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

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

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

    BAME

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

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

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

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

    Test and Trace

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

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

    The app!

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

    PPE contracts

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

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

    And finally

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

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

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

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

    Hear hear.

    22.6.2020

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

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    This paper was developed by a group of primary care clinicians for the Labour Shadow Health Team at their request. We hope it helps illuminate the next steps for primary care.

    WHAT ARE THE RISKS, OPPORTUNITIES AND CHALLENGES FACING  PRIMARY CARE PROVISION DURING AND AFTER ITS RETURN  TO A NORMAL STATE OF OPERATION?

     

    “We will be facing some tough challenges over at least the next year: managing more consultations (and clinical risk) remotely by phone or video; catching up with resurgent patient demand, catching up with the care of long-term conditions (whilst trying to protect groups of vulnerable people from a continuing threat of Covid); managing a backlog of people who need to be referred; and coping with any spikes in Covid. This comes on top of the usual (preceding) strains on limited resources and lengthening ‘winter pressures.’ I don’t think that we will be seen as ‘NHS heroes’ in a few months!”

     

    DIGITAL WORKING IS TRANSFORMING CARE

    Opportunities

    • Easier and more flexible for people and practices, so may aid GP recruitment
    • The complex and subtle nature of the consultation seems to be maintained
    • Communication across sectors can be dramatically improved. One GP described helping a patient with lymphoma – in 10mins he was able to include a Ca nurse and consultant in a conversation with the patient.
    • Telephone triage also successful
    • Bricks and mortar general practice may become less necessary
    • Combining online personalised advice with online access to records opens the way to improved self-care

    Challenges:

    • Digital can widen inequalities and disenfranchise. Experience suggests it is the elderly rather than the poor who struggle the most.
    • The best balance between remote and face-to-face is unclear. Video may be best for follow-ups.
    • Video is seldom preferred by people. The telephone or face to face are most popular.

    Actions:

    • Support the elderly to become more digitally able while ensuring that traditional approaches remain available
    • Support digital cross-sector working: GP/hospital/Social Care
    • Encourage digital mentoring to improve self-care for people with LTCs

     

    SHIFTING TO PROACTIVE WORK WITH COMMUNITIES

    Opportunities

    • The spontaneous rise in mutual community organisations has been remarkable, often outwith the traditional voluntary sector, improving safeguarding and perhaps saving lives.
    • Primary care has been able to embrace that.
    • It offers a model for the future
    • There have been many examples of successful cooperation with communities, but they have been dependent on local circumstances and local heroes.
    • The health gain comes when communities can take more control over the area and their lives
    • The NHS and local government need to create the conditions whereby communities can work collaboratively with the statutory sector sharing decisions with their communities. We need a systematic approach for mobilising civil society, working with NHS and LAs.
    • PCNs offer a good base for such cross-sector working

    Challenges:

    • Sharing decisions with communities is a difficult skill the NHS would have to learn, perhaps from LAs and housing associations.
    • Building on existing work and with councillors would be essential. No new unnecessary initiatives.

    Actions:

    • Jointly fund, via NHS and LA, community development workers in each PCN, working with social prescribers. They would support the statutory sector sharing decisions with their communities.
    • Primary Care to be encouraged to support community groups and community development by, for instance, enabling practice space to be used by communities.
    • Asset mapping with LA and PH colleagues would be one early step
    • Encourage and incentivise cross-sector working.

     

    PRIMARY CARE TO ACTIVELY WORK ON THE SOCIAL DETERMINANTS OF HEALTH AND HEALTH INEQUALITIES

    These have been thrown into sharp relief through the pandemic.

    Opportunities

    • Essential to make any progress on health improvement
    • Community development can assist
    • Local work on poverty, race issues, migrant issues, housing
    • Cross-sector working is essential to do this.

    Challenges

    • The independent contractor status of general practice may hinder this process.
    • Cross-sector working is difficult
    • It is political work

    Actions

    • Promote training GPs with a Special Interest in Public Health, sitting astride the PCN and LA
    • Support areas to become Marmot towns.
    • PCNs to link formally with LAs
    • Boost the status and effectiveness of Well-Being Boards
    • Borough-level linking (not merging) of LAs and NHS.

     

    PRIMARY CARE AND LONG-TERM CONDITIONS INC COVID

    Opportunities

    • The importance of community service provision has been made plain by the pandemic
    • Extensive primary care services and rehab re likely to be required for people recovering from Covid

    Challenges

    • Managing more serious illnesses outside hospital may require differently trained primary care staff such as District Nurses

    Actions:

    • Use a range of approaches to contact those who have delayed seeking help for potentially life-threatening illnesses
    • Digital self-care with remote links to home monitoring such as BP, weight, Peak Flows
    • Secondary care doing remote consultations to reduce the backlog
    • Explore a range of differently skilled staff for primary care

     

    RELAXATION OF RULES HAS BEEN HELPFUL

    Opportunities  

    • There has been relaxation of some bureaucracy
    • Flexible approaches have enabled doctors to return to the workforce.
    • These changes have enabled GPs to devote more time to patient care.

    Challenges

    • Some of this bureaucracy is useful. We don’t want wholesale deregulation: that has often been dangerous
    • It is difficult to know which parts need to be kept and which don’t.

    Actions

    • Explore with the profession which regulatory aspects need to be kept and which don’t.

     

    FUNDING, TRAINING AND STAFFING

    Challenges

    • Primary care, GPs, HVs and DNs remain substantially understaffed. This must change.
    • Different training requirements may be needed for a different future.
    • The RCN is calling for wage increases for nurses

    Actions:

    • A system to support on-going review and remodelling of workforce capacity is needed to ensure that the primary care workforce is responsive to emerging need which may increase over time.
    • Clarification of plans for student health visitors and others who have had their training disrupted during the pandemic

     

    STAFF SAFETY IN THE TIME OF COVID

    • Continued need for PPE to protect staff and patients
    • Mental health support for staff

     

    PRIMARY CARE BUILDINGS

    Challenges:

    • Many primary care buildings were inadequate before Covid
    • Many more now need redesign to cope with new patient flows and requirements for cleaning etc

    Actions:

    • Funding must be found where premises need improving
    • Consider links with housing associations

     

    BOOSTING DEMOCRACY IN THE NHS

    Challenges

    • The NHS has used the Coronavirus Act to push through significant changes to the infrastructure of ICSs. This is baking in the risks posed by them: privatisation, fragmentation and cuts.
    • Hosp reconfigurations are happening rapidly without consultation and no equality assessment

    Actions

    • Call out these dangerous changes and use them to explore new approaches to democracy. For instance:
      • PCNs run with a Board with a broad representation of opinion
      • Link PCNs and local government through local forums with budgets – a form of participatory budgeting
      • Community development would assist participatory democracy

     

    ADVANCED CARE PLANNING

    Opportunities

    • Advanced care planning will need to sensitively change for the better.
    • General practice is well- placed to have discussions that allow patients to express their wishes, which will reduce unnecessary and possibly undignified hospital admissions.

    Challenges

    • There seemed to be sporadic inappropriate behaviour from CCGs and practices issuing blanket DNR notices to care homes
    • The pandemic seemed to cast a harsh light on relationships between some practices and care homes

    Actions:

    • Patients suitable for advanced care planning conversations could be identified— perhaps informed by frailty scores — and discussed in multidisciplinary meetings as part of routine care.
    • The public need to be involved, and the sector need to emphasise that these discussions are about providing quality of care.

     

    SOURCES:

    https://www.rcn.org.uk/news-and-events/blogs/covid-19-out-of-this-crisis-we-must-build-a-better-future-for-nursing

     

    https://ihv.org.uk/our-work/publications-reports/health-visiting-during-covid-19-an-ihv-report/

     

    A brave new world: the new normal for general practice after the COVID-19 pandemic.

    https://bjgpopen.org/content/early/2020/06/01/bjgpopen20X101103

     

    https://www.rcgp.org.uk/policy/fit-for-the-future.aspx

     

    CONTRIBUTORS

    Dr Onkar Sahota

    Dr Duncan Parker

    Dr Joe McManners

    Dr Robbie Foy

    Dr Brian Fisher

     

    CONFLICTS OF INTEREST

    Dr Fisher:

    I am Clinical Director of a software company called Evergreen Life www.evergreen-life.co.uk . We are accredited by the NHS to enable people to access for free online their GP records, to book appointments and order repeat prescriptions. We try to help people stay as fit and well as possible.

    Leave a comment

    This is now our 13th weekly Socialist Health Association Blog about the COVID-19 pandemic. Many of our observations and predictions have sadly come true. The leadership group of the UK Tory government remains extremely weak, without a clear strategy or plan of action. Policy announcements at the Downing Street briefings are aimed at achieving media headlines. The Prime Minister has declared that he is taking charge but on questioning in Parliament was unclear who had been in charge up to this point!

    In this Blog we look at the poor political and scientific leadership and lack of a credible strategy; the faltering start of Test Trace and Isolate (TTI); the demands for an urgent independent inquiry of the pandemic and financial audit of government investments in the private sector; and solidarity with Black Lives Matter.

    Lonely Ministers

    The last Downing Street briefing on Friday the 5th June found Matt Hancock (the Secretary of State in charge of the nation’s health) on his own, reading out the slides and reporting on the continuing high number of new cases and relentless roll call of COVID-19 related deaths. The PMs ‘sombrero’ epidemic curve’ has been suppressed but not flattened as it has in other countries in Europe. Deaths remain stubbornly high here as care home outbreaks continue to spread with 50% now affected and there is belated recognition that hospitals and care homes are places of work where transmission occurs. Transmission occurs between staff, patients/residents, within households and the local community.

    The UK Statistics Authority (UKSA) has challenged the way that statistics are presented at these briefings, and are arguably MISLEADING the public. Remember the international evidence presented on deaths, which was fine when we were on the nursery slopes of the epidemic but became embarrassing when we overtook Italy, France and Spain? World beating in terms of total deaths was probably not what the PM had in mind. Last week the total number of deaths in the UK exceeded that of all the EU(27) countries put together. We are now flying alongside Trump (USA), Bolsanaro (Brazil), Modi (India) and will shortly be joined I expect by Putin (Russia) as a group of the world’s worst performers.

    One of the areas of misrepresenting statistics that has exercised the UKSA has been reporting the number of daily tests. We have drawn attention in earlier blogs to how ridiculous it is to snatch a large round number out of the air and declare it as a target. And so it was with the 100,000 tests per day target and more recently the PMs 200,000 target. The challenge of meeting the Government targets meant that officials and private contractors started to count tests sent out in the post to households rather than completed tests. This was rephrased as test capacity. A similar change in data definition happened when we approached the end of May grasping for the 200,000 target. Suddenly antibody tests and the swabbing antigen tests were both included in the total figure. Ministers did not mention that that these tests have different applications and many thousands are used as part of epidemiological surveys rather than diagnostic tests on individuals as part of track and trace.

    What is the strategy?

    There are calls from politicians and in the media for there to be an urgent and time limited independent inquiry into what has gone wrong here. This is not to punish individuals but actually to help us learn lessons urgently and maybe make changes to the way we are conducting ourselves ahead of a possible second wave. One thing that is missing is a clear strategy that government sticks to and criteria that are adhered to in decision making. The Cummings affair has been a disgraceful example of double standards but the acceleration of changes in opening up the economy, increasing lockdown freedoms and reopening schools are examples where the scientific advice and the published 5 stage criteria are being disregarded. Wuhan eased their lockdown when RO was 0.2. (RO or R zero, where R is the reproductive value, the measure used to track how many people, on average, will be infected for every one person who has the disease.)

    Led by the science?

    The other noticeable change has been the change of mood amongst the scientists advising government through the SAGE committees. Many of them now seem willing to speak directly to the mainstream media and engage in social media interactions. The Independent SAGE group that we referred to last week has become the preferred source of scientific advice for many people. It has been interesting to see how many Local Authorities and their Directors of Public Health (DsPH)have not been urging schools to open up if not ready and the local RO is near or at 1.0. The Chief Scientific Adviser (CSA) has lost control and must be reflecting nostalgically back to when he was at GSK earning his £780,000 pa salary (Ref. Private Eye). But he has managed to shovel a shedload of resources to old colleagues and friends in the industry involved in the endeavour to develop a safe and effective vaccine ‘game changer’.

    The CSA was absent from duty last Friday and so too the CMO and his two deputies. One wonders whether this is a short lived change but maybe they too realise that that they are being set up with the SAGE advisers to take the blame for the UK’s dismal record. The CMO needs urgently to catch up with his public profile and face the media on his own and build some trust with the population, now anxious to be able to believe in someone at the centre of government decision making. Finally there is the NHSE Medical Director who could not be there – no doubt to be the one to remain standing when the SoS announced at 5pm on a Friday evening that all staff in the NHS should wear surgical face masks and all visitors to wear face coverings! An impossible  logistical and supply issue for an organisation which employs over a million workers in many different settings of care. And there was no consultation with the leaders of the NHS or Professional bodies such as the RCN and Medical Royal Colleges or Trade Unions like the BMA/Unite. What a shambolic way to run things – you couldn’t make it up!

    Test, Trace and Isolate (TTI)

    Test, Trace and Isolate (TTI) continues to have a difficult ‘rebirth’ from when it was put down in mid March with a comment from a deputy CMO as a public health approach more suited to third world countries. Baroness Dido Harding (past Talk Talk CEO and wife of Tory MP John Penrose) is meant to be leading this.  She had an uncomfortable time at the Health Select Committee when she had to admit that she had no idea how many contacts had been traced by the 25,000 tracers who had been fiddling on their home computers for days after having self administered their on line training. Typically Ministers had announced the launch of TTI to the usual fanfare and she had to admit that the end of June was a more likely date for an operational launch.

    It is extraordinary that the programme is being run by private contractors, who have had no prior relevant experience. We are already witnessing the dysfunction in passing timely, quality assured information to Public Health England and local DsPH. Local public health contact tracing teams need information on names, addresses, ages and test results to get started on mapping the spatial location of cases, exploring their occupations and contact history. Local contact tracers may need to actually visit these people to encourage compliance after the Cummings affair. They should really get this information straight from local laboratories and be resourced to employ local contact tracers familiar with the local area.  Local DsPH would then look for support from the regional PHE team and not be dependent on the PHE or the GCHQ- sounding Joint Biosecurity Centre.

    This is what happened in Germany, where local health offices (Gesundheitsamter) were mobilised and local furloughed staff and students were employed to form local teams. We have positive examples of local government being proactive too such as in Ceredigion in Wales where rates have been kept extremely low. In the post-Cummings era local teams will get drawn into discussions about the civic duty to disclose contacts and of adhering to isolation/quarantining. Difficult for an anonymous call handler to undertake against the background sounds of Vivaldi.

    Auditing misuse of public funds

    One aspect that an independent inquiry will need to look at is the investment of public funds into private companies without due diligence, proper contracting and insider dealing. We have already referred to the vaccine development and governments and philanthropic organisations have provided over $4.4bn to pharmaceutical organisations for R&D for COVID-19 vaccines. No information is available about the access to vaccine supplies and affordability as a precondition of the funding. The deal with the Jenner Institute at Oxford and AstraZeneca has received £84m from the UK government. Apparently AstraZeneca owns the intellectual property rights and can dictate the price (Ref: Just Treatment). We gather that the company has refused to share the trial data with a WHO initiative to pool COVID-19 knowledge! National governments cannot manage alone this longstanding problem with global pharmaceutical companies who are often unwilling to invest in needed but unprofitable disease treatments, even though they often receive public funds and benefit from close links with University Researchers and Health Service patients and their data. There need to be global frameworks to govern such investment decisions.

    BAME communities and COVID

    We have referred in previous Blogs to the higher risks of developing severe illness and death in Black, Asian and Minority Ethnic (BAME) groups. The Prof Fenton report was finally published this week as a Public Health England report. The report is a useful digest of some key data on COVID-19 and BAME populations and confirms the higher relative risks of severe illness and death in these populations. The report steps back from emphasising the extremely high risks of death by accounting for other factors such as age, sex, deprivation and region. Even taking these factors into account they find that people of Bangladeshi ethnicity had twice the risk than people of White ethnicity. Other South Asian groups such as those of Indian, Pakistani or Afro-Caribbean descent had between 10-50% higher risk of death.

    There has been some controversy about whether this report was edited heavily by Ministers, and in particular whether sections that might discuss structural issues of racism had been cut. Certainly by taking ‘account of’ deprivation and place of residence or region it is possible to choose not to see racism as part of health inequality. Many people will remember the early evidence from Intensive Care Units, which showed that while BAME communities make up 14% of the overall population they accounted for 35% of the ITU patients. How can we forget in the early stages of the pandemic, seeing the faces of NHS workers who had died from COVID? You did not have to be a statistician to notice that the majority of the faces seemed to be BAME people. The BMA have pointed out that BAME doctors make up 44% of NHS doctors but have accounted for 90% of deaths of doctors.

    To be fair, the NHS was quick to send a message out across the health system asking that risk assessments be done taking account of individual risks such as ethnicity, co-morbidities such as obesity/diabetes as well as occupational exposure to risk of transmission. Adequate supply of PPE and good practice does work as very few if any ITU staff have succumbed. As ever it is likely to be the nursing assistants, cleaners, porters, or reception staff who get forgotten.

    The recent demonstrations of solidarity with the Black Lives Matter campaign in the light of the dreadful murder of George Floyd under the knees of US policemen is a reminder that there is a global and long standing issue of racism. The government and all organisations including the NHS need to reflect on the findings of the McPherson report (1999) following the death of Stephen Lawrence that defined institutional racism as:

    The collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage minority ethnic people’.

    We must work to rid our country of racism in individuals, communities,  organisations and government. It will only be achieved through commitment throughout the life course and by stamping out racism and inequalities to achieve a fairer society for all our people.

    7.6.2020

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

    2 Comments

    The SHA has been publishing its COVID-19 Blogs weekly since the 15th March. A number of themes have cropped up consistently throughout as actual events have occurred.

    Too slow to act

    The slow and dithering response by the government has been one such theme. This has been exposed with embarrassing clarity by media investigative teams which this weekend include the Insight team. Their detailed report on the dither and delay leading up to lockdown showed that when Italy and Spain locked down on the 10th and 13th March respectively each had over a million estimated infections in their countries. In the UK we had looked aghast at the footage from Lombardy and Madrid as their health and care system was visibly overwhelmed but the government failed to heed their strictly enforced lockdown policies in the 2 weeks warning we had. During this time from the 8th March the Johnson administration allowed the Five Nations rugby matches to go ahead in Twickenham and Edinburgh, the Cheltenham races, the Liverpool/Atletico Madrid football match on the 11th March and two Stereophonics pop concerts in Cardiff held on the 14th and 15th March. All this was apparently following the science…..

    France locked down on the 16th March with an estimated 800,000 infections and Germany locked down on the 21st March with only 270,000. The Johnson government had resisted calls to lockdown at the same time as France on the 16th March. They waited until the 23rd March by which time the estimated number of infections in the community had almost doubled to 1.5m. This dither and delay lies at the heart of our comparatively poor outcome with the COVID-19 confirmed deaths of 37,000 (an underestimate of all excess deaths). This list includes at least 300 NHS and care workers.

    Protect the NHS

    Germany’s earlier decision has reaped benefits alongside their border closure, effective test, trace and isolate (TTI) policies, with sufficient testing capacity, and led by regional public health organisations. They also have sufficient ITU/hospital bed capacity without the need to build new Nightingale Hospitals. Our government did not close borders or introduce quarantining on entry, and turned out not to have used February to build our testing capacity either.

    The strategic attention in the UK has been to ‘Protect the NHS’ but not in the same way Care Homes. Because of the shortage of testing capacity we had to stop the community based test, track and isolate (TTI) programme. The NHS has stood up well through the dedication of its staff and demonstrated the superiority of a nationalised health system. However from a public health policy perspective the COBR meetings should have been thinking about the whole population and what populations were at high risk such as those in residential and care homes.

    The data in Wuhan had been published quickly and had shown that it was older people who are most at risk of disease and death. We knew all this, the Chinese data has been replicated in Europe but the Government failed to follow through.

    The Privately owned Social Care sector

    Unlike the NHS hospital sector, the care sector, of residential and nursing homes,  are a patchwork of large ‘private for profit’ owners, smaller privately owned and run homes and the charitable sector. There is a registration system and some quality assurance through the Care Quality Commission (CQC). The fact that we do not have a National Care Service along the lines of the NHS has led to operational problems during the pandemic between commissioners, regulators, owners and the staff who run the homes. As privately run establishments there were varied expectations about procuring PPE for the staff in the early phase of the pandemic response. There was also a lack of clarity about whether satisfactory infection prevention and control procedures were in place and able to deal with COVID-19. How had residential and care homes undertaken risk assessments, working out how to cohort residents with symptoms and manage their care? What about staffing problems, agency staff and policies for symptomatic staff to self isolate? It was important early on to consider in what respect COVID-19 is the same as or different from influenza or a norovirus outbreak,

    It seems that the Secretary of State for Health and his staff have been too slow in aligning Public Health England (PHE), GPs and primary care infection control nurses alongside the homes to provide more expert advice and support on infection prevention and control.  It seems also that some nursing homes took patients discharged from the NHS who were still infected with COVID-19, when on the 19th March the Department of Health announced that 15,000 people should be discharged to free up NHS beds. There was no mandatory testing or period of quarantining before these patients were discharged. In this way hospital based infections were transferred to nursing homes.

    The scarcity of PPE (caused by the Government’s failure to heed the results of Exercise Cygnus) meant that professionals felt nervous about entering homes to assess sick residents and sadly to be able to certify death and certificate the cause of death. Rationing of PPE in this sector has contributed to the risk of infection in care staff, which would cause transmission in the care home. Most homes had to lockdown too, stopping visiting and in some cases having staff move into the home themselves at personal risk and disruption to their lives. It became clear that transmission from the community to care home residents was occurring through staff. This has been very hard on these undervalued and low paid staff, who began to realise that they were transmitting infection between residents or from themselves.

    Some of the stories of care staff’s heroism and dedication to their residents is extraordinary. It is reminiscent of Camus’s book The Plague, which recounts heroism undertaken by ordinary people doing extraordinary things. Tellingly Camus also suggests that the hardest part of a crisis is not working out the right thing to do, but rather having the guts to get on and do it. Many care home managers and staff had to do just that.

    Follow the money

    A recent report looked at HC-One, which is Britain’s largest care home group with 328 homes, 17,000 residents and so far 700 COVID related deaths. The operating profits of the company are of the order of £57m but, through the financial arrangements with off shore related companies, the profits “disappear” in £50m ‘interest payments’. While global interest rates have been at historically low levels HC-One have apparently been paying 9% interest on a Cayman island loan of £11.4m and 15-18% interest on another Cayman company for a £89m loan. Apparently HC-One paid only £1m in tax to the HMRC last year (Private Eye 22nd May) through this transaction with off shore interests off-setting their profit. This is not however inhibiting them from seeking government support at this time. A better future would be to rescue social care by nationalising the social care sector, bring the staff into more secure terms and conditions of service and sort out the property compensation over time through transparent district valuations.

    Test, trace and isolate (TTI)

    At long last the government has signalled that it wishes to reactivate the community based test, trace and isolate programme that it stood down over 10 weeks ago. Of course, once the virus had been allowed to spread widely within communities, the TTI programme would have had to modify their objectives from the outbreak control of the early stages. However they could have continued to build the local surveillance picture within their communities, help PHE to control residential and nursing home outbreaks with their community based contacts and prepare for the next phase of continuing control measures during the recovery phase.

    They seem to have at last realised the potential of local Directors of Public Health (DsPH) who are embedded in local government and who, after all, lead Local Resilience Fora as part of the framework of a national emergency plan. The DsPH have links to the Environmental Health Officers (EHOs) who survived the austerity cuts. EHOs are experienced contact tracers well able to recruit and train new staff locally to do the job. This is in sharp contrast to the inexperienced staff now being recruited and used by the private sector.

    The local public health teams also work closely with PHE and NHS partners and so can fulfil the complex multiagency leadership required in such a public health emergency. Building on these strengths is far better than drawing on private sector consultants such as Deloittes, or companies such as SERCO, Sodexo, Compass or Mitie. All these private sector groups have an interest in hiving off parts of the public sector. In addition, unsurprisingly, they have close ties to the government and Conservative Party. Baroness Harding, who has been brought in to Chair the TTI programme, is a Tory peer married to a Tory MP who was CEO of Talk Talk. She was in charge at the time of the 2015 data breach leading to 4m customers having their bank and account details hacked. No surprises, then, that she is asked to undertake this role as a safe pair of hands in much the same way that Tory peer Lord Deighton has been asked to lead the PPE work.

    Game changers – and what is the game?

    In last week’s Blog we mentioned that Government Ministers seem to be fixated on game changers whether novel tests, treatments, vaccines or digital apps. We mentioned last week that treatments like Chloroquine need proper evaluation to see if they are safe and effective. A report in the Lancet on the 22nd May found that there was no benefit. Indeed the study found that the treatments reduced in-hospital survival and an increase in heart arrhythmias was observed when used for treating COVID-19

    Vaccines need to be researched, as they may well be important in the future but remember that a 2013 review from the Netherlands found that they take – on average – 10.71 years to develop, and had a 6% success rate from start to finish.

    The mobile apps trial in the Isle of Wight seems not to have delivered a reliable platform, and of course the Government has probably ignored the apps working splendidly in South Korea and Singapore. Meanwhile Microsoft, Google, Facebook, Faculty and Amazon stand ready to move in. There are major risks with getting into bed with some of these players including the data mining company Palantir.

    Palantir

    This company was initially funded by the CIA but has secured lucrative public sector contracts in the USA covering predictive policing, migrant surveillance and battlefield software. These IT and data companies have been drawn into the UK COVID-19 ‘data store’. While working alongside NHSX and its digital transformation unit wanting to assess and predict demand there are concerns over data privacy, accountability and the possible impact on the NHS.

    Palantir has been of interest to Dominic Cummings (DC) since 2015, according to the New Statesman, when he reportedly told the Cambridge Analytica whistleblower, that he wanted to build the ‘Palantir of politics’. The other company Faculty had close ties too with the Vote leave campaign. Cummings is said to want to remould the state in the image of Silicon Valley.

    Conclusion

    So in the turmoil of the COVID-19 response the government has looked to multiple game changers while ignoring straightforward tried and tested communicable disease control measures. It has succeeded in ‘Protecting the NHS’ (though not against the incursion of the private sector) but allowed the residential and care home sector to be exposed to infection. We welcome the belated return to supporting DsPH and local public health leadership, which has been left out for too long. Let us hope – and demand – that there is also more investment in public health services and not allow Government spokespeople to start to blame organisations such as PHE.

    We worry that they are not being alert to safeguard public services by inviting some dubious partners to the top table. On the contrary they are VERY alert – to the opportunity of inserting private capital (and profit) in the NHS and other public sector organisations. One such company new to many of us is the data mining company Palantir – a company named after an all-seeing crystal ball in JRR Tolkien’s The Lord of the Rings. Lurking in the background is of course the Prime Minister’s senior political adviser DC.

    24th May 2020

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

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

     

    1 Comment

    The Royal College of Nursing, in its super-polite way, has written a letter to the Home Secretary, Priti Patel, asking her to make sure that those risking their lives for us in the NHS, should not have to pay punitive extra charges if they become ill themselves. For NHS workers have been surcharged for NHS treatment since 2015, if they have come from overseas. There is a petition “How can we expect nurses to come to Britain and fill our NHS vacancies, risk their lives when they have to pay £11,000 to use – the NHS?” which you can sign if you wish: http://chng.it/mkPN7jmwzm.

    Doctors, nurses and paramedics have now been granted a one-year exemption. One year!   But Dominic Raab said on Monday (18th May) that there were no plans to extend even the one year exemption to care workers. The Royal College of Nursing would be entirely justified if they decided to call for a strike or work to rule until this unfair surcharge is removed permanently, as indeed would the unions representing all health related workers, including the porters, caterers and cleaners (whose employment in most cases is contracted out under privatisation introduced by Thatcher). But if nurses and other health workers feel unable to strike (especially now, which no doubt the Government are counting on) other unions could take action in support of all health and care workers!

    Maya Goodfellow, author of the book Hostile Environment (Verso, 2019), wrote in the Guardian yesterday (19.05.20): “By asking them to pay twice for healthcare, the government is betraying the very people it applauds so publicly”. She pointed out that the British Medical Association has consistently been saying that all healthcare workers should be exempt from the immigration health surcharge. They are already paying tax and national insurance like everyone else. So they are paying twice for NHS treatment.

    All the other political parties have opposed this surcharge.

    Today in Parliament, Keir Starmer raised the issue again in Prime Minister’s Questions, pointing out that a care home worker would have to work a 70 hour week to make enough to pay the surcharge. I was watching the BBC broadcast, and heard Johnson say, of course, lots of stuff about the wonderful NHS, and the overseas workers that saved his life. But on the key point about them paying hundreds of pounds extra to use the NHS, in which they are risking their lives to work, Johnson had the gall to say “the NHS needs another £900 million from such sources”. I am not quite sure what the other sources of the £900m were, besides the surcharge from overseas workers, that he had in mind, but this was utterly shocking and disgraceful. I also had the pleasure of seeing the Speaker of the House, Lindsay Hoyle, threaten to throw Matt Hancock (Secretary of State for Health) out of the House for speaking over Keir Starmer, which has now been reported in the papers for tomorrow.

    Vivien Walsh, Manchester

    1 Comment

    Black, Asian and Minority Ethnic (BAME) deaths

    Three of the four NHS workers reported to have died from Covid-19 in Oxfordshire to date were from a BAME background.[1] The first ten doctors to die of Covid-19 infection were BAME, many of them born outside the UK. This situation among health workers[2] reflects the pattern for deaths in the general population – the ONS has just found that Black people in the UK are four times more likely to die from Covid-19 than White people[3] –  as well as for deaths among people working in the NHS (including outsourced workers) and, probably, care workers.[4]

    Health and economic inequality sustained by structural racism, and exacerbated by austerity and privatisation of the welfare state, is the cause. The Covid-19 pandemic has highlighted the extreme racial and class inequalities in the UK.[5]  Michael Marmot’s recent Ten-Year Review of inequalities highlights straightened circumstances and poor life chances, and moves away from focusing on the behaviour of individuals. Marmot and the UN Special Rapporteur on Racism remind us of the austerity context within which the current pandemic is taking place, with the UN Rapporteur stating that ‘austerity measures in the United Kingdom are reinforcing racial subordination.’[6]

    NHS England and Public Health England and their leaders must be held to account.[7] The current inquiry to be led by the very bodies being investigated is not adequate. We must hold the Government to account for running down the public sector and undermining the NHS and its capacity to deal with pandemic, for its response to the pandemic, and for exploiting the situation to further privatise the NHS.[8]

    An effective enquiry into Black, Asian and minority ethnic deaths must be based on serious analysis of the interlinked socioeconomic and structural factors that may be involved and an understanding that racism adversely affects health even when these factors are accounted for.

    The socioeconomic effects of racism include:

    Longstanding structural discrimination in employment:

    • Low paid, insecure work with an overrepresentation of BAME workers in health and social care and allocation to higher risk roles.[9]
    • The effects of racism persist amongst medics – and, though less research has been done on this, presumably amongst all workers in the health and care sectors – with the evidence that BAME doctors are much less likely to make complaints around safety due to a fear of recrimination.[10]
    • Frontline, ‘key worker’ roles which do not permit working from home, with relative poor access to limited PPE.
    • The gig economy, and in jobs in domestic work, cleaning, childcare, small retail and family businesses. The economic packages allow many in these groups to fall between the gaps and make shielding for high risk workers and their families impossible.
    • Poorly protected outsourced jobs often with low union membership: the true impact of the policy of privatisation of public services and utilities needs to be investigated. This investigation must cover employment and NHS trust practices, policies and guidelines around the health and safety of all workers on their sites, not just those in their direct employment.
    • The lack of clarity about what constitutes a ‘vulnerable’ worker who should be shielding further increases the risk of pressure on less favoured groups in the population.

    Structural discrimination in housing and access to healthcare with:

    • Relative overcrowding in housing compared with White households.
    • A high proportion of BAME communities in densely populated urban areas of deprivation with (per person) under resourced health and social care facilities and higher levels of air pollution.

    Factors relating to migration include:

    • Whether a person was born outside the UK: 53 of 64 BAME Covid-19 deaths among NHS staff in one study were of people born outside the UK.[11]
    • Immigration status: some overseas workers fear losing their jobs and may feel driven to accepting additional risks.

    Some continue to propose various biological explanations for the prevalence of BAME Covid-19 deaths. Such evidence must be robustly scrutinised and not allowed to distract the focus on the overwhelming socioeconomic causes and the urgent need to address structural racism.

    Action

    Urgent tasks

    The most urgent task is to reduce all deaths from COVID-19 through adequate provision of  personal protective equipment (PPE), workplace practices that minimise risk, and physical distancing. Workers have the right not to work in unsafe conditions and employers have the duty to ensure safe conditions. A working, effective system to trace infection routes must be part of any loosening of lockdown. Local public health teams must be restored to deliver this.[12] All the evidence so far points to the fact that centralised privatised solutions have failed us.

    Research

    A programme of research is urgent to clarify the main factors and provide the basis for new policy. Ethnicity must form part of data collected by health and care services.[13]

    Health and Safety Executive guidelines and definitions in analysing workplace deaths, and procedures for investigating workplace deaths, need to be strengthened to keep workers safe and protected. Currently NHS trusts are left to assess themselves – a clear conflict of interest.

    Beyond immediate tasks

    The government’s hypocrisy must be challenged. Boris Johnson’s government has promised to ‘level up’ areas where health has deteriorated. Oxfordshire County Council leader and chair of the Local Government Association’s community wellbeing board, Ian Hudspeth, called the Marmot report a wake-up call: ‘Councils want to work with government on closing this gap… . Sustainable, long-term investment in councils’ public health services is also needed.’[14] Just one week later, on 4 March, a majority of MPs voted not to call on the Government to end austerity, invest in public health, and implement the recommendations of the Marmot review.[15] Opposition parties must be unrelenting in denouncing this hypocrisy now.

    The Runnymede Trust’s proposal[16] to introduce the socioeconomic duty, making class an ‘equality ground’ should be supported. This would return to the situation before 2010 when Theresa May scrapped the legal requirement designed to make public bodies try to reduce inequalities caused by class disadvantage (the socioeconomic duty).[17] [18]

    Migrant workers are the lifeblood of our NHS, our care system and our society. The hostile environment must end now. That means granting indefinite leave to remain to all NHS and care workers and their families, and abolishing a) ‘no recourse to public funds’ barriers to health and other services, b) charging migrants for NHS treatment, c) charging migrants a health surcharge on top of their income tax, and shutting detention centres.

    Action is necessary to end health inequalities. The Marmot Review’s recommendations must be implemented with race as a ‘social determinant of health’ as put forward by the Runnymede Trust. Inadequate public health expenditure and ‘shrinking the state’ disproportionately affect poorer people including our BAME communities. More ‘austerity’ to ‘pay for’ the pandemic is not an option as austerity widens the health inequalities that lead to disproportionate BAME Covid-19 deaths.

    This briefing gives rise to a number of issues to be taken forward in national and local investigations which we will be pressing Trusts and Local Authorities to undertake.

    Oxfordshire Socialist Health Association Committee

    May 2020

    [1] Oscar King and Elbert Rico, porters, and Philomina Cherian, nurse, at the John Radcliffe Hospital, Oxford, and Margaret Tapley at Witney Community Hospital.

    [2] https://www.hsj.co.uk/exclusive-deaths-of-nhs-staff-from-covid-19-analysed/7027471.article

    [3] https://www.theguardian.com/world/2020/may/07/black-people-four-times-more-likely-to-die-from-covid-19-ons-finds

    [4] ‘Death rate among black and Asian Brits is more than 2.5 TIMES higher than that of the white population, reveals stark analysis by Institute of Fiscal Studies’, Daily Mail, 1.5.20:

    https://www.dailymail.co.uk/news/article-8276097/Clear-disparity-ethnic-groups-Covid-19-deaths-IFS-study.html;

    Office of national Statistics: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsinvolvingcovid19bylocalareasanddeprivation/deathsoccurringbetween1marchand17april

    [5] https://morningstaronline.co.uk/article/coronavirus-highlighting-extreme-racial-and-class-inequalities-–-let’s-vow-end-them

    [6] https://hjt-training.co.uk/un-special-rapporteur-criticises-hostile-environment-policy/

    [7] http://www.irr.org.uk/news/institutional-racism-in-the-nhs-intensifies-in-times-of-crisis/

    [8] https://www.theguardian.com/business/2020/may/04/uk-government-using-crisis-to-transfer-nhs-duties-to-private-sector

    [9] https://metro.co.uk/2020/04/21/nhs-puts-pressure-ethnic-minority-staff-work-coronavirus-wards-12589058/

    [10] https://www.theguardian.com/society/2020/apr/10/uk-coronavirus-deaths-bame-doctors-bma.

    The February issue of the British Medical Journal was devoted to the subject of racism in medicine:  https://www.bmj.com/racism-in-medicine

    [11] https://www.hsj.co.uk/exclusive-deaths-of-nhs-staff-from-covid-19-analysed/7027471.article

    [12] https://www.theguardian.com/world/2020/apr/26/to-tackle-this-virus-local-public-health-teams-need-to-take-back-control

    [13] ‘Ethnicity and COVID-19: an urgent public health research priority’, Lancet: https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930922-3

    [14] https://www.theguardian.com/society/2020/feb/24/austerity-blamed-for-life-expectancy-stalling-for-first-time-in-century

    [15] https://www.theyworkforyou.com/debates/?id=2020-03-04d.903.0

    [16] https://www.runnymedetrust.org/uploads/publications/We%20Are%20Ghosts.pdf

    [17] https://www.runnymedetrust.org/uploads/publications/We%20Are%20Ghosts.pdf

    [18] https://www.theguardian.com/society/2010/nov/17/theresa-may-scraps-legal-requirement-inequality

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    This is now the 8th weekly Blog published by the Socialist Health Association (SHA) commenting on how the Coronavirus pandemic is progressing both locally and globally. The lens we use is a socialist worldview where we aspire to One World and Planetary Health and are as concerned to reduce global as well as local health inequalities. The Covid-19 pandemic has shone a light on local inequalities within the UK as well as stark global inequalities where people find themselves exposed and unable to follow the advice we receive in the UK and other rich countries to social distance and pursue rigorous hand hygiene.

    Health inequalities in the UK

    Last week the Office of National Statistics (ONS) published a report on Covid-19 deaths by local area and by socioeconomic deprivation (www.ons.gov.uk). This covered the period from the 1st March to the 17th April. During this period there were 90,232 deaths in E&W and of these deaths 20,283 involved Covid-19.

    Unsurprisingly London had the highest age-standardised mortality rate with 85.7 deaths/100,000 people involving Covid-19. This is significantly higher than any other region and almost double the next highest rate. In these SHA Blogs, one of our observations has been that London was the early hotspot and should have been shutdown much sooner and been our ‘Wuhan’. Remember all the press reports of bars and restaurants remaining open and people packed into London underground trains and buses?

    In London Covid-19 deaths were 4,950 amounting to 42% of deaths since the beginning of March compared to 1,051 deaths in the South West region of England, which was only 13% of total deaths there. The eleven Local Authorities with the highest mortality rates were all London boroughs with Newham, Brent and Hackney suffering the highest rates. Outside London rates are high in Liverpool, Birmingham and Manchester.

    Newham has the highest age standardised death rate with 144.3 deaths /100,000 population followed by Brent with 141.5 and Hackney with 127.4. In Newham 78% of its population are in BAME groups and 48% live in poverty after rent and household income are taken account of. The three London boroughs are in the most deprived group and across England the most deprived areas have a death rate of 55.1/100,000 compared with 25.3 in the least deprived (118% difference).

    The Index of Multiple Deprivation (IMD) is an overall measure based on income, employment, health, education, crime, the living environment and access to housing within an area. Each area of England is grouped into one of ten deciles and the most deprived is in d1 and least deprived in d10. As we know from work over the last 40 years since the Black report in 1980 – there is a social gradient for mortality and many other indicators of health and wellbeing.  Covid-19 has magnified the difference especially for those in the three most deprived deciles which shows a stark difference between Covid-19 deaths and all deaths. In the least deprived decile the mortality rate for all deaths was 122 deaths/100,000 population, whereas in the most deprived it was 229. The difference between all deaths (classic social gradient) was 88% whereas between Covid-19 deaths the difference was 118%, which is 30% higher.

    A similar picture emerges in Wales where they present the data as differently. The most deprived fifth of areas have a rate of 44.6 deaths per 100,000 involving Covid-19; this was almost twice as high as the least deprived area with 23.2 deaths/100,000.

    The other key finding from the ONS report was on urban versus rural areas. Major urban conurbations had a death rate of 64.3/100,000, which is statistically significantly higher than other categories including urban minor conurbations. The lowest rates unsurprisingly are in rural settings with rates as low as 9/100,000 population. There is a category ONS use called ‘major towns and cities’ in E&W which are built up areas excluding London. Of the 111 major towns and cities the highest mortality rate was in Salford with a rate of 112.6 deaths compared to Norwich with 4.9/100,00. One interesting prosperous market town that was hard hit is Cheltenham with a death rate of 49/100,00, which is significantly higher than the English average!

    Austerity and the slow burning injustice

    In his 2020 report of ‘Health Equity in England: the Marmot Review 10 years on’ Marmot found that the improvement of life expectancy which had been a consistent finding since the turn of the 19th century stalled in 2010 and years spent in ill health increased. He also showed that the social gradient in health became steeper and regional differences increased.

    The two features of Tory government policy during this period was to roll back the State – public expenditure went from 45% of GDP in 2010 to 35% in 2018 – and to be regressive. This meant that the poorer you were the more likely you would be to be disadvantaged by these changes.

    The excuse for the policies enacted from 2010 was the 2008 global financial crisis, which led to a decline in the global economy of 0.1% in 2009. The IMF  has predicted that the global economy will decline by 3% in 2020 on account of the pandemic. Already we have seen Universal Credit claims in the UK rise from 150,000 before the pandemic to 1.4m by the 13th April and rising daily. Marmot points out the risk that it would be a calamity if we face a new era of austerity after the pandemic. We need on the contrary to argue for a better society with less inequality and built by reducing child poverty, improving child health and education, improved working conditions ensuring that everyone has the minimum income to lead a healthy life and creating a sustainable environment in which to live and work creating the conditions for people to pursue healthy living.

    Places affected by conflict and humanitarian crises

    Inequalities are manifest globally as well as locally in the UK. For instance many of the estimated 70m forcibly displaced people worldwide live in insanitary and inhospitable conditions sometimes up to six families living in one tent in a 3sqm area. In these camps people share few latrines and washing facilities and have to queue for food each day. The Covid-19 mantra has been hand washing, social distancing and lockdown. People in conflict zones or refugee camps simply cannot follow this guidance and also have access to very rudimentary healthcare facilities.

    There is an urgent need to put international pressure on warring parties in Syria and Yemen to end restrictions on access to health care and humanitarian assistance. Public health support is needed to provide the conditions that do not allow the virus to spread and substantial financial support to overhaul the present conditions. This is more important and practical than supplying ventilators. The Covid-19 pandemic requires a global response for the most vulnerable populations globally as well as locally in the UK (David Nott Lancet 1st May 2020)

    Another globally vulnerable group are prisoners. In all countries including the UK prisons are a risk being closed communities with people living in crowded and in some countries squalid conditions. Conditions are worse in countries led by leaders like Duterte and Bolsonaro. In the Philippines for example there are an estimated 215,000 prisoners in prisons built for a capacity of 40,000 and in Brazil 773,000 prisoners are crammed into prisons built for 461,000.

    Whether it’s parts of the world with conflict and humanitarian crises or populations suffering from repressive governments there is an urgent need for rich countries to invest in international organisations such as the UN, WHO, UNHCR, UNICEF and AID organisations to try to mitigate the risks that Covid-19 poses on top of already stressed social conditions. It is possible to act locally on health inequalities as well as show solidarity globally.

    So what?

    In our earlier blogs we have been critical of some aspects of the pandemic response in the UK. It is sad to note that the UK is heading to have the worst outcome in Europe with us starting our epidemic behind Italy, Spain and France when Covid-19 hit Europe. The Government have been too slow to take measures such as locking down London and the South East rapidly and should have continued testing, tracking and isolating across the country – especially where the number of cases has been low and well within the capacity of local resources. This would have built practical experience and we would have learnt valuable lessons.

    Now that we have more testing capacity we need to build the programme from the bottom up. Local public health teams in Local Government stand ready to provide local leadership teaming up with professional Environmental Health Officers (EHOs) who have the skills and local knowledge to provide local leadership. Resources need to be targeted at areas of greatest need as we have illustrated through the excellent ONS report. Certainly smart apps will play a part as well as national leadership from COBR on the key features of the test, trace and isolate programme. However there has arguably been too centralised and London based approach to pandemic management. The time is ripe to allow local authority public health, supported by specialist PH resources to work with their Local Resilience Forum (LRF) using their local skills and knowledge to try to bring the pandemic to heel using classic communicable disease control methods of epidemic controls. This will help eliminate the virus, protect the NHS allowing it to reopen for normal business and enable the economy to start up again as soon as practicable.

    Pandemics kill in three ways says Jonathan Quick of the Rockefeller Foundation:

    The Disease kills,

    Disruption of the health service kills

    and the

    Disruption to the economy kills”.

    3.5.2020

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

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    From Mark Ladbrooke, of Oxford SHA branch, and formerly chair of Oxford University Hospitals Foundation Trust (OUHT) Joint Union Committee

    Oscar King, Jr. and Elbert Rico, porters at John Radcliffe Hospital, Oxford, and union activists, died two weeks ago of suspected Covid-19.

    Both of them are married to members of the nursing team at the hospital and Twilight, Oscar’s wife, was admitted to hospital, while their 10-year old daughter is being cared for. Oscar and Rico came from the Philippines and had worked at the hospital since they arrived.
    The Filipino community is extremely important to the NHS – after workers from the UK itself and India they make up the largest proportion of the workforce.

    Patients may not notice the porters as much as they notice doctors and nurses, but their role is just as vital, since they take everyone where they need to go, and move equipment and machinery to where it is required. The Labour Movement has supported junior doctors and nurses in dispute with management (backed by government) at various times – but porters, domestics and catering staff are frequently outsourced and are at the end of the queue.

    As long ago as 1982 the Thatcher government brought in competitive tendering for NHS services such as catering, cleaning, portering and estates maintenance. Oxford University Hospitals Foundation NHS Trust (OUHT), of which the Radcliffe is part, signed up to a Private Finance Initiative (PFI) deal, under which management of the porters, domestics and catering staff was transferred to a private company as the hospital was expanded. PFI was dreamed up when Norman Lamont was Tory Chancellor, but took off under the New Labour Government of Tony Blair after 1997.

    A Unison strike in Dudley in 2000 was the seventh against transfer to the private sector, as part of increasing resistance to PFI. The striking workers won important concessions around secondment, nevertheless management was still transferred to Carillion (which went bust in Jan 2018). The John Radcliffe workers threatened strike action in 2015 around pay cuts.
    Industrial action continues to be taken against PFI and its impact on working conditions, most recently this year in Lewisham (because the outsourcing firm failed to pay cleaners, porters and catering staff the wages that had been agreed) and Paddington. In the latter case, porters, caterers and cleaning staff at St Mary’s, with the support of some of the other staff, including doctors, became employees once again of the NHS.

    We, in the Joint Union Committee and local SHA branch knew Oscar, in particular, as a “brilliant rank and file union leader”. The SHA branch is well connected to the workplace and local unions. They help provide the leadership of the branch. The Chair of the SHA branch, Cllr Nadine Bely-Summers, a nurse, who also represents Oxford City Council on the local Health Overview and Scrutiny Committee (HOSC), demanded answers from Bruno Holtof, chief executive of the OUHT, about the deaths of the two porters:


    – How many staff on site are managed by outsourcing companies or agencies?
    – What personal protective equipment (PPE) was provided by the trust to staff managed by outsourcing companies or agencies?
    – What personal Protective Equipment (PPE) was provided by the trust to staff managed by Bouygues and other outsourcers eg G4S? When was this provided?
    – Are staff being put under pressure to return to work while reporting sick?
    – How are the frontline outsourced staff who are vulnerable being treated?
    – Is the Trust legally liable for Health and Safety breaches on its premises including those by outsourcing companies and agencies?

    In response to her demands the Director of Public Health has promised to investigate further.
    BAME Labour activists working with Oxford City’s Labour Council have raised concerns that this may be part of a worrying national picture of an especially high death toll among black and Asian workers, as reported on various TV channels and in several daily newspapers in the last week.

    The local city council has written to the Chief Executive of the NHS Trust asking for an explanation.
    Nadine said “We must seek assurances from all NHS Trusts that there is day-to-day monitoring carried out to make sure there is not a disproportionate impact of the rates of infection and death on ethnic minority workers, and that adequate PPE are being provided at all times to all staff groups”.

    Stop Press!

    The Chief Executive of the Trust has written back to the council saying, among other things:
    We note, however in the case of reporting incidents in relation to Covid-19, that the HSE have indicated that “[in] a work situation, it will be very difficult, if not impossible, for employers to establish whether or not any infection in an individual was contracted as a result of their work. Therefore, diagnosed cases of Covid 19 are not reportable under RIDDOR ( Reporting of Injuries, Diseases and Dangerous Occurrences Regulations )  unless a very clear work related link is established.”

    We are unable to comment in detail on specific individual cases but are able to note that there is not currently evidence to support such a link in relation to these two staff members. However we can confirm that reporting and investigation will take place in line with HSE guidance where a diagnosis of Covid-19 is directly attributed to an occupational exposure.

    Oxford and District Labour Party Executive has asked Anneliese Dodds (Labour Oxford East) to raise this issue in parliament. She reports that Labour is planning to raise such issues on workers’ memorial day.

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    From Stephen Watkins, retired Director of Public Health, Stockport.

    Based on 119 deaths in a patient-facing workforce of about 800,000, the Health Service Journal (HSJ) suggests that death rates in NHS staff are no higher than in the general population.

    It is important to remember the difference between mortality rate (deaths per 100,000 people at risk) and fatality rate (proportion of deaths in those actually infected).

    It is not possible to draw an accurate conclusion without age-specific mortality rates (not fatality rates) for the general population and for NHS patient facing staff. The crude mortality rate for NHS staff based on the HSJ figures would seem to be about 14 per 100,000 per current duration of epidemic. (“Crude” means not adjusted for age and sex).

    Based on the Lancet article by Verity et al[1], the age-specific fatality rates in people of working age, based mainly on Chinese figures, appear to be between 0.03% in people aged 20-29 and 0.59% in people aged 50-59, then increasing to 1.93% in people aged 60-69. Assuming a reasonably even spread of ages between 20 and 65 the average would be 0.3%.

    Applying this to the 14 per 100,000 mortality rate would equate to 4,666 cases per 100,000.

    Therefore assuming the accuracy of the Chinese fatality rates, and assuming an even spread of ages between 20 and 65 in the NHS workforce, the mortality rate in the NHS population is what would be expected if the death rates were the same as the general population if 4.6% of the working age population has been infected to date.

    If fewer than 4.6% of the working age population has so far been infected, the rates in NHS staff are higher. If more than 4.6% of the working age population has so far been infected,  the rates in NHS staff are lower. We do not however have accurate age-specific incidence rates for the general population from which to make an accurate assessment.

    However, if there were a 4.6% incidence rate in the general population there would now have been 2,990,000 cases and the Government is not quoting anything like that figure.

    Subject to caveats about the inaccuracy of the data and the extreme approximations made in the calculation, it would appear that rates in NHS staff are significantly higher than in the general population. This may, however, not be true if the rates of infection in the general population are being grossly understated, which could well be the case.

    [1] Robert Verity et al, “Estimates of the severity of coronavirus disease 2019: a model-based analysis”, The Lancet online 30. 03.20.

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    The SHA started to publish its Covid-19 Blogs on the 17th March and since then have issued weekly blogs. It is extraordinary to reflect on this being our sixth commentary on the socialist health view of the unfolding global pandemic.

    In earlier Blogs we have covered many different topics and each Blog reflects on particular issues that have sprung up over the past week and identified as emerging issues. In this week’s Blog we will look at social care, testing, and possible steps out of lockdown.

    1. Social Care

    This has rightly hit the headlines over the past week as the plight of our care services and their residents have been under the media spotlight. We knew from the early data from China mid January that the C-19 virus seemed to particularly harm older people and particularly adults with underlying conditions such as obesity, diabetes, heart and lung disease. Mortality rates in these at risk groups is comparatively high and 90% of deaths in the UK have been in the over 60 year olds with half of these deaths being in people over 80 years old. This has led the UK government to define vulnerable groups and also those ‘very vulnerable’ people who need to be ‘shielded’ from exposure to the virus. The very vulnerable shielded groups are estimated to a number 1.5m and are self isolating indoors for 12 weeks. Many but not all of these very vulnerable people will be in residential or nursing homes.

    Having identified these at risk populations, attention needed to be directed towards those sub populations of older or vulnerable people who were living in residential or nursing homes. These institutions are high risk as ‘closed communities’ accommodating a group of high-risk individuals who would be at risk of an outbreak of C-19 within that setting.  Decisions have had to be made by the management of these residential and nursing homes to, in many cases,  exclude relatives from visiting.  Some brave and extremely committed care staff have decided to move themselves into the nursing or residential homes to reduce the risk of them bringing C-19 in from their own homes and local community. It cannot be a surprise to hear now about outbreaks in these establishments causing disease and death to workers and their residents. Again like other aspects of this pandemic response – we had early warnings from Italy and Spain about the isolation and risks that this sector faced. Did we do enough quick enough?

    SHA President Prof Allyson Pollock published an Editorial in the BMJ on the 14th April, which identified that social services in the UK are amongst the most privatised and fragmented in the world, and have been underfunded for decades. Between 2010 and 2018 local authority spending on social care in England fell by 49% in real terms. The UK has 5500 providers operating 11,300 care homes for older people and 83% of these care home beds are provided by the for-profit sector, it is more privatised than the US.

    She also reports that care services employ 1.6m care staff (1.1m full time equivalent) of which 78% are employed by the independent sector. Pay is low; 24% of people working in adult social care are on zero hours contracts, and in March 2019 around a quarter were being paid the national living wage of £7.83 an hour or less. The sector is 120,000 workers short, and agency staff, are commonly employed and move from care home to care home. Social care has been a low priority for PPE supplies despite the high risks for residents and staff.

    Valiant efforts have been made by the sector with heroism shown by these low paid workers as well as stoicism by residents, many of whom may well be bemused and depressed as to why they no longer have visitors as well as the unusual PPE equipment being used by staff. It will have been difficult to plan for the various contingencies when cases emerged in homes, to access testing of staff and residents, to successfully isolate cases and discuss whether residents should be moved to hospital to obtain extra levels of care. Such admissions to more resourced NHS facilities should be an option even if cases would not meet eligibility for ITU care or wishing to be subject to that level of intrusive care. There should be options available, rather than simply assuming appropriate care will be delivered in that setting by stretched staff with relatively few registered nurses, no medical presence on site and few resources of PPE and other equipment such as oxygen supplies, oxygen delivery equipment and monitors such as oximeters.

    The SHA has been concerned about the social care sector for years and has developed policies to transform the sector under the banner ‘rescuing social care’. At the 2019 Labour Party Conference the SHA called on a future Labour Government to legislate for a duty to provide a universal system of social care and support based on a universal right to independent living. This should be based on need and offering choice; be free at the point of use, universally provided and fully funded through progressive taxation. This new National Care Service (NCS) should ensure that there are nationally agreed qualifications for staff, a career structure and enhanced pay and conditions of service. Recognition of informal carers is needed too with clarity about rights and support. The policy proposal has many other facets and stops short of integrating the NCS with the NHS. However close working would be built in and integrating data and information into a common system would be expected.

    As for many of the issues that have arisen so far with the pandemic the social care sector has not been in a strong position to push back C-19. The underpaid staff, the high vacancies and the often unsuitable, adapted accommodation is rarely fit for modern care needs. The fragmentation of the sector with ‘for profit operators’ finding it hard with constrained funding has led to vulnerability in the sector as well as the residents. Maybe this will be the time that showed how, rather than a shiny green badge, the social care service should be taken into a publicly funded national care service.

    1. Tracking, Tracing, Testing, and Treating (isolating)

    One of the criticisms we have made of the Government’s pandemic response has been the decision on the 12th March to pull back from testing for cases in the community and contact tracing. It may turn out that this was a policy decision driven by the lack of availability of tests rather than a decision made not to control community spread. On the 24th February there had been 9 confirmed cases of C-19 in the UK and the WHO had announced that countries should ‘ prioritize active, exhaustive case finding and immediate testing and isolation, painstaking contact tracing and rigorous quarantining of close contacts

    By the 22nd March there were 5683 confirmed cases and yet even then the WHO advice was ‘ find those who are sick, those who have the virus and isolate them. Find their contacts and isolate them’.  In outbreaks you do not always have confirmatory tests available but can make public health decisions based on the history and observation in the context of the unfolding epidemic. We seem to have forgotten the cardinal symptoms of continuous cough and fever.

    We have pointed out in earlier Blogs that countries that have been successful so far in controlling C-19 such as South Korea and Taiwan have been ones that have used widespread testing, tracing contacts and quarantining them. Germany has also been an example of a Western European country that has used this traditional communicable disease control methodology to save lives and protect their health service. Such a public health approach is most important in epidemics like this where there is no vaccine and no effective therapeutics other than sophisticated intensive supportive care.

    It is symbolic that the data that is presented at the daily press briefings has in the main used hospital testing data, hospital admissions and until recently exclusively hospital deaths. TV crews have been crawling over ITUs to get extraordinary footage of these wonderful NHS teams doing outstanding and stressful work. The incredible success of building Nightingale Hospitals in record time has been a reminder of the extraordinary efforts made in Wuhan to meet urgent need.

    However outside hospitals we have had the social care sector relatively unprepared, people self isolating in their homes and having to gauge the seriousness of their symptoms with intermittent telephone calls to NHS111. The disease has been spreading across the country from London to other metropolitan centres and then into smaller towns and rural areas. We could and should have shutdown London earlier as this has been our Wuhan. Local surveillance is limited and active contact tracing thought to be irrelevant even when many areas across England, Wales and Scotland had few cases. Environmental Health Officers in Local Government have not been mobilised. An opportunity missed.

    We have also seemed content to keep our airports and seaports open with little if no border health security. Again other countries who have managed to control this pandemic stopped and controlled air traffic, quarantining arrivals from high risk areas and making basic investigation on history (?cough) and taking travellers temperatures. Not difficult to do and look at Australia and New Zealand for actions on this source of new infections of a virus with high levels of transmissibility. In the UK it is estimated that over 190,000 people flew into the UK from China between January and March with no testing/quarantining.

    1. Evidence of unpreparedness

    The UK seems set to be one of the countries in Western Europe with the worst outcome in regards to mortality rates from C-19 despite the effectiveness of the NHS, which has withstood the pressure. We are often said to have an exemplar emergency planning system, the government had a pandemic as No. 1 risk on the national risk register, kept stockpiles and has computer modellers of world class.

    Yet we do not seem to have acted on the emergency planning exercises such as the 2016 Operation Cygnus (‘swan’ flu). We are now aware that in Sept 2017 the National Risk Register of Civil Emergencies reported that “There is a high probability of a flu pandemic occurring with up to 50% of the UK population experiencing symptoms, potentially leading to between 20,000 and 750,000 fatalities and high levels of absence from work’.

    There have been disclosures recently that are worth referring to that set out the timelines which showed the Prime Minister distracted and absent from COBRA meetings in January/February (A comprehensive countdown to how Britain came to have one of the highest COVID-19 per capita death rates – http://www.bylines.com). Also there has been an Insight team report for the Sunday Times on the 19th April 2020 (Coronavirus: 38 days when Britain sleepwalked into disaster). The current Secretary of State is an actor in this drama and the former Secretary of State for Health Jeremy Hunt who has been a critic of some aspects of the Governments response was of course in power during this time. We are told that ‘pandemic planning became a casualty of the austerity years when there were more pressing needs’ and ‘preparations for a no-deal Brexit sucked all the blood out of pandemic planning’

    1. Getting out of lockdown

    There are various scenarios that are being set out about how to get out of lockdown once the number of new cases decline and the first wave is thought to be ‘over’. This is likely to take time as the curve is flat and the proportion of the population with resistance is thought to be quite low. The government are hesitating about setting out the scenario and talking too much about the delivery of an effective, safe and tested vaccine. This usually takes 12-18 months and can never be guaranteed. They also are talking up the possibility of an effective drug therapy but we all know that viral illness do not lend themselves to highly effective drug treatments as we know with the Tamiflu debate after the 2009 H1N1 pandemic. So really we should again consider more immediate and classic public health control measures that have been shown to work in this pandemic.

    This will need health scrutiny and effective border controls that New Zealand and Australia have used successfully. There will within the country need to be effective systems of testing, contact tracing and quarantining with every day life respecting physical distancing and the use of facemasks. South Korea has shown the way that this can be enhanced and made more bearable by using mobile phones loaded with new technologies. These will warn people if at risk and disclose red, amber or green status. This will allow the economy to restart and people begin to get out and about again. The very vulnerable will in the early phases of this need to be protected.

    Prof Pollock in a recent BMJ editorial (Covid-19: why is the UK government ignoring WHO’s advice) states that ‘this means instituting a massive, centrally co-ordinated, locally based programme of case finding, tracing, clinical observation, and testing. It requires large teams of people, including volunteers, using tried and tested methods updated with social media and mobile phones and adapting the guidance published from China’ and other countries who are implementing such systems.

    This will require a change of mindset in government and from their medical and scientific advisers but as J.M.Keynes said:

    When the facts change, I change my mind. What do you do?”

    20th April 2020

    Published by Jean Smith on behalf of the SHA Officers and Vice Chair’s

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    BUYING BEDS FROM PRIVATE HEALTHCARE PROVIDERS

    Can the minister explain why the Government has chosen to buy beds from private healthcare providers rather than requisitioning private hospitals and staff as the Spanish Government has done?

    The Centre for Health and Public Information (CHPI) has demonstrated that the government’s deal to purchase their entire capacity in return for covering their “operating costs, overheads, use of assets, rent and interest” is in effect a bailout for private hospitals. https://chpi.org.uk/blog/who-benefits-from-the-nhss-bailout-of-private-hospitals/

    Based on the accounts (2017 or 2018) of their operating companies, four of the largest private hospital providers (Spire, BMI, Nuffield, Ramsay) have an average gearing (total debt / equity) of over 300%. This means that they are heavily reliant on debt to finance their businesses, and are therefore potentially vulnerable to a prolonged period of low or non-existent demand.

    Without the deal, private healthcare providers would face the same fate as other industries who are experiencing a significant drop off in demand due to the virus. Crucially it also represents a bailout for the landlords and lenders of the private hospitals whose investments would also be at risk if the hospitals were unable to honour their payments.

    Why is the Government acting to protect private healthcare providers, and the profits of their investors, rather than taking the alternative approach of requisitioning private hospitals and their staff to support the NHS?


    What payments will the government have to make for requisitioned private health care capacity?


    Can the government provide assurances that the contracts signed for ventilators from known Tory backers like Dysons and JHB are of the required standard to enable gradual re-establishment of breathing?

    CARE AND NURSING HOME RESIDENTS

    Are you confident that all care and nursing home residents who are symptomatic are being tested for COVID-19?


    Why there is a difference in priority for the NHS and Care sector?

    Please supply any figures of death rates and infection rates as incidence and prevalence.  It should surely be easy for every care home retirement village and other institutions to collect daily stats and report regionally.

    How can you ensure that Trusts, NHS charities and local authorities work together to provide a system coordinated response?


    PUBLIC HEALTH ADVICE

    Why does the Government advise 7 days isolation for those who are symptomatic for COVID-19 while the WHO advice, followed in most of Europe is to isolate for 14 days?

    CONTACT TESTING, TRACING AND NUMBERS

    • What is the best estimate of the proportion of the population who have had Covid-19?
    • What is this estimate based on?
    • Is there any community surveillance for Covid-19 taking place? If so what are the details? What are the results?
    • How much contact tracing is done for patients who have been diagnosed as having Covid-19?
    • What role will contact tracing play in managing the easing of the current public health measures?
    •  What steps is the government taking to have a robust tracing capacity in place as we emerge from the current public health measures?
    • What criteria will be government use in terms of R0, new cases, patient deaths, herd immunity, contact tracing capacity etc to inform any decision to ease current public health measures?
    • How many of the NHS and care staff who have died in this epidemic are from overseas?

    The figures now emerging for the deaths of those working in the NHS cover the very substantial numbers of outsourced workers, a cohort that the public just don’t know about. Aside from being cheaper and allowing corporates to cream off a profit, these workers are treated as second class employees, with worse conditions, oppressive supervision, abysmal support and non-existent occupational health. Aside from low pay and the insecurity of zero hours contracts there are countless ways in which they are coerced to “just get on with it”, risking serious harm.

    The DHSC is undercounting numbers of health workers infected, can the government give assurances that they will provide accurate figures and include out sourced agency and locum staff?

    Hospitals have been asset-stripped for years by outsourcers, PFI partners and management and IT consultants, and Lansley’s Health and Social Care Act has undermined the structural coherence of the NHS. The malign results of this we now see with hospitals struggling against collapse with the untold sacrifices of heroic staff. And even here, the government (Matt Hancock) has consistently under stated the numbers of deaths of NHS staff: on Friday he said the number was 19 when it was 31 and he repeated the 19 figure on Saturday when it was in the 40s and in the public domain. Can we be assured that Mr Hancock will provide accurate figures and strive to remain on top of his brief?

    We know the numbers of front line workers losing their lives to Covid is now in excess of 40  – why has the government not acknowledged this nor yet apologised for their gross mishandling of PPE supplies.


    The finger-prick antibody tests that Hancock has ordered are widely regarded as unreliable with low sensitivity and specificity. Can we be assured that this is not the case?


    With respect to testing – why has the government wasted millions on a test which quickly proved not to be reliable. Who sanctioned this?


    What are the step changes to increase current testing capacity to 100,000 by the end of the month?  When will each new site come on stream and how much capacity will be added – and then say what actually happened – on a weekly basis?

    What really is the approach to testing front line staff? Pretending to test all front line staff is pointless as someone who is negative today could be positive tomorrow – so this would mean testing everyone everyday which would need significantly more capacity than planned. Are they testing staff who are currently self isolating and not at work and those who become symptomatic?

    What is their approach to testing care home residences and staff? Initially this should focus on those home with assumed cases and needs to be done in a consistent way

    FUTURE FUNDING

    We are pleased to hear of the Prime Minister’s recovery, and noting his praise for the dedication and commitment of NHS staff, will he now reinstate the NHS as the preferred provider when work is commissioned?

    Given the inability of local Public Health teams to provide an adequate local response to the epidemic given recent cuts and reorganisation, will be now ensure the reinstatement of Public Health powers and budgets?


    Public support for the NHS has never been higher, arguably because the population understands better than this and the previous Tory government how vital it is to national life. Will the government undertake to reinstate the NHS on its former footing as a National health service, and undertake to spend the same proportion of GDP on it as comparable countries?

    COMMUNITY SERVICES

    There is likely to be a wave of people being discharged from hospitals who remain very ill. Given the shortfall in GP and District Nurse numbers, how does the SoS expect that these patients will be adequately supported?

    Is now the time to commit to a significant increase in District Nurse numbers with upskilling to enable more people to remain at home post-Covid with GP support?

    PPE

    PHE has continually prevaricated about the spec – and in comparison to other countries still falls short, yet even that is still proving impossible to obtain for too main frontline workers, both in hospitals and in the community. We know the supply chain in England in particular is flawed because the Cabinet Office brought in an a ‘middle man’ without any experience of handling PPE or the manufacturing industry. Cabinet Office must be told they should be stood down with immediate effect from their role in England and allow industry to liaise directly with hospital Trusts, primary care bodies and care organisations for fast track targeted purchasing to unblock this ASAP.

    Why has the government persisted in shipping PPE/ventilators equipment from abroad  –  some of it substandard or out of date  – when we have received skilled offers from such as GTech in Worcester offering 30k ventilators ( not CPAPs) and the British textiles manufacturing industry being continually blocked from their significant capacity to provide PPE  – some of which is now going abroad in frustration?

    Tough Questions

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