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    The following is a major speech from Shadow Health Minister Justin Madders.  In Parliamentary terms it is extremely critical of the government.  Even though the prime minister may have lowered the tone of debate, this is polite, measured, and at  the end, does threaten the PM with his P45.  I work with Justin a lot, and have developed considerable respect for his honesty and integrity over the years.

    Jean Hardiman Smith

     

    As we know, we are now a year into this pandemic. It has been a year unlike any we have experienced before, and it certainly was not the one we would have hoped for. The virus has turned the world as we know it upside down. We have seen the very best of many: our frontline health and social care workers who have selflessly looked after us, our key workers who have kept our vital services running and our country going, and our communities who have come together to support one another, especially those in need. But it has also been the very worst of times for many: families kept apart for months, individuals and businesses left with no support and, of course, the grim milestone of more than 120,000 deaths from coronavirus, which was reached this weekend. We know that each life lost is a tragedy that leaves behind devastated family and friends, and that death toll does need explaining. I will return to that issue later, but I would like to start on a more positive note.

    As the Minister referred to in his opening remarks, more than 17.5 million people in the UK have received their first dose of the covid-19 vaccine. I echo his congratulations to everyone who has been involved in that roll-out. From the scientists to the NHS to the volunteers, it has been nothing short of brilliant, and it is something for us all to celebrate. While we are on the subject, we should also extend our congratulations to Mark Drakeford and the Welsh Government for becoming the first country in the UK to get through the first four priority groups.

    I am sure that all of us have breathed a sigh of relief or even shed a tear when a parent or vulnerable family member or friend has received their first vaccine dose. Yesterday’s news that all adults in the UK will have been offered their first dose by the end of July is very positive indeed, but can more be done? When Simon Stevens says that the NHS could deliver double the number of vaccines it currently is, we will all be asking, why is that not happening? With research showing that some minority groups are well behind the general population in terms of take-up, another question that I am sure Members will want to raise about the roll-out is: what can the Government do to vaccinate more people in hard-to-reach communities?

    I am sure that many Members will have been moved by the story of Jo Whiley and her sister, Frances. She has talked about the anxiety shared by many families across the country. We know that people with learning disabilities are much more likely to die from coronavirus than the general population, with the death rate in England up to six times higher during the first wave of the pandemic, but currently only people with severe learning disabilities have been prioritised for the vaccine. I am sure the Minister is aware that over the weekend, at least one clinical commissioning group announced that it will be offering the vaccine to all patients on the learning disability register as part of priority group 6. I would be grateful if the Minister updated us on whether there are any plans to consider that issue again.

    I have one last question regarding the vaccine. We have asked a number of times for the Government to publish figures on how many health and social care staff have been vaccinated. The Secretary of State said last week that a third of social care staff had still not been vaccinated, so I hope that when the Minister responds to the debate, she will be able to update us on those figures and on what more we can do to improve take-up in that group. It is vital that we look after the people who look after us in social care and the NHS. Our NHS rightly deserves huge congratulations on its impressive and speedy vaccine roll-out, but despite its incredible efforts, it will still take many months before the vaccine offers us widespread protection. With the emergence of new variants, increasing pressures on our health service and continuing high rates of transmission, it is vital that Ministers do everything possible to ensure that frontline health and care workers, who are more exposed to the virus, are fully protected.

    Healthcare staff deaths are now estimated to be approaching 1,000. That is tragic. We know that our frontline workers face higher risk. During the surge in cases last month, the British Medical Association reported that more than 46,000 hospital staff were off sick with covid-19 or self-isolating. A survey conducted by the Nursing Times during the last two weeks of January found that 94% of nurses who work shifts reported that they were short-staffed due to similar absences. We support calls from the BMA and the Royal College of Nursing to urgently review PPE guidance and increase stockpiles of high-grade PPE such as FFP3 masks for all frontline NHS employees. I hope the Minister can update us on what plans the Government have to ensure that health and social care staff are fully protected.

    Finally, we need a plan for staff to address what comes next. Just as the nation needs a recovery plan, the NHS workforce needs one too. We must not forget that we entered this crisis with a record 100,000 vacancies in the NHS. What I hear from staff, who have now been working flat out for a year, is that they desperately need a break, and they need a tangible demonstration that their efforts are truly valued. The NHS rightly has a special place in the hearts of the people of this country, but without the staff, the NHS ceases to exist. That is why we need to recognise that we cannot keep dipping into that well of good will, and that at some point, NHS workers need cherishing as much as the institution itself.

    I cannot mention PPE without briefly addressing last week’s High Court ruling that the Government had acted unlawfully by failing to publish details of covid-related contracts. Why has the Secretary of State not come to Parliament to explain himself? Is breaking the law such a common occurrence in Government nowadays that it does not warrant an explanation from those responsible? The Government’s approach to procurement during the pandemic has been marred by a toxic mix of misspending and cronyism. We all understand that the Department was and is dealing with many pressing issues, but transparency is important, and accountability matters. Of course, we need to remember why there was such a rush to get PPE in the first place—it was because the Government had ignored the warnings and allowed stockpiles to run down. The pandemic has been used too often as an excuse for standards to slip, but it really should not need saying that transparency goes hand in hand with good government.

    Another area where we need greater transparency is the Government’s general response to the pandemic to date. With the highest number of deaths in Europe, those in power now need to answer why that has been the case, because such a grim death toll was not inevitable. If it is the right time to undergo an expensive and disruptive reorganisation of the NHS, it is also the right time to have the inquiry into covid that the Prime Minister promised more than six months ago. The families of the deceased deserve answers, and we all need to know that lessons have been learned and that the same mistakes will not be made again. If we look at what has happened so far, we can see that there has been a tragic failure to learn the right lessons. That is why what we have heard from the Prime Minister today matters, because we are not out of the woods yet. Infection rates, though they are reducing, remain high; there are more people in hospital now than there were at the start of the second lockdown; and there are still more than 1,000 people being admitted to hospital every single day. So, what we do next, when we do it and how we do it remains critical.

    The Opposition have been clear all along about the importance of following the science. We know where not following the science takes us: it leads to the worst death rate and the deepest recession in Europe. It leads to the farce of the Prime Minister refusing to cancel Christmas plans, only to U-turn three days later, and it leads to the shambles of children returning to school for one day, only to find it closed the next. We know that the virus thrives on delay and dither. As we approach a year of life under restrictions, any ambiguity over when, where, why and how the restrictions will be eased in the coming weeks and months is just as big a threat as the virus itself.

    Before I conclude, I just want to say a bit about test and trace. We did not hear anything new from the Prime Minister on that today, but it nevertheless remains a vital part of the pandemic response. We need to remind ourselves that the number of new cases is still above 10,000 each day, and that every day thousands more people are required to self-isolate. For this lockdown truly to be the last, we need to continue to cut transmission chains and the spread of the virus, so this continuing blind spot when it comes to supporting people to self-isolate is as baffling as it is wrong.

    When we first came out of lockdown, the scientific advice repeatedly stated that the easing of restrictions would work only if there was a fully functioning test and trace system in place. That was true last year and it is still true today. We still do not have all test results back within 24 hours, as the Prime Minister promised would happen last June, but perhaps most important are the continued low compliance rates with self-isolation. The Government have known for many months that the lack of financial support to those self-isolating has resulted in extremely low adherence rates. Surveys between March and August last year found that only 11% of people in the UK notified as having been in recent close contact with a confirmed case did not leave their home. That figure has improved a little recently, but it is still well below where it needs to be.

    Around a quarter of employers will only pay statutory sick pay for such an absence. The Secretary of State has previously said that he could not survive on statutory sick pay, so we should not be surprised when others cannot do so either. We also know that seven in 10 applicants are not receiving self-isolation payments from councils, with one in four councils rejecting 90% of applications. They are rejecting them not because there is no need but because the rules have been so tightly drawn that seven out of eight people do not qualify for a payment under Government rules. When Dido Harding herself says that people are not self-isolating because they find it very difficult, a huge question needs to be answered about why the Government have still not acted to rectify this.

    Last month, the Government announced more cash for councils for self-isolation payments, but that was to last until the end of March, and actually the amount handed out was the equivalent to one day’s-worth of people testing positive. That is clearly not enough, and what about after March? We need confirmation of how much support will continue to enable people to self-isolate after that date. Following reports in The Independent late last week that some people working for the NHS through private contractors, such as cleaners, porters and kitchen staff, were being denied full sick pay for covid-related absences because of the removal of supply relief, we need a commitment that this will be investigated urgently and that the direction of travel will be reversed so that everyone in the NHS is properly supported. The Government should be setting an example here, not leading a race to the bottom. On wider financial support, where is the road map for businesses that will still be operating under restrictions for many months to come? We know that the Budget is next week, but they need clarity and support now.

    In conclusion, what the Prime Minister announced today has to be the last time the word “lockdown” passes his lips. There must be no more false dawns and no more boom and bust. With this road map, relaxations should now be clear and notified to the affected parties in advance, but also approved by this place in advance. There should be no more muddle between guidance and laws; no more regulations published minutes before they become law; no more businesses having to throw away thousands of pounds-worth of stock because decisions are reversed at a moment’s notice; no more of the stop-go cycle; and no more hopeless optimism followed by a hasty retreat. This time really has to be the last time. The vaccine has given us hope. It has given us a route out of this. With a year’s experience of the virus and with multiple vaccines on the way, there can be no excuse for failure this time. The Prime Minister has said that he wants the road map to be a one-way ticket. I hope he is right. We all want him to be right, but if he gets it wrong, he should expect nothing less than a one-way ticket to the jobcentre.

     

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    Author: B Fisher on behalf of Keep Our NHS Public

    The SHA asks you to support this great project if you can. Please spread the Crowdfunder with friends, families and in your networks – we need to know why so many deaths – why so many families, the NHS and social care were let down so very badly.

    The target for funds will sustain our campaigning efforts.

    Please share the crowdfunder for the KONP People’s Covid Inquiry:

    https://www.crowdfunder.co.uk/peoples-covid-inquiry.

    People’s Covid Inquiry site for info and evidence:

    https://www.peoplescovidinquiry.com/

    https://www.crowdfunder.co.uk/peoples-covid-inquiry

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    HIV i-Base continue to report on COVID-19 vaccination and treatment. The Q&A service on the i-Base website has been answering many questions about coronavirus vaccinations.

    Please see this new question:

    Are animal products in the COVID vaccines? Are they Halal? https://i-base.info/qa/16668

    Answer:

    The vaccines are safe and recommended if you are Muslim.

    • There are no animal products in the Pfizer, Moderna or Oxford vaccines.
    • There are also no traces of pig products or egg products.
    • These vaccines are all Halal safe.

    The video in the i-Base link above is from Imam Yunus having the vaccine at Newham Hospital in East London.

    As chaplain of St Barts, Imam Yunus talks about how the vaccine is safe, effective and Halal.

    Please note this video is included as an information resource. It is not directly liked to HIV and i-Base was not involved in producing it.

    This is one of more than 45 questions about COVID vaccines. It was produced by and for people living with HIV.
    Q&A on COVID vaccines: are they safe and effective?
    https://i-base.info/qa/16330

    Copying and distribution of i-Base infomation is encouraged – and free – but please credit HIV i-Base as source.

    Comments Off on Are animal products in the COVID vaccines? Are they Halal?

    NHSE/I consultation on

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

    Response to the consultation by

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

    8 January 2021

    1. Overview

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

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

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

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

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

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

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

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

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

    In summary, the proposals:

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

    We discuss the details in the following two sections.

    1. ICSs during 2021/22 and before legislation

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

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

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

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

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

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

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

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

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

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

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

    • The single pot budget

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

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

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

    • Provider collaboratives

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

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

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

    • ICS membership

    There are two potential aspects in this regard.

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

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

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

    • Public accountability

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

    • Competition and contracting

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

    • Social care

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

    • Public health

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

    • Workforce planning

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

    • Moving staff and their terms and conditions

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

    1. ICSs after legislation

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

    The next steps document proposes two options for legislation.

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

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

    NHSE/I prefer Option 2.

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

    • Major reorganisation

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

    In September 2019, NHSE/I stated:

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

    • Competition and contracting

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

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

    • Fate of CCGs

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

    • ICS membership

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

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

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

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

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

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

    1. Conclusion

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

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

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

    END

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

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

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

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

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

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

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

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

     

    ICS Next steps Consultation Response 08Jan21

    2 Comments

    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.

    https://doctorsinunite.com/2020/05/29/schools-should-not-take-in-more-pupils-on-1st-june-unless-it-is-safe-to-do-so/

    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 https://doctorsinunite.com/2020/05/25/isolate-trace-and-support-is-the-only-safe-way-out-of-lockdown/ 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:

    http://www.instituteofhealthequity.org/resources-reports/build-back-fairer-the-covid-19-marmot-review

    And this on iSAGE making schools safe: https://www.independentsage.org/wp-content/uploads/2020/11/Safe-schools-v4b1.pdf

    Dr Jackie Applebee, Chair Doctors in Unite.

    Comments Off on This is a statement released by Doctors in Unite. SHA members supported the drafting.

    HIV i-Base continue to report on COVID-19 research and treatment as a supplement to HIV treatment research and information.

    Copying and distribution of i-Base infomation is encouraged – and free – but please credit HIV i-Base as source. You can see this Q&A here or read it below:

    Q&A on COVID vaccines: are they safe and effective?

    The following questions were for a community UK-CAB workshop on COVID vaccines. Answers by Angelina Namiba and Simon Collins.

    Are vaccines against COVID-19 effective?

    Yes, any approved vaccine has been very carefully studied in  a wide range of people.

    These first vaccines are highly effective. Both the Pfizer and Moderna vaccines prevent COVID symptoms in 95% of people. They also prevent severe COVID-19.

    These vaccines are much better than first thought possible. Early in 2020, a vaccine would have been approved if it was only 50% effective.

    Which vaccines are being used in the UK?

    The only vaccine that is currently approved in the UK is called BNT162b2.

    It is made by Pfizer/BioNTech. It was approved in the UK on 2 December and in the US on 12 December 2020. A second similar vaccine, developed by Moderna/NIH has just been approved in the US. It will also be approved in other countries too. The EU plans to approve these two vaccines within the next few weeks.

    However, other vaccines are being used in UK studies (see below). These include a vaccine from Oxford University and Astra-Zeneca called ChAdOx1. Another study using a Janssen vaccine is just starting. As new vaccines are approved we will add them to this page.

    Why should I get a vaccine?

    The main reason to get the vaccine is to protect yourself against COVID-19.

    COVID-19 can be deadly – it is much better to be protected. Even people who recover from COVID-19 often have symptoms that last for many months. This is called long COVID and is still being studied.

    If you have been offered the vaccine it is because of your personal level of risk. The vaccine may also protect your friends, family and contacts at work.

    Is my risk high enough to need the vaccine?

    Yes, there is only a limited supply of these vaccines. In the UK, for at least the next few months, you will only be offered the vaccine if your personal risk is high.

    This will be because of your age and your health or because you work in a high risk job.

    Do I have to get the vaccine?

    If the vaccine is for your own health, then this is always still your choice. You do not have to have the vaccine.

    Please talk to your doctor if you have any worries or concerns. Or if you’re unsure about having the vaccine.

    If you are offered the vaccine because of your job, not having the vaccine might affect the work you can do.

    Are vaccines against COVID-19 safe?

    Yes, based on the results from large studies, any approved vaccine will also be very safe.

    For example. the Pfizer vaccine was studied in more than 44,000 people without any serious side effects.

    There are only a few situations when this vaccine needs to been given more carefully. This includes people who have a history of serious allergy reactions to different foods or medicines – as with other vaccines. In this case the vaccine should only be given where there is medical support in case this reaction occurs.

    How do we know the vaccine is safe?

    Technically, no medicine or vaccine can be proved to be safe! This is because we can’t measure safety, we can only measure risk.

    So instead of saying something is safe, it is more accurate to describe the risk. With COVID vaccines we can say there is a very low risk of side effects.

    Compared to the very real risks from COVID-19, using the vaccine is much safer than not using it. This is known from research studies in tens of thousands of people. The studies recorded every side effect or any potential side effect.

    Additional safety data comes after the vaccines are used outside of studies. This will include from people who were not included in the main studies. This led to a caution in people with history of serious allergic reactions (see next Q).

    What if I have a history of allergy reactions?

    As in the question above, even people with a history of serious reactions can still use the vaccine. This includes people who have reactions to vaccines, medicines or foods.

    However, if you currently need to carry an anti-allergy syringe, you need to be vaccinated in a clinic in case a reaction occurs.

    Two health workers in the UK with a history of severe reactions did react to the vaccine. Both people have now recovered. More information will be collected on cases like this.

    Can I develop an allergic reaction to the vaccine?

    Yes, although the risk is small and relates to your history of allergies.

    For the Pfizer vaccine, anyone with a history of severe allergy reactions should have the vaccines in a setting that can safely manage reactions.

    What about if I have immune suppression from HIV or cancer treatment?

    Yes, the vaccine is still recommended if you are HIV positive or if you have cancer. This is because of the high risk from COVID-19.

    Although the leaflet that comes with the vaccine includes talking to your doctor first if you have a reduced immune system, this is not related to a safety of the vaccine. It is because the protection from the vaccine might not be as strong.

    This means that even after both doses of the vaccine, it will still be important to be careful, for example by wearing a mask and social distancing.

    As more people are vaccinated, researchers will look at responses in people who were not widely included in studies.

    What if I have other inflammatory or autoimmune conditions?

    As above, the vaccine is still recommended for people living with inflammatory or autoimmune conditions.

    In this, it is very similar to getting a flu vaccine. Anyone who can use the flu vaccine can use a vaccine against COVID-19.

    These include:

    • Inflammatory rheumatic diseases (rheumatoid arthritis, axial spondyloarthritis, lupus).
    • Inflammatory bowel disease (Crohn’s disease and ulcerative colitis).
    • Psoriasis.
    • Multiple sclerosis.
    • Organ transplant recipients.
    • People on chemotherapy.

    This is because of the high risks from COVID-19.

    Although many people with these and other complications were not directly studied in vaccine studies, there is no safety concern. As above, the caution is that the vaccine might not be quite as effective.

    Ongoing research though will be looking at this.

    Does the vaccine interact with other medicines?

    No. There are no medicines that can not be used with these vaccines. If you are taking other treatment, there is no need to stop this to have a vaccine.

    Although it is good to ask about interactions with current medicines, there are no interactions with the vaccines. If you are worried, it is easy to double-check this with your doctor.

    Your doctor will also know your medical history and whether one type of vaccine might be better for you than another.

    Could the vaccine interact with my HIV meds?

    There are no interactions between the COVID-19 vaccines and HIV meds.

    Will my HIV viral load blip when I have the vaccine?

    Technically though, there is not enough results from HIV positive people in the first vaccine studies to report this yet, though this will be reported later.

    However, based on other vaccines this is unlikely to happen.

    Any vaccine has the potential to increase viral load for a short time. This is the same as to any active infection (including flu and colds).  As with the answer to other questions here, it is okay to approach the COVID vaccination as if it was the annual flu vaccine – which is widely recommended for people living with HIV.

    If your viral load is generally undetectable any increase is likely to be very small. For example, with the flu vaccine, it might increase from less than 50 to maybe 80 or 100 copies/mL – and only for a few days or a week. This is too low to affect the risk of transmission.

    Other vaccines, for example for hepatitis B, don’t cause HIV viral load to blip.

    As a guide, unless you get symptoms from the vaccine, your HIV viral load is likely to stay undetectable. If you get symptoms, any small blip is likely to be undetectable again within a week.

    Can the vaccine interact with estrogen and/or testosterone treatment?

    There are no interactions between the COVID-19 vaccines and estrogen and testosterone.

    Are the vaccines safe in pregnancy?

    Great question. So far there is little data because pregnancy was an exclusion for the main studies. But if you are pregnant, the vaccine is still recommended.

    Also, women will still have become pregnant during these studies – and certainly afterwards. These data will all be collected during the study.

    When these data are available they will be widely publicised.

    Other studies are looking at vaccine responses during pregnancy.

    Are the vaccines safe in children?

    So far vaccines have only been studied in people who are aged 16 and over.

    Further research is planned to look at younger people.

    What is in the vaccine that they are going to offer me?

    None of the COVID vaccines in the UK contain any live viruses. There is no risk of catching coronavirus from the vaccine.

    The active parts of a vaccine though only use a protein from the outside of the coronavirus. Or they tell your boby how to make these proteins.

    This will not cause an infection though.

    Vaccines also include other ingredients that help the vaccine work. For example the Pfizer vaccine contains traces of sodium and potassium. This is sufficiently low to still be called sodium-free and potassium-free.

    It also contains sucrose and this, together with all other ingredients, is listed on the patient leaflet that you get before the injection. This is also online now if you want to check first (see fruther information in the final question).

    How is the vaccine given?

    The Pfizer vaccine is given as an injection into your upper arm. A second booster dose is given again, three weeks later. You reach the best protection seven days after the second dose.

    Do I still need to social distance after the vaccine?

    Yes, so far, it is still better to reduce the risk of catching coronavirus.

    A few people might not be protected by the vaccine. We also don’t know how long protection will last. You might also still become infected without symptoms. You could then pass this to other people.

    Even after the vaccine, please continue wearing a mask. Please continue recommendations for social distancing.

    Can I get COVID-19 from the vaccine?

    No. This is easy to answer.

    There is zero risk of getting COVID-19 from the vaccine.

    The vaccines do not contain coronavirus itself.

    What are the symptoms/side effects from the vaccine?

    Most side effects to the Pfizer vaccine were mild or moderate.

    Very common side effects were similar to getting the flu vaccine. They generally got better within a few days. These were reported by more than 1 in 10 people.

    • Pain at injection site.
    • Tiredness.
    • Headache.
    • Muscle pain.
    • Chills.
    • Joint pain.
    • Fever.

    Common side effects included injection site swelling, redness at injection site, and nausea. These were reported in less than 1 in 10 people.

    Uncommon side effects, in less than 1 in 100 people included enlarged lymph glands or just generally feeling unwell.

    Am I going to get sick with the COVID-19 vaccine like the flu jab?

    No necessarily, but maybe. So far the COVID vaccine is similar to getting a flu vaccine. And just like the flu vaccine, the response will vary for different people.

    The question above shows that symptoms are similar to the flu vaccine and are nearly always mild.

    Should I wait to see how people similar to me react first?

    This is a good question – and sounds very reasonable. But within a week or two another 500,000 people will have used the vaccine in the UK.

    Any serious concerns will be reported long before you are likely to be offered the vaccine.

    However, if you are okay leading a very isolated life, then waiting is a choice. But if you still want to interact with people, then waiting will be more risky than having the vaccine now.

    How long will protection last?

    This will only be known with more time. Protection should last for at least a year and hopefully a lot longer. Some vaccines, for example hepatitis B and tetanus only need a boost every ten years.

    Which vaccine is best?

    So far, all the leading vaccines look very good. Getting access to any vaccine now is more important than which vaccine you use.

    What if I already had COVID-19? Does it matter where this was severe or mild?

    People who already had COVID-19 are still recommended to use the vaccine. It doesn’t matter how severe or mild this was.

    Will my GP or HIV doctor give me the vaccine? Can I choose?

    Who gives you the vaccine will depend on which vaccine is being used.

    The Pfizer vaccine will generally be given at health centres or hospitals. This is because of limits in how it can be stored.

    If you are offered a different vaccine in the next month or two, this might be given by your GP. This is early stage for the vaccines but it is unlikely to be your HIV doctor. You are not likely to be able to choose.

    Why should I get the vaccine if the person giving me the vaccines hasn’t had it yet?

    The decision on who gets the vaccine first are decided by an expert advisory group.

    If this group recommends you get the vaccine, then this is because your individual risk makes this important.

    Will the vaccine stop me catching COVID-19? Or just from getting ill? Or maybe both?

    The vaccine will definitely reduce risk of getting ill, but the answer is “probably both”.

    The vaccines are approved because they reduce symptoms of COVID-19.

    The first studies didn’t measure whether people caught coronavirus, just whether they had symptoms of COVID-19.

    Most mild symptoms later confirmed as COVID-19 were in people who didn’t get the vaccine. Importantly, nearly all the most serious cases of COVID-19 were also in people who got the placebo (inactive) injections.

    Technically, some people might still catch coronavirus and be infectious but without symptoms. This is still an ongoing research question.

    Studies with the Moderna and Oxford vaccines include some results showing that the risk of catching coronavirus is also reduced.

    Is the vaccine safe if I have other health problems as well as HIV?

    Yes, vaccines are recommended in people living with HIV and other health problems.

    The more serious your other health problems, the more important it will be to be protected from COVID-19.

    Can I get the vaccine if I have or have had hepatitis C?

    Yes, vaccines are recommended in people living with hepatitis C or who previously had hepC.

    Is the vaccine safe if I use chems like crystal meth, GHB or mephedrone?

    Yes, the vaccines do not interact with drugs used for chemsex.

    However, taking a break from the chems for the week of the vaccine will make it easier to know whether you get any side effects.

    If the social context for using chems means you are having more partners, the protection from the vaccine will be especially important.

    Is the vaccine affected by ethnicity? Will it affect me differently because I’m black/brown?

    No, vaccines studies include people of different ethnicities. They are created for everyone.

    Ethnicity does not affect immune responses or risk of side effects.

    Are black and brown people more at risk of getting side effects?

    No, as with the question above, ethnicity has not been linked to any better or worse outcomes.

    Have vaccine trials included black and brown men and women living with HIV? Or do the findings just relate to the experiences of HIV positive white gay men?

    Unfortunately, most vaccine studies only included very small numbers of people living with HIV. So far, the ethnicity breakdown of the HIV positive group has not been presented. All the HIV positive participants might be black and brown women.

    For example, the Pfizer study with more than 44,000 people only included about 120 people living with HIV. The results did not show that HIV as any impact on how the vaccines work.

    However, there is a lot more data about ethnicity.

    About 10% of the people in the US sites were black or African American. There were no differences in how well the vaccine worked or in side effects compared to the rest of the study population.

    Who approved these vaccines? Were the interests of my community represented?

    Vaccine are approved by the same organisations that approve medicines. They were approved for all people.

    • This is the Medicines and Healthcare products Regulatory Agency (MHRA) in the UK.
    • In Europe it is  the European Medicine Agency (EMA)
    • In the US it is the Food and Drug Administration (FDA).
    • Other countries and regions have similar organisations.

    Each of these groups is made up of expert advisors who are mainly scientists and doctors but that sometime include community voices.

    The panels are responsible for representing interests of all people who are going to be using these products.

    The FDA is especially open as it publishes the detailed study results online for everyone to read. It also webcasts the meeting that decide on where a vaccine or medicine is approved.

    How do I know I’m being treated equally? How do I know this isn’t experimentation in black people?

    These concerns are very real. Nearly all countries still have structures that are not equal. Many have a history where people were treated differently.

    In the UK, this still affects access to important services that include education and medical care. This is even when there are policies to make access fair.

    However, ethnicity has been linked to higher risk of COVID-19 in black, Asian and minority ethnic (BAME) communities. This actually makes access to the vaccines even more important.

    As all the studies included people from all ethnicities. There is good data to show they are at least as safe and effective.

    COVID vaccines will be offered to people of all ethnicities. As has been seen in the news all ethnicities have the choice to use the vaccine.

    If the government didn’t protect me from coronavirus, why should I trust them with the vaccine?

    Perhaps luckily, the government are not directly involved in either producing the vaccines or in running the studies that look at how well they work.

    The government is also not directly involved in deciding which vaccines are approved.

    Whether or not you use any medicine or vaccine is a decision that you make with your doctor as an individual.

    I’ve experienced racism in the health system and receiving HIV care. How can you tell me this won’t be the same?

    I am sorry for any previous experiences within the NHS. I am also sorry if you have not been treated fairly in the past.

    Although I can not guarantee this will not happen again, there is a lot of information about how to deal with this.

    I can however provide information on COVID-19 and the vaccines. This shows that the benefits of the vaccine so far are much greater than the risks from not getting the vaccine.

    Why did we get a COVID-19 vaccine so quickly, but there is still no vaccine for HIV?

    There are two answers here.

    The practical answer is that the threat from COVID-19 were so serious that many more resources became available. The urgency of COVID-19 led to a larger budget – and luckily, this has been more effective than anyone first hoped.

    A more technical scientific answer is coronavirus is relatively stable. Unlike HIV the structure of the proteins doesn’t change and so a vaccine based on these proteins with continue to work.

    HIV is still a more difficult virus to overcome because it makes small changes every day. So HIV vaccines that might work very well on Monday will be out-of-date on Friday because of these small changes.

    HIV does have at least 30 approved treatments. These enable to lead long and health lives.

    There are many other infections where we also need new vaccines. Hopefully the advances for COVID-19 will help for other vaccines.

    If vaccines are now available, should I still join a study?

    This is an important question because other vaccines are still being studied.

    In the UK this includes a vaccine from Oxford University and Astra-Zeneca called ChAdOx1.

    Another study is due to start using a vaccine from Janssen.

    Joining one of these studies might let you get a vaccine before you are offered on from the NHS.

    If you do get offered an NHS vaccine after joining a study, you can still use the approved one. The study will tell you whether or not you got the active vaccine. The researchers can also study your response to the second vaccine.

    In practice, new studies will hopefully look at switching between different vaccines.

    If the vaccine is lifesaving, why is not available to everyone in the world?

    You are right, for a vaccine to be really effective, everyone will need to use it. This includes in all countries.

    Many organisations, including the World Health Organization (WHO), have been working all year to also make access fair.

    For example, the international COVAX programme is aiming to vaccinate two billion people during 2021. This includes more than 100 low and middle income countries including across Africa, Asia and South America.

    So optimistically, at some point, everyone will have access.

    In practice, high income countries that could afford the first commercial vaccines have bought most of the first stock.

    But some of the next stock during 2021 – and more importantly newer vaccines – will be available for the COVAX programme. This might not be until later in 2021 and 2022 though.

    Where can I get more information?

    The following links are to different sources for more information.

    i-Base run an information service if you have individual questions that you would like answered.
    https://i-base.info/qa

    i-Base report news about COVID-19 treatment and vaccines in a monthly bulletin.
    https://i-base.info/htb

    British HIV Association (for information about HIV and COVID-19).
    https://www.bhiva.org/Coronavirus-COVID-19

    UK patient information leaflet for the Pfizer/BioNTech vaccine
    (PDF)

    FDA 50-page document with detailed results on Pfizer vaccine.
    https://www.fda.gov/media/144245/download

    YouTube website to watch the US CDC hearings for COVID vaccines
    https://www.youtube.com/playlist?list=PLvrp9iOILTQYiZunwmtiIRt52poVP8D02

    Article on why vaccine is recommended for people with immune suppression and autoimmune conditions.
    https://www.medscape.com/viewarticle/942853

    Website for WHO COVAX programme for global access.
    https://www.who.int/initiatives/act-accelerator/covax

    The People’s Vaccine – a collaboration of large charities including Oxfam.
    https://www.oxfam.org/en/tags/peoples-vaccine

    Comments Off on Q&A on COVID vaccines: are they safe and effective?

    John Lister (editor Health Campaigns Together, co-editor The Lowdown)

    This is an opinion piece – it is not SHA policy

    Despite all the other issues that might be expected to be priorities, it seems NHS England remains focused on driving through its plans for yet another reorganisation, to establish a network of 42 “Integrated Care Systems” (ICSs) to control services at local level – and possibly even fewer than that, with the possibility some smaller ICSs might also merge

    A new 39-page NHSE consultation document “Integrating Care” at the end of November follows on from a volley of instructions to local health chiefs in a circular on July 31, which appeared to be about rebuilding services after the first peak of Covid infection, but took the opportunity to drive forward the process of merging Clinical Commissioning Groups (CCGs) and establishing ICSs in a final page of instructions.

    The new document piles on pressure for prompt government action, setting an ambition of securing new legislation that would allow the whole of England’s NHS to be run through ICSs by 2022.

    It makes the extraordinary claim that the establishment of ICSs – driven relentlessly from the top by NHS England, and resisted at local level by local government bodies, GPs and campaigners – is in fact “a bottom-up response.”

    It rehearses the stock arguments for creating ICSs, with lofty, inflated and largely baseless claims that the handful of early ICSs “have improved health, developed better and more seamless services and ensured public resources are used where they can have the greatest impact.” In fact all the improvements that have been made along these lines have been made under existing legislation, with ICSs, lacking power or authority, having been able to do little or nothing.

    There are also multiple references to “digital” and “data” as ways of driving system working and improving outcomes, despite the lack of evidence for these claims. New “digital” technology and number-crunching for “population health management” are among the more lucrative areas in which private companies from the US and elsewhere are seeking to gain a profitable foothold, not least through the Health Systems Support Framework established by NHS England.

    Many campaigners remain justifiably suspicious of the extent to which ICSs, which have been set up and function largely in secret, would be in any way accountable to local communities if given statutory powers.

    And while Integrating Care argues for the need to establish ICSs as “statutory bodies” with real powers, notably “the capacity to … direct resources to improve service provision,” there are real fears that NHS England, facing more years of tight and inadequate budgets, sees ICSs and system-wide policing of finances as a way of more ruthlessly enforcing cash-cutting reductions or restrictions on availability of services through “control totals” limiting spending across each ICS, and growing lists of excluded “procedures of limited clinical value”.

    The HSJ, normally happy to go with the flow of NHS England, has pointed out how vague are the proposals in the new document, and raised questions over funding:

    “While the paper makes it clear the current system doesn’t work, it gives little indication of what a better solution will look like and how that efficiency drive will be maintained.

    “For example, it said ICSs will be given a ”single pot” of money from which to manage spending priorities. But there is no framework for how this will be spent that assures fairness, value for money and quality outcomes.”

    Integrating Care suggests two alternative routes to establishing a legal status for ICSs; one by setting them up as new “joint committees” once the remaining unmerged CCGs had been merged to leave one per ICS, with the resulting loss of local accountability. The joint committees would enable NHS “commissioners, providers and local authorities” to take decisions collectively, although NHSE admits that this leaves “many questions” about accountability and clarity of leadership unresolved.

    In the second option an ICS would effectively take the place of a CCG, replacing its governing body (along with its GP membership model) with a new board consisting of representatives from the “system partners” – including representatives of NHS providers, primary care and local government alongside a Chair, a Chief Executive and a Chief Financial Officer. In other words the CCGs, having been merged into bodies far larger in scope than the original 207 CCGs, would be abolished, with their commissioning role taken over by the ICSs.

    This second model is the one favoured by NHS England. But it has raised concerns amongst GPs, some of whom fear that they and primary care as a whole would once more be marginalised by new structures that could be dominated by bigger providers, and especially by large-scale acute hospital trusts.

    GP Online has highlighted “alarm” among GPs over the development of ICSs, and a recent motion adopted by Doctors in Unite which warns:

    “ICSs have been introduced and developed undemocratically, without consultation and with a lack of transparency. Their aim is to impose ‘reduced per capita cost’ control totals to force unproven and unsolicited innovation, including elements of privatisation and paid for care, in each system’s struggle to meet local population need.”

    NHS Providers, representing trusts and foundation trusts, has also expressed some reservations, warning that:

    “It makes sense to collaborate and deliver different services at different levels of scale, but all of these partnerships will need appropriate resourcing and cannot necessarily continue operating from within the existing staff base. …

    “What we do know is that trust leaders – and partners from across the health and care system – are cautious about any top-down, inflexible reorganisation of the NHS, particularly in the middle of a pandemic.”

     

    Will ministers back NHSE plan?

    While NHS Providers expect an NHS Bill to be announced in the next Queen’s Speech and introduced in the late spring next year, this is up to ministers. In pushing hard and publicly now for legislation NHSE might be motivated by concern that the Johnson government (whose manifesto this time last year promised legislation to carry through NHS England’s Long Term Plan, which includes ICSs) may have since changed tack.

    Last month the Department of Health published outline plans for “Busting bureaucracy” which appeared to back the NHSE approach, and committed to “bring forward legislative reform to reduce bureaucracy and promote collaboration across the health and care system,” building on “previous NHS recommendations to remove the two current procurement regimes which apply to clinical healthcare services and replace them with a new procurement regime.”

    However revelations that Matt Hancock had been held back during the summer from plans to speed through the promised changes, and that  a secret Downing Street “task force” on health policy has been meeting over the summer and autumn – without inviting NHSE chief executive Sir Simon Stevens – suggest the PM may have been steered away by his advisors from what appeared to be a common agenda.

    The only legislation on the NHS since last December’s election gave Johnson a Commons majority of 80 was to lock in the government’s inadequate promise of an extra £20 billion in real terms (£33.9bn in cash terms) by 2024 – effectively limiting government health spending.

    And while the Covid pandemic has clearly preoccupied ministers and MPs since the early spring, the lack of any firm timetable or commitment for government action does raise the possibility that they have pulled back from the new legislation which NHSE argues is necessary to roll back key sections of the 2012 Health and Social Care Act – and pave the way for ICSs.

    However we should not confuse NHSE’s moves to limit the requirement to put services out to tender with rolling back privatisation. As we have seen with so many Covid contracts, awarding contracts without competitive tender does not by any means end privatisation – or the “market” in health care, separating purchasers (commissioners) from providers.

    The whole focus of NHS England’s proposals is on limiting contracting and competitive tendering …  to clear the way for even large-scale mergers of providers, which are free to involve the private sector as “partners” or as sub-contractors.

    The Lansley Act’s version of tendering has already to a large extent been supplanted by the proliferation of “Framework contracts” in which NHS England or its privatisation sub-division NHS Shared Business Services sets up a list of pre-approved providers including private companies, non-profits and some NHS-led organisations, which can be allocated contracts WITHOUT formal tendering or competition, or from which a small group can be selected for a ‘mini-competition’.

    Because no public process or advertisement is required, this type of contracting out/privatisation can take place with little or no public scrutiny.

    So far, regardless of the government’s obvious hesitancy, it appears that the consensus assumption within the NHS is that NHSE will get legislation along the lines it has requested.

    Even then there are many unknown factors. How far does Johnson’s clique of advisors really want to go with NHS reform? How fast?

    How much priority can they and will they give it as Brexit chaos breaks out from January?

    Do they really want now to marginalise Stevens and replace him with a more pliable Tory crony like Dido Harding – who would lack any credibility with NHS chiefs?

    What we do know is that whatever the organisational changes, without additional revenue and capital funding and a properly resourced workforce plan the NHS is headed for constant crisis.

    And for the Johnson government to assert greater central control over the NHS as it fails, or visibly attempt to privatise the most popular public service would be risking electoral disaster. We will have to wait to see which way they will go … and whether Johnson will – as rumoured – reshuffle his government, or even seek an early exit from Downing Street.

    Problems for campaigners

    There are also tough decisions for campaigners on how best to respond. The process of transition from CCGs towards ICSs is already well-advanced with the majority of CCGs already merged, and 29 of the target 42 ICSs now formally in place. This makes any nationally coordinated campaign extremely difficult.

    However the mergers have also served highlight the fact that defending the status quo against NHS England’s plans is also a non-starter, since merged CCGs are already showing themselves more than capable of implementing policies as bad as many fear from ICSs.

    In Nottingham, for example, the merged CCG covering the city and the whole county has embarked on a vicious combined attack on one of the best performing primary care practices in the area, putting the services up for tender while slashing the per capita funding by over 40% – with a subsidiary of the US-owned Centene corporation apparently lined up to snatch the contract.

    With CCGs as bad as this, and with as little accountability to local communities, ICSs could prove to be little worse.

    So while campaigners will continue to resist the forced mergers of more CCGs, the wider campaigning goal must not be limited to retention of the structures created by the 2012 Act.

    NHS England want to repeal only selective parts of the Act. But to create any chance of genuine local accountability it’s necessary to scrap the remaining elements of the Act and the competitive market and purchaser/provider split it entrenched, to roll back tendering and privatisation, and create unified local health boards.

    In other words the alternative would be genuine re-integration of health services split asunder since the days of Margaret Thatcher. However there’s no sign of any government appetite for such progressive reform, or of opposition pressure in this direction.

    So with the Johnson government still bolstered by a huge Commons majority it appears that for the time being genuine integration is an ambition that is largely limited to propaganda, while campaigning focuses on exposing the flaws in the current system and fighting every move that advances privatisation.

    (This article is adapted and updated  from an article in The Lowdown (December 6).

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    MASS TESTING PROGRAMMES FOR COVID 19 USING NOVEL TESTS

    SITUATION

    Last week [November 9th] the government proudly announced a major expansion of the UK s testing programme to provide rapid access testing of asymptomatic people for COVID 19 [1].

    They claimed this programme was : –

    • a“ vital tool to help control this virus and get life back to normal “
    • a partnership between national Test and Trace and local public health directors ‘
    • to develop the evidence base on how testing with rapid reliable COVID-19 tests can be delivered at scale

    Liverpool has nearly completed a two -week “pilot” programme to offer rapid testing to the half a million people who live in the city.

    The stated aim of this pilot is to: –

    “identify many more cases of COVID and break chains of disease transmission” and

    “ to protect those at highest risk from the virus and enable residents to get back to their day to day lives

    Meanwhile the Government has also announced following a report by Public Health England / Porton Down [2] that they are extending this pilot and releasing 600000 lateral flow test kits for local authorities to use on asymptomatic people “ at their discretion “.

    So far, 87 Local Authorities have opted to take part in this new pilot programme. Each will receive weekly batches of 10000 test kits

    ASSESSMENT

    The roll out of mass testing on people without symptoms is happening at an alarming pace

    SAGE s advice [14] on 10 September 2020 was that: –

    “Prioritising rapid testing of symptomatic people is likely to have a greater impact on identifying positive cases and reducing transmission than frequent testing of asymptomatic people in an outbreak area”.

    Some highly respected scientists and public health doctors have criticized the conclusions drawn from the evaluation of these novel tests – namely that they are sensitive and specific enough to use on asymptomatic people.

    Others have described these mass testing programmes [originally part of Operation Moonshot] to be “scientifically unsound unethical, unevaluated and a costly mess “ [3,4]

    What are these concerns?

    [Refs 3,4,5,6 7,8]

    1 Accuracy of the tests

    1. The relationship between these novel tests being positive and clinical infectiousness is unknown. [8]

    Sensitivity

    2 The lateral flow tests chosen for mass testing are not sensitive enough to accurately detect infection when used on asymptomatic people.

    Between 1 in 4 and 1 in 2 infectious cases will be missed, when used in the field. Many people will be given false reassurance that they are not infectious and need to have repeat “gold standard” PCR tests to confirm the results.

    Specificity

    3 When infection rates are low or prevalence is falling as it is in Liverpool , a large number of people will falsely test positive and be told to self isolate. Many will experience the harmful and regressive effects of self-isolation.[ 7 ]

    2 Design and evaluation

    The National Screening Committee and National Institute for Health Research (NIHR) have not been involved or asked about the design of this programme.

    Their design lacks transparency and a clear set of objectives.

    No criteria or protocols for evaluation have ever been made available in the public domain.

    Unlike other screening programmes, there is no systematic call or recall of an identified, registered population and no expectations about population reach or uptake.

    [Initial findings from the Liverpool pilot would appear to indicate that those most at risk of being infected have been the least likely to come forward for testing.

    Positivity rates amongst the 110, 000 people tested so far are low [about half that of the current prevalence [ 2.2%] in the north west region [11]

    3 Follow up of positive cases and their contacts

    More cases will generate many more contacts to follow up

    In Liverpool, follow up of positive cases and their contacts has been entrusted to the national Test and Trace system. Over the last 4 months, this national system has only been reaching around 58% of contacts  [10] i.e. well below that required to stop onward transmission.

    4 Ethical issues

    The ethical basis for expanding mass testing using novel tests is very shaky.

    These pilot programmes have not undergone the normal process required for ethical approval.

    People are invited to have a test which has not yet been properly peer reviewed. The results of these tests if positive could have serious consequences for their personal freedoms, income and well-being. [7]

    There are also concerns about the process and practices for gaining consent to participate.

    4 Sustainability

    The government has, yet again, chosen to use a separate and privately run infrastructure to deliver this mass testing pilot programme.

    If rolled out nationally, the Liverpool population mass testing programme would need the equivalent of 260, 000 army personnel to deliver it. It is hugely expensive and not sustainable.

    Other options, such as using existing well distributed highly accessible primary care services [including local pharmacies] to provide rapid access testing should have been explored.

    5 Overload of local authorities and public health teams

    The burden of organizing new testing programmes for asymptomatic people will place another strain on already overburdened local public health teams.

    Their priorities should be to: –

    • Identify and manage clusters of cases /outbreaks in high risk settings such as schools, care homes, prisons and other geographical hot spot areas [12]

    • Improve adherence to isolation through organizing support and accommodation for people who are finding it difficult to self isolate. [13]

    6 Implementation

    Implementation has so far been rushed –leading to long queues of both symptomatic and non-symptomatic people, wrong invitation letters issued by schools and questionable practice in relation to “ informed consent”.

    The lack of rigour and consistency with respect to research design and implementation across different local authorities means that it will be very difficult understand the impact of these new mass-testing programmes on COVID transmission.

    Conclusion

     The widespread introduction of these mass screening pilot programmes using novel tests can have serious consequences for people’s lives.

    Politicians need to understand that concerns expressed about the choice of tests and the design of these programmes are not just a matter for academic debate or professional discussion.

    Accepted standards for design, ethics and evaluation must be adopted – otherwise they could seriously undermine public trust, confidence and future willingness to engage in helping to control this pandemic.

    RECOMMENDATIONS

    1. The continued roll out of these mass screening pilot programmes should be paused immediately.
    2. 2 The UK National Screening Committee should have oversight of their design and implementation
    3. Mass screening ‘pilot “programmes should be funded as research – and undertaken through the NIHR in order to ensure public and patient benefit
    4. Primary care service [including local pharmacies] should be the preferred route for the future distribution of rapid access tests if these are recommended for use by the general population

    References

    1 https://www.gov.uk/government/news/more-rapid-covid-19-tests-to-be-rolled-out-across-england

    2 https://www.ox.ac.uk/sites/files/oxford/media_wysiwyg/UK%20evaluation_PHE%20Porton%20Down%20%20University%20of%20Oxford_final.pdf

    https://www.bmj.com/content/370/bmj.m3699

    Operation Moonshot proposals are scientifically unsound]

    Jonathan J Deeks, Anthony J Brookes, Allyson M Pollock

    BMJ 2020; 370: m3699  (Published 22 Sep 2020)

     

    4 https://www.bmj.com/content/371/bmj.m4436

    https://www.sochealth.co.uk/2020/11/05/asymptomatic-covid-19-screening-in-liverpool/

    6 https://blogs.bmj.com/bmj/2020/11/09/screening-the-healthy-population-for-covid-19-is-of-unknown-value-but-is-being-introduced-nationwide/

    7 Waugh P. NHS test and trace chief admits workers fear “financial” hit if they self-isolate. Huffington Post 2020 Nov 7.

    8

    https://journals.sagepub.com/doi/full/10.1177/0141076820967906

     

    9 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/926953/S0743_SPI-M-O_Statement_on_population_case_detection.pdf

     

    10 https://www.gov.uk/government/publications/nhs-test-and-trace-england-and-coronavirus-testing-uk-statistics-1-october-to-7-october-2020

     

    11 https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/coronaviruscovid19infectionsurveypilot/6november2020#regional-analysis-of-the-number-of-people-in-england-who-had-covid-19

     

    12 https://www.cdc.gov/coronavirus/2019-ncov/global-covid-19/operational-considerations-contact-tracing.html

     

    13 Covid-19: breaking the chain of household transmission. BMJ2020;370:m3181.doi:10.1136/bmj.m3181 pmid:32816710

    14 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/926953/S0743_SPI-M-O_Statement_on_population_case_detection.pdf

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    Attached is the advice / guidance just published by Public Health Wales’ TAC advisory group.

    It reports that infection and transmission rates are higher than previously thought, though the mechanism for this is not well understood.

    Preventive measures such as social distancing, hygiene, face masks for older pupils ( and encouraged in younger pupils) and ventilation must be instituted. Health education should promote good practice outside the classroom and school. The potential of asymptomatic testing should be considered.

    It argues that teaching is a low risk occupation and that school closures are a relatively weak anti-spread measure.

    In view of the negative impacts of school closures, it should be a very last resort.

    https://gov.wales/sites/default/files/publications/2020-11/technical-advisory-group-evidence-review-on-children-and-young-people-under-18-in-preschool-school-or-college-following-the-firebreak.pdf

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    Recently the Chancellor Rishi Sunak won widespread plaudits for altering the terms of his financial support for workers whose jobs are under threat because of the restrictions introduced in response to the pandemic.  The furlough scheme is back, leaving the workers affected with just 80% of their wages, rather than 67%.

    This was simply a tactical retreat.  The government has clearly signalled it is conducting a ferocious attack on living standards but has had to recalibrate what it can impose right now.

    It should be clear that the scale of this attack on the living standards of the working class and poor, is much more ruthless than the austerity of 2010 or in some respects even than Thatcher in the 1980s.  As a result, it should be equally clear that success for the government would be a decisive shift in favour of big business and the rich, at the expense of workers and the poor.

    Since class warfare is being waged, anyone who preaches social peace now is simply making it harder for the working class and its allies to defend themselves against a major defeat.

    Ratcheting down, not levelling up

    The claims that the Boris Johnson government is engaged in ‘levelling up’ poorer areas of the country belong with the falsehoods that he is ‘implementing Corbyn’s policies’, is ‘spending like a socialist’, has ‘abandoned austerity’.  They are all pure hokum. They are proposed by those wishing to blunt any opposition to the government, and repeated by those who clearly do not understand what is going on around them.

    All these claims fall apart as soon as the government meets any resistance, as the excellent campaign for free school meals by Marcus Rashford and others shows.  Donating £12 billion to SERCO, Deloitte’s and other private sector companies, most of whom are intimately connected to the Tory Party, while they for long refused £120 million for free school meals is not levelling up, implementing Corbyn’s policies or socialist spending or any other of the spurious claims.

    Austerity is properly understood as a transfer of incomes and wealth from poor to rich, from labour to capital. So, in the very first austerity Budget by Osborne and Cameron there were £12 billion in cuts to social security while business taxes were cut by almost exactly the same amount.  Clearly, even in simple accounting terms (leaving aside any economic effects) this had nothing to do with reducing the deficit, as was claimed.  But it did transfer government spending from the poor to the rich. Austerity has continued in the same vein, with varying intensity ever since. Previously, Thatcherism used the cloak of monetarism in order to effect exactly the same type of transfer, largely through an assault on the unions and tax breaks for the rich.

    In the same fashion, the overwhelming bulk of every package announced in the current crisis is to benefit big business.  So, of the initial £330 billion emergency package that was finally announced after the March Budget, £300 billion was in the form of loan guarantees to the banks to avoid losses on their business lending.   In contrast, just £1.6 billion is for local authorities who are under enormous pressure both from reduced revenues and much higher outlays to meet the mounting effects of the crisis caused by the pandemic.

    The attack on the working class

    The centrepiece of the class warfare being waged by big business and their government is on wages, hours and employment.  Here, the ratchet down effect is the most wide-ranging in its effects.

    This is easy to demonstrate.  Before the crisis began, however low wages were for workers across many sectors, they did at least receive 100% of those wages.  Under furlough conditions, where work was supposed to be suspended, this has been reduced to 80%.  At the same time, and completely against the rules, many companies committed fraud by forcing staff into work for no additional pay. Up to a third of all employees were asked or forced to come in, according to one estimate.

    In addition, a large number of firms are in the process of making that reduction permanent.  Three high profile employers, British Gas, British Airways and the BBC have all launched fire and rehire schemes to reduce wages and conditions.  Many others are following suit but are less well known.  As the end of the previous furlough scheme approached, the government tried to enforce a reduction to 67% of wages for some topped up by 5% from employers, and no support at all for those caught in the spurious ‘Tier 2’ restrictions.  The fear over the probable immediate collapse in jobs forced a tactical retreat.

    Now that furlough is back, there has been a return to 80%, at least for the time being. But even if this is the full extent of the reduction, it still represents an enormous and dramatic shift from labour to capital.  Nothing on this scale was achieved under austerity.

    The intention of the ruling class and the Tory government is as far as possible to make this reduction permanent.

    Mainstream economists have long studied the issue of the determinants of wages for obvious reasons.  There is a whole literature devoted to what they describe as the problem of rigidities that lead to ‘sticky’ wages, that is the difficulty in driving down nominal wages (here is just one example pdf, there are innumerable others).

    This ‘stickiness’ of wage growth is shown in Chart 1 below.  The annual growth in wages in nominal terms is shown in orange, the growth in wage in real terms (after adjusting for inflation) is shown in blue.  Nominal wage growth hardly fell at all in the last recession.  The brief dip in wages occurred in the first few months of 2009 and began to recover very slowly in later months.  It was only the simultaneous fall in the value of the pound, which drove up prices in an economic slump, which caused real wages to fall over a more prolonged period, from mid-2008 to the end of 2009.  But even wages in these terms began to recover in early 2010.

    Real wages for public and private sector workers fell after the June 2010 ‘emergency Budget’ all the way through to October 2014.  This was a result of government policy.  Only as the Coalition government geared up for an election the following year by loosening government spending did real wages start to crawl higher.  The austerity policy was highly successful in cutting real wages, as it was designed to do.

    Chart 1.  UK Nominal and Real Wage Growth, % change

    If everything else is unaltered, the combination of economic weakness, rising import prices and rising real wages from 2010 onwards was bound to damage profits severely. The centrepiece of the austerity policy was to combat this profits-damaging combination of factors.

    The chosen method was a public sector pay freeze.  Not only did this have the direct impact of cutting real wages (as well as cuts to pensions) for approximately 1 in 6 UK workers (over 5 million of them) in the public sector where union densities are highest, but it also had a ‘demonstration effect’ (pdf), of setting a nominal wage freeze or similar in the private sector as well. With prices still rising because of the effects of the weakness of the currency, real wages for workers started to fall once more.

    However, as appealing as it may be to employers to cut wages if they can, this does not by itself resolve the issue of profitability especially if the overall business conditions are characterised by sluggish growth and rising import prices. The austerity policy of driving down wages was only successful in raising the level of misery. It was not successful in its overall aim of raising profits.

    Worse, from the perspective of the architects and supporters of austerity, nominal wage growth continued to rise at a very modest pace after 2014 and continued to rise until the current pandemic began.  Real wage growth was more erratic, undercut by rising inflation once more in 2017.  But even so, no blow had been struck which cut wages sufficiently to raise profits on an enduring basis.

    This trend in profits is shown in chart 2 below.  Initially, profits fell as they tend to during a recession.  Sales were falling and as noted above wages remain ‘sticky’.  (The ONS data shown is actually a measure of the rate of return on capital, not strictly profits, but it is a useful guide to profitability).  Subsequently profitability did recover but only moderately.

    Yet profitability continues to remain below 2008 levels. And, as regular readers of SEB will know, profitability never rose sufficiently to spark an upturn in private sector investment. From the perspective of the capitalist class as a whole, there is no incentive to raise investment, which means adding to the productive capacity of the economy, if the rate of return on existing investments is depressed below usual levels.

    Chart 2.

    The reserve army of labour

    In the last recession and under the austerity policy real wages fell initially by 6% and only recovered over a very prolonged period. Under Thatcher, real earnings for those in work did not fall at all.  Instead, her policy addressed the problem of low profitability by massive deindustrialisation that created 3 million unemployed.

    The current policy is a combination of these two.  Through government policy wages are being slashed by 20% for very large parts of the workforce, even including those on the National Minimum Wage.  At the same time there is a sharp rise in the level of unemployment, and some businesses will fold.  The combination of these two factors, the sharp reduction of wages and the surge in unemployment is government policy.  It is a new development and its architects will be hoping that one reinforces the other, that much higher unemployment will be a decisive factor in keeping wages low long after the public health crisis is over.

    This mechanism was first analysed by Marx as the creation of the ‘industrial reserve army’ of labour. Marx says the reserve army of the unemployed exists in no previous form of society except in capitalism, and is integral to it.

    “The industrial reserve army, during the periods of stagnation and average prosperity, weighs down the active labour-army; during the periods of over-production and paroxysm, it holds its pretensions in check. Relative surplus population is therefore the pivot upon which the law of demand and supply of labour works. It confines the field of action of this law within the limits absolutely convenient to the activity of exploitation and to the domination of capital.” – Karl Marx, Capital, Volume One, Chapter 25

    In general, high or sharply rising unemployment holds the risk that it may produce social unrest and political discontent.  The government of an advanced industrialised country may choose to engineer a sharp rise in unemployment in an attempt to restore profitability, or it may choose to try to cut wages.  But both stratagems entail high risk.  Combining the two is exceptionally high risk.  Only in a period of desperation and generalised crisis would they be attempted or could they be potentially successful.

    Under the cloak of the public health crisis which their own policies have helped to create, the current government is attempting such a strategy. Naturally it is in the interests of all workers, all the oppressed and vast majority of society that they are not successful.

    By Tom O’Leary

    Article first appeared on Socialist Economic Bulletin on Nov 09, 2020

    https://us3.campaign-archive.com/?e=4aa60afb48&u=c5349f9d4e4d450b6d8558d09&id=2cc2d12870

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    Issue: 111 – 10 November 2020

    Pfizer Covid-19 Vaccine

    This could be the only good Covid-19 news we have had in a very long time. Regulators have still not approved the vaccine though, but allegedly this will happen soon. According to DHSC guidelines issued in September 2020, the top priority list for those being given the vaccine is older adults resident in care homes and care home workers, 80 years of age and over and health and social care workers, 75+, 70+. 65+, and high risk adults under 65.

    The Government has an agreement with Pfizer to buy 30 million doses, with 10 million due by the end of December 2020.

    Very Steep Rise in Secondary School Covid-19 Infection Rates

    The National Education Union (NEU) has analysed Covid-19 infection data published by the Office for National Statistics. The NEU states that Infection rates in Secondary schools in England are an astonishing 50 times higher since September 2020. In Primary schools the rise is nine times. The NEU maintains these figures clearly show that schools are engines for virus transmission.

    The NEU recommends schools staying open only for children of key workers and for vulnerable children during Covid-19 lockdown. The NEU membership is 450,000 teachers, lecturers, educational support staff and leaders. More at:

    https://neu.org.uk

    As a postscript to this, when I researched infection rates across many Ealing neighbourhoods on 9 November 2020 the three highest rates were in neighbourhoods containing secondary schools – Northolt South (349 cases/100,000), Southall Green (310.1) and Cuckoo Park, Hanwell (280.9).

    Hospitals are Breeding Grounds for Covid-19 Infections

    On 9 November 2020, ‘ITV’ reported that of the 12,903 new Covid-19 cases between 18 September and 18 October 2020. 1,772 were acquired in hospital. Of the 700 new hospital cases in south east England, 23% were contracted in hospital.

    It seems for all kinds of reasons hospital staff and patients are not being tested on a regular basis. By 20 November 2020, allegedly, all patient-facing NHS staff will be asked to test themselves at home twice a week with results available before coming to work.

    Covid-19 Lockdowns Impacting the Mental and Emotional Health of Young People

    The NSPCC AND Childline are both reporting increasing telephone and counselling sessions. Young people are increasingly presenting with feelings of isolation, anxiety, insecurity and eating and body image disorders. More at:

    www.nspcc.org.uk

    www.childline.org.uk

    Is Covid-19 Population Testing (Mass-Screening of Asymptomatic People) in Liverpool Simply the Wrong Thing to Do?

    80 test centres and 2,000 troops involved. This sounds expensive. But will it ‘work’? Professor Allyson Pollock, a recognised Public Health expert, has her doubts. On 3 November 2020, as part of the Government’s £100 billion ‘Operation Moonshot’, population-wide Covid-19 testing of asymptomatic people in Liverpool was announced. Eight test centres opened on 6 November 2020.

    Professor Pollock has pointed out that this initiative is at odds with the SAGE advice of 10 September 2020 and with the current World Health Organisation (WHO) guidance. SAGE and WHO favour prioritising the rapid testing of symptomatic people, contact tracing and identification of infection clusters. Her concerns about the Liverpool pilot include:

    • a diversion of public money and resources. The OptiGene tests have cost £323 million.

    • the use of inadequately evaluated Covid-19 tests (direct LAMP test (OptiGene) and a lateral flow assay (Innova)

    • WHO evaluations of similar tests suggest between 1% and 5% of people without infection may get false positive readings. (With 392,000 adults in Liverpool these false positives could number anything between 3,920 to 19,600 adults)

    • there is no evidence demonstrating that Covid-19 mass screening can achieve benefit cost-efficiency

    • smaller pilot studies should have been carried out first before launching a massive pilot study of 498,000 people. (Allegedly a pilot was carried out in Manchester and it was found that half of the infections were missed).

    More at:

    https://allysonpollock.com

    The ‘Sunday Times‘ of 8 November 2020 leaked that three towns would be added to the mass-testing project. One is thought to be in The Midlands and one in the south of England. This would add another 100,000 people to be regularly tested.

    Reduced Support for the Homeless in Lockdown 2

    During Lockdown 1 many homeless people were put up in hotels, hostels and other forms of accommodation. This Government funded ‘Everyone In’ strategy was deemed to be successful in saving lives and reducing Covid-19 infections rates during Lockdown 1.

    Now it appears that money is running out to support the homeless and getting them off the street during Lockdown 2. Almost half of the night sleepers in London are foreign nationals and under the October 2020 post-Brexit legislation they could face deportation if found sleeping in the street.

    One week into Lockdown 2

    On day one of Covid-19 National Lockdown 2 (5 November 2020), I researched the following Ealing Covid-19 infection rates per 100,000 people. A week later I did this again:

    Southall Park: 265.3 became 244.1

    Ealing Broadway: 247.6 became 281.4

    Acton Central: 147.8 became 113.7

    West Ealing: 132.9 became 122.9

    A very small sample I know, but in three out of the four neighbourhoods the rate had fallen.

    Government’s Vaccine Taskforce Chair Spends £670,000 on Public Relations

    Kate Bingham, Chair of the Government’s Vaccine Taskforce, has allegedly hired eight Admiral Associates public relations consultants at £167,000/year each. Ms Bingham, a qualified biochemist and venture capitalist, was hired by the Government in May 2020. She is married to Jesse Norman MP. Bizarrely she reports directly to Prime Minister Johnson.

    Town/Hospital Based NHS Activist Groups Slowly Being Marginalised

    Three main factors at work here. Firstly the demolition of local CCGs. In 2018/19 there were 195 of them. By 1 April 2021 they will all have been closed down and ‘replaced’ be some 42 regional CCGs. Secondly, the Covid-19 response National Lockdown 2 has shifted commissioning from local, through regional, to a national undertaking. Thirdly, Covid-19 has allowed NHS bodies and Local Authorities to remove citizens from any effective, real time involvement in statutory body public meetings. In Ealing, for example, virtual, public Council care meetings employ MS-Teams software in a restricted, unhelpful fashion.

    NHS NWL EPIC

    On 17 December 2019 In NHS North West London (NWL) a public engagement initiative called ‘EPIC’ was launched at a workshop. 80 people attended of whom 34 were ‘patients’. EPIC is being used ‘to gather public opinion about local and NHS activities, involving ‘local residents in shaping and co-producing our services’. NHS NWL EPIC has built a ‘Citizen’s Panel’ of 4,000 north west London residents. The make up of the panel is allegedly representative of the 2.5 million residents in the region. I applied to join this panel but my application was ignored. Another EPIC Citizen’s panel meeting – this time a virtual one – was held 27 October 2020. In this meeting the idea of a ’Patient Forum in each borough’ was floated. The local Healthwatch, the local Council and the local voluntary sector would be invited. No timescale was set and it’s obvious that the forums would have no statutory significance whatsoever.

    Public Involvement Charter (PIC)

    EPIC is also developing its own ‘Public Involvement Charter’ (PIC). The PIC has admirable intentions and ‘core values’ – ‘the right to be involved, influence, improving outcomes, inclusion, engagement as residents want, information and transparency’. And all this as ‘we move more towards the (non-statutory) Integrated Core System (ICS)’.

    With all the generosity I can muster, I find the non-statutory EPIC, Citizen’s Panel and the Public Involvement Charter to be underwhelming, likely to be expensive and probably a complete waste of NHS and citizen’s time.

    Eric Leach

    Comments Off on Our NHS in Crisis

    The Socialist Health Association is appalled by reports that Kate Bingham, who heads up Boris Johnson’s vaccine taskforce, has charged the government £670,000, for what is described as a ’team of boutique relations consultants.’ Each consultant is reportedly paid £167,000 a year – more than the Prime Minister. There appears to have been no formal process to appoint Bingham to chair Britain’s vaccine taskforce.

    This would appear to be a gross waste of public funds, which are desperately needed to fight the Covid pandemic.

    The Sunday Times reported that Bingham had shared government documents to investors at a $200-a-head virtual conference – an appearance that was not signed off by ministers. At the same time, she manages private investments in companies developing coronavirus drugs.

    We note that Ms Bingham, a venture capitalist, is married to Jesse Norman, a Tory Treasury minister, which only underlines the potential conflicts of interest.

    The SHA calls for the pandemic to be fought through the NHS and other public bodies, and not to be outsourced to private interests.

    https://www.thelondoneconomic.com/politics/kate-bingham-vaccine-tsar-runs-up-670000-taxpayer-funded-pr-bill/08/11/

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