move:
      1. How potential school outbreaks would be identified and managed in the absence of a fully functioning test/ treat/ isolate programme, particularly as some businesses are reopening at the same time.
      2. How schools will be supported by local public health services unless further resources and decision-making powers are decentralised to allow a robust and appropriate and rapid local multi-agency response

    The SHA believes that this decision has been reached without a clear rationale on the benefits and risks, and without demonstrating that the 5 key tests have been met:

    Test one: Making sure the NHS can cope

    Test two: A ‘sustained and consistent’ fall in the daily death rate

    Test three: Rate of infection decreasing to ‘manageable levels’

    Fourth test: Ensuring supply of tests and PPE can meet future demand

    Fifth test: Being confident any adjustments would not risk a second peak that would overwhelm the NHS

    We would add a Sixth: A fully functioning test/ treat/ isolate programme

    The SHA believes that the decision has been reached without sufficient consultation with key stakeholders and before the 5 tests have been fully met. In addition, the National Education Union has set 5 tests specific to educational settings, and we support their belief that in many areas these have not been met.

    We expect a more supportive response from the Dept for Education including investment into online learning and into a revived Sure Start model.

    The SHA believes that schools should be reopened at the right time but that the Government should make the best efforts to ensure that there is a consensus for when this should happen based upon relevant expert input rather than political pressure.  This has clearly not been achieved, as it has been in other countries that have gradually opened schools.

    We encourage Local Authorities and Academy Trusts to follow the example of LAs such as Liverpool, Haringey, North of Tyne, Hartlepool, and Brighton – and devolved governments in Wales, Scotland, and NI – in making it clear that they will not reopen schools until they feel it is safe.


    Actions for schools during the coronavirus outbreak updated 18th May. Department of Education for England

    NEU five tests for Government before schools can re-open

    ONS figures reveal 65 COVID-related deaths in education workforce

    Which occupations have the highest potential exposure to the coronavirus (COVID-19)? ONS May 11th

    Coronavirus (COVID-19) related deaths by occupation, England and Wales: deaths registered up to and including 20 April 2020 May 11th

    Prof John Edmunds

    Prof Devi Shridhar, Professor of Global Public Health, Edinburgh Uni &  Ines Hassan.

    Schools re-close in France after 70 new Covid cases following re-opening  6-11yr classes. NB. French schools starting age is 6 not 3.

    Comparative school age starts

    NB. Denmark is also 6 and easier to manage s/d. long term impacts of formal learning too soon

    Formal learning in early years linked to criminality in teens–evidence-from-denmark-.html

    Posted by Brian Fisher on behalf of the Policy Team.

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    Vested interest alert – yes I’m claiming that word back – I come from a family of school staff, teachers, TAs, school governors. The dedication and hard work of all school staff, caretakers, cleaners, cooks, governors have shown for the safety, education, well-being, in many instances feeding, their pupils throughout this crisis has been extraordinary.

    I am totally dismayed at any criticism. Staff have the well being and safety of their pupils at their very heart. Their views on the total opening of schools and the views of their representatives have to be totally respected. The issue is complex. In Liverpool, the elected City Mayor has chosen not to open schools on June 1st as a safe-guarding issue as this wonderful city is still reeling from a high rate of infection. Questions are being asked as to why Mayor Joe Anderson has taken this stance when schools in Denmark, led by our sister party, are opening. Joe has never said Liverpool can’t open its schools, he has said when it’s safe to do so and only then. Each local authority has its own characteristics, not only in terms of levels of this dreadful pandemic, but the physical nature and age of its school buildings, levels of deprivation, staffing, the amount of public funding available and not available, the differing needs of its pupils. Country by country comparison is far too simplistic. This is an educational, health and societal issue.

    We all want all our children back in school and we are most worried about our most vulnerable, where home-schooling in a cramped flat with no outdoor space is stretching our children’s educational and physical and mental health well-being. I have family members with differing views – what I do know is that they are taking decisions based on local circumstances and always with the education and health of their pupils and staff foremost in their thinking. What is clear is that our health and education services, so starved of resources in this dangerous and false economy of austerity, especially in cities like Liverpool, have to be funded properly based on demographic need. I sincerely hope this Government remembers that but I fear not. Is it safe to open schools to children other than those of key workers or classed as vulnerable? There will always be risk – the question is how to reduce it. We must now learn from other countries – transmission from children to adults, children returning to schools in Italy presenting with multisystem inflammatory syndrome weeks after exposure.

    The UK did not have community testing, contact tracing and isolation early. Surely the question is are schools safe enough to open? Which means we need information and monitoring at a local level, the amount of new cases locally and rates of transmission. Local data should be driving policy and assuming a date for the entire country is ideologically rather than data driven. We need to get children back into education, but a locally managed data driven approach has to be the only way. Prioritising testing over a date. Listening to our teaching staff and our unions.

    For Liverpool in present circumstances – I’m with Joe.

    Theresa Griffin Labour MEP North West 2014-2020

    Member SHA

    1 Comment

    Unite Press Release

    Immediate release:  Wednesday 7 November 2018

    Vote for Cornwall’s children’s services to remain in-house applauded by Unite 

    Cornwall Council’s decision today (Wednesday 7 November)) to keep children’s services in-house, and not to outsource them, has been hailed as ‘a significant victory’ by Unite the union.

    The council’s cabinet voted to adopt the option – outlined in its One Vision blueprint – to keep children’s services in-house from April 2019.

    However, Unite warned that the possibility of parents paying for health visitors to carry out vital health checks on their babies and children still remains as the ‘means tested charging’ wording is in the One Vision document.

    Unite regional officer Deborah Hopkins said: “We welcome the decision of the council’s cabinet to keep children’s services in-house and not outsource them to a separate company.

    “It is a very significant victory for the people of Cornwall and a big set-back for the insidious privatisation agenda.

    “We welcome the council’s announcement that parents won’t be means tested when they require children’s services, such as a visit from a health visitor.

    “However, that possibility is still within the wording of the One Vision framework and until that is finally jettisoned from the document, Unite will be following developments in the weeks and months ahead very closely.

    “Unite is keen to work collaboratively and constructively with the management of children’s services to ensure the best possible outcomes for families and children in Cornwall, which is one of the poorest counties in England.”    

    The other option that councillors rejected today was for a so-called ‘alternative delivery model’ by a company that is separate from the council with the potential to make profits from parents.

    The introduction of charging is in the document’s section on Drawing on funding opportunities where one proposal is: ‘Introduce means tested charging for a range of family support services’.

    About 235 health visitors and school nurses are transferring into a Cornwall Council integrated children’s service in April 2019, to work with a multi-disciplinary team, alongside services for families and young people.

    A recent survey revealed that nearly 20 neighbourhoods in Cornwall are among the 10 per cent most deprived in England, according to The Index of Multiple Deprivation.

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    Mean societies produce mean people

    Babies haven’t changed much for millennia. Give or take a few enzymes this perfectly designed little bundle of desires and interests has not needed to evolve much. Of all primates, the human is the most immature at birth, after which brain growth accelerates and is ‘wired’ according to the kinds of experience the infant has. Provided there are a few familiar and affectionate people there to care continuously for him or her, baby will be fine. If not, evolution has taken care of that too. You live in a cruel world and treat him roughly? He will develop into a compulsively self-reliant and ruthless individual with little concern for others. Mean societies produce mean people. Through attentive care in the early years we may hope to produce thoughtful, curious and confident young people but our social arrangements are essentially hostile and competitive. Having a baby is regarded as an expensive undertaking rather than as a contribution to the future of society.

    Encouraged by successive governments our world is geared to markets. “It’s the economy, stupid” means you can’t do anything without considering the immediate cost. The more this idea takes hold the stupider we become. The current government’s dedication to continuous welfare cuts hits children disproportionately. Neoliberalism is the enemy of children.

    Evolutionary imperatives

    This is not the environment in which humans evolved. An infant in a hunter-gatherer band – the way we all lived for 99% of our time on the planet – would have spent many hours being held, and not only by the mother. “Infants with several attachment figures grow up better able to integrate multiple mental perspectives”. We are programmed from the start to seek out third positions, to acquire the “capacity for seeing ourselves in interaction with others and for entertaining another point of view whilst retaining our own, for reflecting on ourselves whilst being ourselves.”

    Systematic comparisons between sedentary foraging and farming people living now in neighbouring parts of the Congo basin show how much more egalitarian the foragers are. Men and women see themselves as equal. They hold and converse with their tiny children more intensively, they let the baby decide when to wean and teach them to share from an early age. Violence is rare, though teasing is common. Such children are more socialised than in the west and at the same time protected from catastrophe in the event of the mother’s death. Amongst the farmers, in contrast, “corporal punishment is not an uncommon response for young children who do not listen to or respect their parents or older siblings”.

    In the modern world little public money is available for perinatal services, parental leave, for quality child care and universal education, affordable and secure homes, healthy food, subsidised transport and energy, sports fields, swimming pools, libraries, parks and playgrounds that make rearing children and adolescents more manageable and more successful. Tax, like children, is seen as a ‘burden’. So governments of all parties sign up to reducing it, yet still find money for bank bailouts and unsustainable wars. Whether local or national, tax should be a contribution to the common good, an instrument of social justice. It is collected from citizens, for citizens. In the current climate this equation is neither acknowledged nor understood. Yet something has been understood that was not clear before. There is a greater recognition that early intervention is a good idea: “the brain can be sculpted by experience”; the sooner the better.

    Start at the beginning

    When a woman becomes pregnant her physical and mental states impact on her child. From conception onwards the health and resilience of children – and the adults they will become – is compromised by stress, diet, maternal weight, drugs, genes and insecurity in their parents. Besides the impact on the mother herself, anxiety and depression during pregnancy and after it have significant long term effects on the child’s physical and mental health – particularly on boys – generating huge social costs. Pregnancy is a dangerous time for some women. The most socially deprived mothers are more likely to have very premature births or perinatal death. Low birthweight leads to poor outcomes; early intervention can reduce that.

    Elegant research shows how already by a few months old babies are engaged in triadic relationships; they are affected by tensions between the adults caring for them. When caregivers are uncooperative infants may be “enlisted to serve the parents’ problematic relationship rather than to develop their own social competence”. Children will more likely thrive if caregivers – parents and grandparents, childminders, daycare and children’s centre staff, nursery teachers – get on with one another, like a good team. “Communication between parents and care providers is crucial to the quality of care.”

    The routine availability and presence of health visitors and other staff supporting new parents and of Sure Start centres for children and families create the conditions for reliable care of children. In a context of skilled early years provision, infants whose parents are paid to spend time with them in the early months are less likely to die. “A ten week extension in paid leave is predicted to decrease post neonatal mortality rates by 4.1%”. This remarkable finding represents just the tip of an iceberg of developmental damage and pathology, modifiable by intensive early support for families.

    Better training and pay for early years staff improves outcomes and reduces turnover. UK needs to learn from continental Europe the tradition of pedagogic professions: proper pay, status and training for the job, particularly when the families most in need are hard to engage. Looking after small children is demanding and stressful, requiring continuous professional development such as reflective discussion groups in which colleagues both support and learn from each other. Work with young families is a professional skill.

    Inequality undermines trust

    A collaborative partnership between caregivers does not in itself cost money, but is undermined by social disintegration, the most poisonous source of which is rising inequality. In Britain this has reached levels not seen since the 1920s. The much maligned 1970s was actually the most egalitarian in our history. Consider this: one index of social health is the number of boys born in comparison to girls. Because the male fetus is more vulnerable to maternal stress, women produce fewer boys when times are hard. (For example there is a fall in the ratio of boys to girls a few months after disasters such as massive floods or earthquakes, or the terrorist attack on 9/11). In England and Wales the highest ratio of boys to girls occurred in 1975. In terms of contented mothers it was the best of times.

    Inequality creates stress in parents who can’t keep up, and anxiety in the better off who fear sliding down. No one is comfortable on a steep slope. It makes all of us less trusting and more averse to communal commitments, such as respecting our neighbours and paying tax. Infant mortality, mental illness, drug abuse, dropping out of education, rates of imprisonment, obesity, teenage births and violence are all higher in unequal countries like ours.

    Though often disappointed, our ancient baby is born to expect some kind – a rather conservative kind – of socialism. What will today’s infants be talking about in 2050? If they know any history they will regret lost opportunities; our collective loss of vision that led to wasted generations. The success of the post war consensus was due in part to the fact that it lasted longer than one or two parliamentary terms, so that children could grow up, get educated and housed, find partners, get work and free healthcare without overwhelming instability or despair. The needs of a baby born today are precisely what they were for one born in the 1950s, or 50,000 years ago. New knowledge of infant development is catching up with evolved wisdom, yet we continue to ignore both, and build bigger obstacles to secure attachments.


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    How do early circumstances influence us later in life? Previous studies have found that socio-economic factors in early life can continue to have persistent impacts throughout one’s life and, coupled with circumstances in adulthood, jointly contribute to later health. Understanding these influences can therefore be beneficial to policies aiming to reduce health inequalities. This is why studies using longitudinal data, and especially those sampling a specific cohort, are particularly useful in disentangling the relationship between early life and later health.

    The 1958 British National Child Development Study (NCDS) makes available rich data, ideal for this line of study. The NCDS has followed over 17,000 individuals born in 1958 for 50 years, providing information across different domains (e.g. physical, social, and health) and at different stages in life. Yet socio-economic circumstances are difficult to measure in practice, because they are multi-dimensional and sometimes unobserved. So, how can we represent complex pathways by realistic statistical models?

    Our research proposes a structural model that connects the socio-economic circumstances in childhood, partnership history in adulthood, and health in midlife (Figure 1). Around 50% of individuals in our British cohort (currently in their 60s) grew up in families with unfavourable conditions in at least one of the four dimensions of socio-economic circumstances that were identified in the early phases of the study.

    Effects of childhood circumstances

    Figure 1: Path diagram showing the effects of childhood socio-economic circumstances (SECs) on later health

    Having performed the analysis, we are able to formulate four sets of conclusions.

    1. Do childhood socio-economic circumstances directly influence midlife health?

    We find that the estimated effects of father’s social class, financial difficulty, and material hardship in childhood on midlife health to be significant and similar in magnitude, before and after controlling for partnership experiences. This suggests the influence of these factors during one’s childhood are long-lasting and persistent, and that those with unfavourable conditions in these aspects are significantly more likely to be in poor health at age 50 (Figure 2).

    Figure 2: Predicted population-average probabilities of being in poor health state at age 50 for each level of childhood socio-economic circumstances

     probabilities of being in poor health state at age 50 for each level of childhood socio-economic circumstances

    Note: Marginal probabilities are computed keeping all the other covariates fixed at their observed values for each individual. Individual-specific random effects are simulated from the estimated distribution.
    1. Do partnership experiences influence midlife health?

    We find that individuals who have formed their first partnership later in life tend to have a lower risk when it comes to developing health issues at age 50. Also, among those who have started the first partnership at the same time, cohort members who have spent longer time single before the age of 50 have a higher chance to be in poor health in midlife.

    1. Are there any indirect effects of childhood socio-economic circumstances on midlife health?

    The results suggest that an unstable family structure in childhood pushes up the likelihood of poor midlife health but the effect is not directly transmitted: rather, only through an indirect path via one’s own partnership experiences. We find that unstable family structure significantly increases the likelihood of the early formation of first union and that of subsequent dissolutions.

    Back to the health submodel, cohort members who formed the first partnership early are significantly more likely to be in poor health in midlife, and those with shorter partnership episodes, i.e. those who spent a higher percentage of time single, have a relatively higher risk to develop health issues at age 50. The evidence confirms the hypothesis that the influence of childhood socio-economic circumstances on midlife health is partially mediated by partnership experiences.

    1. Do different partnership experiences share common influences not captured by observed characteristics?

    Our analyses find that such shared influences do exist. Certain individuals who form their first relationship early tend to be less likely to suffer a relationship breakdown. In the future phases of the study, we will investigate the individual-specific characteristics relevant to this correlation – such as whether those with a mutual interest in being in a quality relationship tend to maintain the union, lowering the risk of separation.

    First published on the British Politics and Policy blog

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    So what is Jeremy Hunt doing about it?

    Obesity was a factor in more than 525,000 hospital admissions last year, and obesity rates have risen from 15% in 1993 to 27% in 2015. Child health experts describe the level of childhood obesity in the United Kingdom as a “state of emergency”.

    As a GP with over 30 years’ experience, I can state that the vast majority of consultations are for conditions such as diabetes and heart disease – linked to lifestyle or diet. I would estimate that 50-70% of costs to the NHS would be not just reduced but eliminated if patients’ diet and exercise regimes were improved.

    Children born since the 1980s are up to three times more likely than older generations to be overweight or obese by the age of 10. The number of overweight children admitted to hospital has risen from 872 in 2000 to 3,806 in 2009. And over the past decade, the UK has seen a four-fold rise in youngsters needing medical attention as a consequence of being obese.

    I am distressed that poor diet is such a feature of the lives of our children and young people. Barring genetic or catastrophic disease, accidents and maybe the ageing process itself, our health is in our hands. Central to tackling this is creating an environment where it is normal, easy and enjoyable for children and young people to eat healthily.

    At best, politicians pay lip service to the problem – at worst, they play politics.

    Jeremy Hunt has described the rise in childhood obesity as a “national emergency” – and when he was appointed health secretary in September 2012, he promised a “game-changing” response.

    It’s been more than four years since the Academy of Medical Royal Colleges submitted a 10-point plan, following a one-year review of the evidence on policies to tackle the obesity epidemic. Its proposals included a tax on sugary drinks, banning junk food advertising to children, restrictions on fast food outlets near schools and compulsory nutritional standards in hospitals.

    The government published its childhood obesity plan for action in August 2016. The plan, heavily influenced by food and drinks lobbyists, was a watered-down version of proposals the government had been preparing to publish. Except for a levy on sugar-sweetened beverages, no other proposal has been implemented.

    This week at the Conservative party conference in Manchester, Hunt repeated the same message – while wearing a Tate & Lyle lanyard. Prof Russell Viner, health promotion officer at the Royal College of Paediatrics and Child Health, said: “It’s a really poor choice of sponsor and sends a very mixed message. On the one hand the government says it’s determined to tackle obesity and to bring in the sugar tax. On the other, they’re giving major prominence to a sugar company at their conference.”

    According to Prof Robert Lustig, a child obesity expert at the University of San Francisco, sugar (including sweeteners) and processed carbohydrate are the biggest culprits in childhood obesity. He describes sugar as being addictive and toxic and has called for a ban on the sale of sugary drinks to under-17s and a consumer tax on any substance with added sugar.

    I accept that the government has to tread a difficult line between telling us what to eat and letting “Big Food” feed us junk food and sugary drinks without any disincentive – but that’s what government is for. It took us far too long to agree to real action against smoking.

    As cases of both type 2 diabetes and obesity continue to rise exponentially, Hunt must act urgently and decisively. The government needs to take more robust action to tackle the impact of deep discounting and price promotions on the sales of unhealthy food and drink. As a first step, the health secretary should accept and implement all the Academy of Medical Royal Colleges’ proposals as a matter of urgency.

    Let’s deal with obesity now before it overwhelms the health service.

    First published in the Guardian

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    Delivered to the Royal College of Paediatrics and Child Health  11 July 2017

    Good morning and can I start by paying tribute to the Royal College and to thank you for hosting me today. It is a pleasure to be at this great Royal College. A Royal College embarking on celebrating 21 years since granted a Royal Charter, 21 years where you have spoken out for children and ensured the voices of children are heard at the very highest level.

    It was Nelson Mandela who told us: “There can be no keener revelation of a society’s soul than the way in which it treats its children.” If that great man was right, then our country is in a great deal of difficulty. The state of children’s health in the UK, and in England in particular, should be a matter for profound concern and concerted action. But sadly currently it isn’t.

    We can point to nearly any element of children’s health, from care for disabled children, to child and adolescent mental health, to childhood injury, and, to childhood obesity. In all those areas we find examples of good practice but the overall picture reflects social inequality and failure, sometimes on a massive scale.

    And my argument today is despite all the other challenges that face us as policy makers, from how we navigate Brexit with its inevitable impact on the NHS or we confront the fiscal and societal challenges of an ageing population, we must not allow the health and wellbeing of the next generation to be neglected and overlooked.

    So as Labour’s shadow health secretary, I want to put children’s health at the heart of Labour’s vision for a 21st Century National Health Service, and at the heart of our drive to improve the health of our nation.

    It’s an ambition that has long been part of my Party’s mission. In the Labour manifesto of 1945 we stated: “Labour will work specially for the care of Britain’s mothers and their children – children’s allowances and school medical and feeding services, better maternity and child welfare services.”

    During the recent general election campaign, in which the future of the NHS played such a central role, we quite deliberately placed a focus on children’s health – talking of an ambition to make Britain’s children the healthiest in the world.

    So today I want to say a bit more about why children’s health is so central to my vision to improve the wellbeing of the country.

    And I’m also here today to announce Labour’s new Child Health Forum, where we’re inviting experts like yourselves, and members of the public across the country, to get involved with developing the detail of our policy platform.

    We know that what a child experiences in the womb and through its early years has a profound effect on the rest of its life. As the review into health inequalities carried out by Sir Michael Marmot and commissioned by the last Labour government stated:

    “The foundations for virtually every aspect of human development – physical, intellectual and emotional – are laid in early childhood. What happens during these early years, starting in the womb, has lifelong effects on many aspects of health and wellbeing – from obesity, heart disease and mental health, to educational achievement and economic status.”

    The message is clear – if we don’t get children’s health right we will never have a healthy adult population in this country.

    Yet when we consider how we are placed internationally we see the United Kingdom is not doing well in key areas of child health compared to other countries in Europe. For example, the rate of deaths to children under the age of one year old is higher than all our neighbouring countries and considerably higher than Scandinavian countries.

    Breastfeeding remains lower than many other comparable countries; we fare poorly on aspects of physical health such as obesity.

    Just last week the Children’s Commissioner revealed that there are estimated to be over two million children with health-related vulnerabilities, including 800,000 with mental health disorders.

    Sadly the Government’s response to the issue of child health has been piecemeal, fragmented and unstrategic.

    Indeed the Sustainability and Transformation programme have had shamefully little to say about improving children’s health and wellbeing.

    In the general election we said we would halt these plans and review whether they’re really delivering for patients. Whatever the future of STPs today, a big test of them will be whether they deliver for children.

    And now we see the consequences of the lack of an overarching approach. Let me offer three examples.

    Firstly on immunisation. It doesn’t matter whether it is vaccination against measles, mumps, rubella, meningitis, diphtheria, tetanus, pertussis and even polio.

    Immunisation rates are falling and, in some cases, have been on a downwards slide for each of the last three years. Children in England are not being protected as well as children in the rest of the UK.

    In the official report on immunisation, vaccination coverage in England at one, two and five years of age was, for all reported vaccinations, below that of the other UK countries.

    Secondly in the crucial area of childhood obesity, we are currently failing our children on an enormous scale.

    Not only has the government’s feeble effort at a childhood obesity strategy fallen flat but they continue to push through massive cuts to public health and education budgets.

    They even tried, and hopefully it would seem failed, to deprive children in the first three years of primary school of their free school lunch.

    It’s important to recognise that childhood obesity not only leaves children susceptible to major health problems such as diabetes, high blood pressure, asthma and cancer in later life, but, during childhood it also is associated with poor psychological and emotional health due to issues such as stigmatisation, bullying and low self-esteem.

    But despite all of the evidence, there is a profound lack of action – and the result is that levels of obesity amongst our schoolchildren are continuing to increase.

    More than one in three children in year six in our primary schools are either overweight or obese – and there is little sign of the problem doing anything other than getting worse.

    If the crisis in childhood obesity is not tackled, half of all UK children will be obese or overweight by 2020.

    Not only is it a betrayal of the nation’s children it makes no sense for the future sustainability of the NHS either.

    The UK spends about £6 billion a year on the medical costs of conditions related to being overweight or obese and a further £10 billion on diabetes, but less than £638 million a year on obesity prevention programmes. Unless we act we are building up future pressures on the NHS.

    Thirdly, perhaps the Government’s biggest failing is on Children’s Mental Health.

    Half of all lifetime cases of psychiatric disorders start by age 14 and three quarters by age 24.

    Around 13% of boys and 10 per cent of girls aged 11-15 have mental health problems – at least three young people in every classroom.

    Suicide is the leading cause of death in young people aged 15-24. Supporting our young people’s mental health is crucial, particularly through prevention and early intervention.

    Yet just 11% of children’s mental health needs are met by the NHS while the NHS spends 14 times more on adult mental health than the children and adolescents’ service.

    We know that in in many parts of the country CAMHS budgets are raided to fund wider gaps in the NHS because of the lack of ring fence.

    Cuts in one part of the system as usual lead to pressures elsewhere in the NHS. Indeed today I’m publishing our new analysis from the House of Commons Library that shows the number of young people presenting at A&E with mental health problems has risen 33% over three years.

    The backdrop to all this is of course inequality in health and rising child poverty.

    For example, infant mortality, an area where the UK has one of the worst records in Europe, is more than twice as high in the lowest socio-economic groups in our society compared with the most well-off.

    Similarly, obesity is twice as common amongst children living in the most deprived areas as compared to children in the most privileged areas.

    Your own RCPCH report, State of Child Health, from earlier this year makes clear: “Children living in our wealthiest areas have health outcomes that match the best in the world. But the gaps between the rich and the poor are stark, and some of the outcomes amongst our deprived groups are amongst the worst in the developed world.”

    The number of children living below the poverty line has increased by 400,000 since 2010, reversing a decade of major progress under Labour. At a local level, the figures are even more appalling: in some areas as many as 47% of children live in poverty.

    A boy born in Chelsea has a life expectancy of over 84 years. Yet just five miles away, a boy born in Islington can only expect to live to around 75 years of age.

    Child poverty is a scar across Britain and one we’re determined to confront.

    A third of the most deprived children are predicted to be overweight or obese by 2020 compared to just under a fifth of the most affluent.

    And 5-year-olds in the most deprived constituencies are almost seven times more likely to live with dental disease than their peers in Jeremy Hunt’s local authority in Surrey.

    So improving the health of all our children regardless of their background is central to Labour’s health strategy. Put simply, no child will be left behind under the next Labour Government.

    Just as the last Labour Government had as its driving mission to eliminate child poverty, so for me as Health Secretary in the next Labour Government it will be a driving mission to defeat child poverty and child ill health.

    So what should our response be?

    Our starting point will be familiar to everyone engaged in the debate about the future of the NHS, namely workforce and resources.

    So first on workforce.

    Today you have published new evidence of the strain on the paediatric workforce.

    Prior to reaching consultant level, children’s doctors train for around eight years.

    This study shows that almost one in five of paediatric trainee positions are currently vacant even though trainees themselves report high levels of enthusiasm for the speciality.

    Even more alarming is that this figure jumps to nearly one in four in more senior trainee positions, and almost 90% of children’s units express concern over how they will cope over the coming six months.

    I’m also publishing today new analysis of the community child health workforce with 10% of school nurses, 11% of health visitors and 12% of district nurses lost to the NHS in the past two years.

    It’s a scandalous loss of expertise and particularly concerning against a backdrop of a drop in nurse trainees.

    As if the cuts to the current workforce aren’t bad enough, there appears to be no account being taken of the growth taking place in the overall number of children. In the next ten years, the number of 0 to 16 year olds in the UK is projected to grow by almost 700,000.

    So, to make sure all children have access to the services they are entitled to, and to reduce health inequalities, we are committed to investing in the child health and public health workforce.

    We would ask Public Health England and Health Education England to work together to identify how the public health workforce will need to be developed and shaped to support the UK’s new ambition of having the healthiest children in the world.

    But it’s not only in the area of workforce that the government are failing our children:

    This Government’s failures in acute services are well documented. The sustained underfunding of the NHS has pushed staff to the brink and has caused a collapse in patient standards. Waiting lists are up, treatments delayed and A&E targets have been abandoned.

    Our research reveals the impact this is having for children in hospital.

    Procedures to repair broken bones, remove rotten teeth or insert grommets are among more than 40,000 operations that have been cancelled over the last four years.

    Over 12,000 surgical procedures on children and young people were cancelled last year alone, that’s an increase of 35% in three years.

    These are children waiting in pain and suffering for treatments and, as you in this room know, there will be serious long term effects to their physical and mental wellbeing.

    In a separate piece of research we looked at the number of hospitals which have had to close wards because of maintenance problems – one hospital in the North of England told us of a utilities failure in their maternity unit – no electricity throughout the night, beds that couldn’t be adjusted, and no heated mattresses for the babies.

    So the NHS’s biggest financial squeeze in history, capital budgets raided, public health budgets siphoned off, with valued early intervention services at risk, and the outcome is that local authority public health services are planning on spending less on 0-5 children’s health this year than last.

    It is beyond debate that our NHS and care system now needs more investment.

    And at the election Labour pledged a boost of £7bn to turn round NHS services and deliver a long overdue pay rise for staff by scrapping the pay cap.

    And we promised to properly and effectively ring fence local authority public health spending in order to protect non-NHS services too.

    But for Labour it’s a priority, not only to boost investment in our health and care system, but to make sure that money is used well.

    And for me the starting point in gaining best value for health spending is to prioritise prevention.

    So improving children’s health services is not only the right thing to do in putting children at the heart of our NHS policy, we will also instigate a new drive for effective action on prevention across government.

    Labour strongly supports a ‘Health in All Policies approach’ and there is no better place to start than by addressing the serious problems confronting the country in children’s health.

    At the election we began to set out the basics of how this would work:

    Labour would introduce a Child Health Bill, legally requiring all government departments to have a child health strategy to set out how they will support this new ambition and to work in an integrated way in order to deliver that strategy.

    We want to work with experts like you to develop a new Index of Child Health to measure progress against international standards, looking at for example obesity, dental health, under fives (including breastfeeding, immunisation and childhood mortality), and mental health.

    Let me be very clear on this, unlike the current government, we do not shy away from developing clear plans for better child health, neither do we shy away from collecting and publishing the data that can inform those plans.

    Labour is not scared of setting targets to improve our children’s health and we have a strong track record of taking the action necessary to achieve our collective goals in improving health.

    One of the areas where we face a number of challenges is around diet and nutrition.

    I’ve spoken of how the UK has one of the worst childhood obesity rates in Western Europe.

    Tooth decay is the single most common reason why children aged five to nine require admission to hospital. More than four in 10 children in England (42%) have not seen an NHS dentist in more than a year even though ideally, they should have a check-up every six months. The role of dental public health has been diminished in recent years, and we will make it a priority.

    The Labour Party’s manifesto pledged to halve childhood obesity within ten years. And we would introduce legislation banning junk food advertising from being broadcast before 9pm, stopping unhealthy food from being promoted during primetime television, such as the X Factor, Hollyoaks and Britain’s Got Talent.

    Our shadow education secretary, Angela Rayner and shadow public health minister, Sharon Hodgson, pledged to extend free school lunches.

    I want to see more schools do what the Charlton Manor School I visited in Greenwich does, where the inspirational head teacher, Tim Baker, has deliberately put healthy eating and nutrition at the heart of the school ethos.

    We want also to go further and do more to help mothers and under fives:

    Breastfeeding rates in the UK are among the lowest in the world. Just 44% of mothers in England were recorded as breastfeeding at their six to eight week health visitor review in 2014-15.

    For Labour in government it will be a priority to offer better support to mothers and to reinstate the infant feeding survey.

    We should be considering specific initiatives, like the “1001 Critical Days Strategy”, to give support to mothers from conception to age two.

    So Labour would develop a cross-departmental initiative to support breastfeeding, with a national public health awareness campaign promoting breastfeeding, including in the workplace and proper investment in peer support.

    We fully understand that a successful approach to breastfeeding requires the time and resources being available to give proper support for new mothers, whilst making sure that mothers who are unable to breastfeed, for whatever reason, are also supported.

    Perinatal mental illnesses affect at least 10% of women, but access to mental health services is variable at best. Maternal mental illness approximately doubles the risk of subsequent mental health problems in children.

    According to one estimate, the long-term cost to society of a single case of perinatal depression is around £74,000, mostly because of adverse impacts on the child.

    The NSPCC have done some excellent work as part of their All Babies Count campaign to make the case for pregnant women and new mums at risk of, or suffering from, mental illness to be identified as early as possible and given appropriate and timely expert care. We agree.

    Of course the Prime Minister has promised parity of esteem for mental health – but has so far failed to deliver. Labour’s strategy will be focused on prevention and early intervention, whilst ensuring acute CAMHS receive the money they have been promised.

    Labour will work towards eliminating the scandal of Out of Area Placements for acute mental health treatment.

    And Labour will introduce statutory high quality PSHE into all schools to ensure teachers, parents and pupils know how to spot, report and cope with online, and other types of abuse and bullying.

    We know there are many pressures which can cause adverse childhood experiences from poor housing and deprivation to problems at home. Its time also for a full understanding of the pressures of social media and to ask ourselves what action should be taken.

    Social media has revolutionised the manner in which young people communicate with themselves and the outside world.

    An increasingly digitised world brings welcome benefits but also negative effects such as cyber-bullying.

    The University of Manchester produced a report last week, looking at the common themes in the lives of young people who die by suicide. The study found suicide-related internet use in 26% of deaths in under 20s, and 13%t of deaths in 20-24 year olds, equivalent to 80 deaths per year.

    We know that a child growing up with a parent who has alcohol or drug abuse issues can impact on the health and wellbeing of the child. I have worked with an excellent charity called NACOA and I spoke in the House of Commons earlier this year about my own experience as a child of an alcoholic. We believe it’s time to put in place a clear cross-government strategy to support such children.

    The shameful picture of child health in England is terrifyingly real and should be receiving urgent attention from all who are concerned about the future health and wellbeing of our country, and particularly, its children.

    Of course, there are other extremely important challenges facing us at the present time but that is no excuse for the current disregard for the state of child health.

    The Conservative government is squeezing our NHS and taking money from our public health system and our schools.

    Labour will make child health a national priority and one which brings together all of the academic, medical and economic expertise that we have in this country, to design and implement a programme that can ensure that, at some point in the not too distant future, we can point to our record on the health of our children with pride rather than dismay.

    Labour has a strong track record on improving the health of children and young people. Amongst many other things, we can proudly point to the success of Sure Start and the continuing success of the teenage pregnancy strategy.

    We also created a properly resourced public health system that enabled us, for example, to implement, right across the country, the very important Healthy Schools programme.

    Much of this success is in danger of being reversed. The raiding of public health budgets and the downgrading of the public health system, including the invaluable network of public health observatories, places us at an enormous disadvantage in taking forward steps on child health.

    Nonetheless, despite being in opposition, Labour has shown the way forward on child health. For example, it was Labour that managed to steer through parliament the legislation on protecting children from tobacco smoke in cars and the introduction of standardised cigarette packaging.

    In the absence of government leadership and action on child health, Labour will, over the next 12 months, convene a series of workshops which will draw together the evidence and expertise that we know exists in abundance in the field of child health.

    We will develop evidence-based and feasible proposals for the action that is needed, not just to halt our relative decline in terms of the health of our children, but to create a dynamic programme for the country that can gain widely based public, professional and political support and which will give our kids the chance to have the healthy childhood they deserve.

    So today I’m launching our new Child Health Forum, so that you can feed in your ideas, let us know what you need from the nation’s health and care system, and together we can work to give every child in the UK truly the best possible start in life.

    Thank you.

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