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    SHA COVID-19

    Blog 5  

    12th April

    The Socialist Health Association (SHA) has published its weekly Blogs on the COVID-19 pandemic since the 17thMarch 2020. This provides a narrative of political and health issues over the past 5 weeks.

    A lot has happened over the past week and we will address some of these developments from our socialist health perspective.

    1. Situation update

    So far in our Blogs we have drawn attention to how the UK has been to slow to respond to the pandemic threat since the warnings from Wuhan started at the end of December 2019 and were confirmed in mid January 2020. This was despite the fact that an infectious disease pandemic ranks No 1 in the UK government risk register and we knew that this was a Sars like virus.

    The Tory government had not paid attention to the various simulation exercises that have been done over the past few years most notably Exercise Cygnus in 2016, during Jeremy Hunt’s time as SoS for Health. The exercise simulated ‘swan flu’ and showed that there was a serious risk that the NHS would be overwhelmed with lack of PPE and insufficient ITU beds. Recommendations to increase stockpiles were ignored in a time of austerity and PPE equipment such as face visors were evidently deemed too difficult to store. It is interesting to note that many of the facemasks have a use by date from before that time. Even as far back as the Swine flu pandemic in 2009 the relatively small number of ITU beds has not been addressed and we have seen how relatively low the NHS acute bed numbers, as well as the ITU beds/1000 population are comparatively. The government have it seems been more interested in preparing for Brexit at the end of January than for a real pandemic threat. Instead of building up stockpiles of ventilators and other equipment the government have had to turn in emergency to their friends such as Dyson and JCB but it is no surprise that delivery takes time as medical equipment needs testing and tough quality assurance.

    We have also pointed to the laisser faire approach to this pandemic even after it became a global threat. The scientific advisory group ‘modellers’ had by late February warned the government that the country faced the possibility of suffering 500,000 deaths from Covid-19. So at this time we knew that this was a virulent virus that was easily transmitted person to person and if not suppressed would spread within communities rapidly and seek to move out to new areas. The religious community in South Korea was a clear case of transmission from Wuhan and rapid spread within a religious community in Daegu. In mid February this was traced back to Patient 31 by their effective contact tracing and testing protocol. South Korea, to their credit, stamped on the virus and did not allow it to spread and has only had just over 200 deaths within its population of 52m who continue to enjoy freedoms outside lockdown.

    As the virus began to spread we saw countries closing their borders and screening people arriving from air or sea. New Zealand and Australia are examples of this tough policy and they have managed to keep the virus from penetrating the country at scale. New Zealand has had four deaths and Australia 60 by 12th April. The UK note is also surrounded by sea and with Ireland is a separate landmass from Europe but we have not introduced any significant border health checks at any time.

    In Europe we all watched with mouths open when health services in Lombardy were overwhelmed and people who had been on skiing holidays had already returned to the UK and started to spread the virus here. What actions did the Border Forces take? How actively did we follow up reports of fever and cough in returning travellers? Do we even now check peoples travel history and report symptoms on return to the UK? Our death rates now are moving to exceed Italian and Spanish rates and compete to be the worse in Europe.

    Some of the success of countries such as Germany and Denmark has been closing their borders and undertaking health checks, testing and advising quarantining/isolation if needed. Denmark closed the border on 13th March (final day of the UK Cheltenham Gold Cup meeting in the UK) and a few days later closed schools, universities and banned gatherings of more than 10 people. Denmark which, is a small country of only 5.6m, has had 273 deaths by the 11th April. Scotland in comparison with a population of 5.5m has already had 566 deaths. Denmark is now considering loosening the lockdown requirements whereas Scotland still fears new spread.

    However frightening Covid-19 virus is in terms of its effects on people it is a virus, susceptible to soap and water and unable to spread between human beings unless spread by aerosol or droplets by coughs and sneezes or hand to face contamination. Basic communicable disease methodologies work – hence the WHO advice to test, trace and treat by isolation. No need to rely exclusively on mathematical models but tried and tested methods of infectious disease control measures. We hear very little of the most basic ‘tests’ namely asking people about their contact history and what symptoms they have. In the early days of this pandemic we had all heard about the cardinal symptoms and signs of Dry Cough and Fever. In the current situation that is enough for classification as a possible if not probable case. This then needs follow up with an antigen PCR test to confirm. Tracing other contacts and testing them and all contacts need to be isolated/quarantined. We realise that we have missed the boat now but should acknowledge that this is basic public health methodology in use for decades but not used here even at the start of the epidemic spread in the UK. Public Health trainees were often told – use more shoe leather than computer software when involved in outbreak management. The UK seems to be bemused by other countries testing temperatures with thermal imaging meters or checking if people have stayed in isolation as advised. God forbid people wearing face masks either!

    In earlier blogs we have also referred to the reluctance to learn from policies in countries that have been successful in suppressing the pandemic. Take facemasks, which are used widely in Asian countries, who have had success in controlling spread. It just seems to make sense (have face validity) that a virus transmitted from nose and throat to others would be hindered in person to person spread if everyone was wearing a face mask. A recent review by the respected evidence based group in Oxford recommends the precautionary principle in a time like this. The CDC in the US is recommending the use of facemask too especially as we look to reducing lockdown rules. Rather than say we need a randomised control trial – just do it! Of course in the UK it is almost impossible to buy quality facemasks, hand sanitiser gel or often latex gloves!

    The situation we find ourselves in is that PPE seems to be rationed and sadly there remain reports from NHS and social care clinical staff that they cannot get proper PPE supplies. Again we see TV reports of other countries in the world where many essential workers –non health care providers have access to PPE equipment which reassures them and is symbolic to others about the risk of cross contamination. Our bus drivers and other public facing non-NHS public servants have been exposed to risk.

    The government has struggled with scaling up the logistics and thanks to the Armed Forces supplies are getting through. However Public Health England (PHE) who were fast off the blocks once the Chinese Government shared the genome of Covid-19 have been unable to seriously scale up the PCR testing capacity. It remains to be seen whether the 100,000 tests by the end of April will be delivered. It is said by management consultants – ‘Never promise more than you can deliver’. It is also recommended; ‘don’t stretch the truth’. We have sadly seen this transgressed by Matt Hancock promising the ramping up of testing, supply of PPE. His boast of purchasing 3.5m antibody tests before they have been shown to be valid is embarassing. Reminds us of the Brexit Ferry contract from a company that had never managed a Cross Channel Ferry service.

    The vaccine is of course much more important than the antibody test and we applaud the progress that researchers have made but do caution that we should not promise more than can be delivered. A safe and effective vaccine requires safety and effectiveness trials and this all takes time.

    1. Inequalities and risk factors

    One of the striking findings of this pandemic is the susceptibility of Black and Minority Ethnic (BAME) groups to the virus. It has been striking that the first group of doctors who have given their lives to the virus have been Black or South Asian heritage. Some of the areas where the NHS has had pressures are also areas with relatively high Asian populations (Brent, Luton, West Midlands). This risk factor will of course have social, economic and cultural determinants alongside some biological factors such as a higher risk of diabetes and cardiovascular disease. There are very few health conditions where socio-economic factors do not affect incidence and prevalence. The two hospital porters from Oxford who died recently of Covid-19, were out sourced workers, both of Filipino heritage and like doctors and nurses exposed to risk at work. Their NHS fellow workers allegedly offered to share PPE in the early stages of the pandemic!

    We are familiar with the social gradient of disease and death. So it is no surprise that in the USA we are also seeing African American citizens are losing their lives disproportionately. For example in Michigan 15% of the population is black, but account for 40% of the deaths. Chicago has a 30%  African American population and this group have a 70% death rate. These ratios are also reflected in Louisiana in the deepsouth, especially New Orleans, where the Mardi Gras celebrations continued regardless of the pandemic.

    These global health inequalities will also be mirrored in Africa when the virus moves down that continent. Think of our discourse about the dearth of PPE and medical equipment such as ventilators. In the Central African Republic of the Congo (CARC) with its 5m population it is estimated that they have 3 ventilators. On the international market prices have responded to demand. Costs of a ventilator on the market have jumped from $9000 to $20,000 over the past few weeks. The CARC‘s GDP/capita is $1.3 per day with very poor health infrastructure.

    It is good to hear that the British Government has donated Aid to the UN and WHO to support Low and Middle Income Countries combat the pandemic. It is in all our interest that these countries and their people weather the storm. One World and Planetary Health – we are all mutually dependent.

    1. 3. Political Leadership

    One of the issues that has emerged through the experience so far with this public health emergency is the quality of political leaders. We have already drawn attention to Denmark with Mette Frederiksen who is a woman and the country’s youngest–ever PM. Last week we referred to Angele Merkel’s clear leadership in Germany, which is doing extremely well so far in controlling Covid-19. Think too of Jacinda Ardern the Labour Prime Minister in New Zealand who in her short time as PM has had to deal with three different emergencies – the Mosque massacre, the Whakaari/White Island volcanic eruption and now the Covid-19 pandemic.  She has provided exemplary leadership by going hard and going early. She placed the country in total lockdown on the 25th March and softened the blow by using a slogan – ‘be kind’. Epidemiologists have praised her ‘brilliant, decisive and humane leadership which has seen New Zealand achieve a remarkably efficient implementation of the elimination strategy. Of course the country will still be susceptible to Covid-19 but the health protection measures have worked so far and unlike the UK will not have such high death rates/population.

    1. A great science policy failure?

    Richard Horton, Editor of the Lancet, has said that the global response to Sars-CoV-2 is the greatest scientific policy failure in a generation. The signals were clear. Hendra in 1994, Nipah in 1998, Sars in 2003, Mers in 2012 and Ebola in 2014; were all caused by viruses that originated in animal hosts and crossed over into humans. Covid-19 is caused by a variant of the same coronavirus that caused Sars. The US Institute of Medicine (IOM) in 2004 concluded that; “the rapid containment of Sars is a success in public health, but also a warning. If Sars recurs health systems worldwide will be put under extreme pressure and continued vigilance is vital”

    The IOM report quoted Goethe:

    Knowing is not enough; we must apply.

    Willing is not enough; we must do”

    Sadly we have known about this threat since Sars emerged in 2003 and we have undertaken simulation/emergency planning exercises as recently as 2016 which tested resilience for ‘swan flu’. However it looks like we did know but we did not act.

    13.4.2020

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

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

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

    1. From a Unison rep in NHS Greater Manchester:

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

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

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

     

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

     

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

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

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

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

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

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

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

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

    Blog from Vivien Walsh

    Comments Off on News From the Frontline

    Jeremy Corbyn wrote a long letter to Boris Johnson on 31st March.
    As well as wishing him a speedy recovery, Jeremy made some strong points about aspects of the current crisis, and asked for immediate action on:

    • Full PPE now for Health and social Care workers
    • Test Test Test
    • Expand Social Care
    • Enforce Social-distancing and Protection
    • Bolster Support for Workers
    • Lead a Global Reponse

    (the 4  pages of the letter are attached)

    Posted by Jean Smith on behalf of SHA member Diane Jones.

    Comments Off on A request from Jeremy Corbyn for Urgent Action on the Corona Virus crisis
    Unite national officer for health Colenzo Jarrett-Thorpe said: “At this time of national emergency caused by the coronavirus pandemic, it is right that the legal protections covering whistleblowers in the NHS are highlighted.
    “Unite, which has 100,000 members in the health service, will be monitoring the situation very closely in the weeks ahead and will give maximum support to any member who may face disciplinary procedures as a result of raising legitimate concerns, for example, the lack of personal protective equipment (PPE).
    “The current legislation protecting whistleblowers has been further underpinned by the NHS Staff Council statement of 28 February and the English Social Partnership Forum statement on 1 April.
    “Any NHS worker that suspects they are being victimised for whistleblowing should contact their ‘freedom to speak up’ guardian which every trust in England should have in place. If they are a union member, they should contact their workplace representative or local union office.
    “There have been anecdotal stories on social media that some NHS bosses may have been clamping down on those wishing to expose failings in the system and improve the well-being of patients. If we discover concrete evidence that this is happening, we will act immediately to support our members.”

    The NHS Staff Council statement of 28 February 2020

    https://www.nhsemployers.org/-/media/Employers/Documents/Pay-and-reward/NHS-Staff-Council—Guidance-for-Covid-19-Feb-20.pdf?la=en&hash=70C909DA995280B9FAE4BF6AF291F4340890445C&hash=70C909DA995280B9FAE4BF6AF291F4340890445C

    English Social Partnership Forum Joint Statement on Industrial relation – 1 April 2020

    https://www.socialpartnershipforum.org/media/166314/SPF-Covid-19-statement-final-and-formatted.pdf

    Protection for whistleblowers in the UK is provided under the Public Interest Disclosure Act 1998 (PIDA).The PIDA protects employees and workers who blow the whistle about wrongdoing.

    For more information please contact Unite senior communications officer Shaun Noble

    Email: shaun.noble@unitetheunion.org

    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.
    Comments Off on Unite statement on whistleblowing in the NHS during the coronavirus emergency

    31/03/2020 cllralanhall BlogPress Leave a comment

    Personal Protective Equipment, known as PPE is in demand. There are reports that there is a shortage in hospitals and care facilities.

    The Daily Mirror reports that hospitals listed as having shortages include Rotherham General Hospital, Bristol Children’s Hospital, Hillingdon Hospital in Uxbridge, Royal Devon and Exeter Hospital and at St Thomas, Lewisham and two other unnamed hospitals in London.

    “The correct PPE must be made available at every site that might require it. This is vital in order to protect our patients but also to protect the lives of the life-savers.”
    DAUK’s Dr Natalie Ashburner in 

    @DailyMirror @nashburner#COVID19 #testNHSstaffhttps://t.co/Mhd2UISZeF

    — The Doctors’ Association UK (@TheDA_UK) March 19, 2020

    The view from the NHS frontline is explained here:

    https://youtu.be/WphmagWsCUI

    Dr Samantha Batt-Rawden, an intensive care doctor and president of the Doctors’ Association UK, told Nick Ferrari that more doctors will die unless they get proper equipment.

    In a further twist, healthcare workers who raise their concerns are facing being “gagged”. Helen O’Connor, GMB says in The Guardian “It is scandalous that hospital staff speaking out publicly face being sacked by ruthless NHS bosses

    who do not want failings in their leadership to be exposed. Suppression of information is not just a matter of democracy, it is now a major public health issue.”

    The Local Government Association has sent a letter to the Secretary of State for Health, Matt Hancock MP. It says that there is an urgent need for Government to move faster in making PPE available for the adult social care sector. Sufficient supplies that are of acceptable quality are needed immediately. Councils and their provider partners also need concrete assurances about ongoing supplies for the days and weeks ahead.

    Councillor Alan Hall has written to the Director of Public Health for Lewisham seeking reassurances for both hospital and social care staff locally. The full letter is below:

    Catherine Mbema
    Director of Public Health – Lewisham

    Dear Catherine,

    I have been informed that the lack of Personal Protective Equipment for cleaning staff at Lewisham Hospital is a real concern. Trade Unions say that there is a shortage of supply and that staff are very worried. It has been described as “a total nightmare”.

    As the Public Health Lead across Lewisham, I would be very grateful if you could raise the shortage of supply with the NHS and the Hospital and reassure us that PPE will be available.

    Whilst I write, personal carers have reported shortages and inadequacies nationally. Can an assurance that all Lewisham Council and NHS staff have been provided with effective PPE?

    May I take this opportunity to thank you and your team for all the incredible work that has been placed upon you. I have always campaigned against Public Health cuts and the short sightedness of this is surely been borne out now.

    Kind regards,

    Alan

    Cllr Alan Hall

    In an article on the United Nation’s website, there is a chilling message:

    “COVID-19 will not be the last dangerous microbe we see. The heroism, dedication and selflessness of medical staff allow the rest of us a degree of reassurance that we will overcome this virus.

    We must give these health workers all the support they need to do their jobs, be safe and stay alive. We will need them when the next pandemic strikes.”

    Please help: NHS Staff need adequate PPE now https://t.co/XLsLDNaz5g via @socialisthealth

    — Alan Hall (@alan_ha11) April 1, 2020

    Comments Off on PROTECT ALL FRONTLINE HEALTHCARE WORKERS

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

    1. Global crisis

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

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

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

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

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

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

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

    1. The public health system

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

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

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

    1. Local government and social care

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

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

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

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

    1. The NHS

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

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

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

    1. Maintaining people’s standard of living

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

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

    1. Conclusion

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

    24th March 2020

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    20/03/2020

     

    OPEN LETTER TO THE PRIME MINISTER FROM THE SOCIALIST HEALTH ASSOCIATION

    Dear Mr Johnson,

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

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

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

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

    1. You are placing staff at risk

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

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

    1. You are placing patients at risk

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

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

    1. You are placing communities at risk

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

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

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

    This pandemic is likely to add to that grotesque toll.

    1. You are placing the NHS at risk

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

    1. You are placing Social Care at risk

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

    1. You are placing democracy at risk

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

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

     

    WE EXPECT YOUR GOVERNMENT TO:

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

     

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

     

    Chair SHA

    Dr Brian Fisher, London

    Vice-chairs SHA

    Dr Tony Jewell

    Tony Beddow, Swansea

    Norma Dudley, London

    Mark Ladbrooke, Oxford

    Secretary

    Jean Hardiman Smith, Ellesmere Port

    Treasurer

    Irene Leonard, Liverpool

    Co-Chair KONP

    Dr Tony O’Sullivan, London

     

    Co-signatories

    Dr John Carlisle, Sheffield.

    Terry Day, London

    Carol Ackroyd, London

    Corrie Louise Lowry, Wirral

    Caroline Bedale, Oldham

    Hazel Brodie, Dumfries

    David Taylor-Gooby, Newcastle

    Peter Mayer, Birmingham

    Dr Alex Scott-Samuel, Liverpool

    Dr Jane Roberts, London

    Dr Judith Varley, Birkenhead

    Vivien Giladi, London

    John Lipetz, London

    Jane Jones, Abergavenny

    Dr Kathrin Thomas, Llandudno

    Dr Louise Irvine, London

    Dr Jacky Davis, London

    Dr Coral Jones, London

    Dr Nick Mann, London

    Dr John Puntis, Leeds

    Brian Gibbons, Swansea

    Anya Cook, Newcastle,

    Alison E. Scouller, Cardiff

    Punita Goodfellow, Newcastle upon Tyne

    Parbinder Kaur, Smethwick

    Gurinder Singh Josan CBE,  Sandwell

    Jos Bell, London.

    Steve Fairfax Chair SHA NE, Newcastle upon Tyne

     

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

    4 Comments

    COVID-19 Pandemic

    The SHA wants to contribute to the tremendous national and international debate about controlling and mitigating the worst effects of the COVID-19 pandemic. We will base these thoughts through the lens of a socialist society, which advocated politically in the 1930s to create the NHS in the UK and for other socialist policies, which see the social determinants of health being as important as the provision of health and social care services as we strive for a healthier and fairer society.

    This blog will be the first of a series and will cover

     

    1. A global crisis
    2. The Public Health system
    3. The NHS, Local Government and Social Care
    4. Funding for staff and facilities
    5. Staff training, welfare and support
    6. Vulnerable populations
    7. Assuring Universal Basic Income

     

    1. A global crisis

    This COVID-19 pandemic has already been cited as the greatest public health crisis for at least a generation. The HIV/AIDS pandemic starting in the 1980s had a much slower spread between countries and is estimated to have caused an estimated 25-30m excess deaths so far.  The potential scale of this type of respiratory viral infection pandemic with a faster spread means we should probably look back to the 1957 Asian flu pandemic and indeed the 1918 post war ‘Spanish flu’. The 1918 pandemic led to an estimated 40-50m global deaths and was when there was also no effective vaccine or treatment for the new variant of flu. So basic public health hygiene (hand washing), identifying cases and quarantining (self isolation) are still important. We recognise this as a global challenge, which requires global solidarity and the sharing of knowledge/expertise and advice.

    The WHO, which is part of the United Nations, needs our support and is performing a very beneficial role.  This will be especially important for those Low Middle Income Countries (LMICs) who often have unstable political environments and weak public health and health systems. Remember the Democratic Republic of the Congo who have only just seen off their Ebola epidemic, war torn Syria and the Yemen.

    The USA and other high-income countries should be unambiguous about recognising this as a fundamental global pandemic requiring collaboration between countries along the principles of mutual aid. The UN and WHO need our support and funding and we look to international financial organisations such as the IMF/World Bank to rally around in the way that the world banking system showed they could in their own self inflicted 2008 financial crash. The WHO has recently referred to Europe as the epicentre of the pandemic and we urge the Government to put aside their ideological objections and co-operate fully with the EU and our European partners.

     

    1. The public health system

    The UK itself is in a relatively strong position with a national public health service, which has focus at a UK level (CMO/PHE), scientific advisory structures (SAGE), devolved governments, municipalities and local government. The NHS too still has national lines of control from NHSE to the NHS in England and the equivalents in devolved countries. The Tory ‘Lansley’ reforms in England destroyed the health authority structure below national levels (remember the former Strategic and District Health Authorities) but at least PHE has a regional organisation and Local Government have Directors of Public Health. We regret the fact that the 10 years of Tory austerity has depleted the resources in PHE and Local Government through not funding the PHE budget adequately and not honouring the public health grant for local authorities. We hope that the recent budget will mean that the public health service and local government does receive the financial and other resources required to help lead the pandemic response. Pandemics have always been high up in the UK risk register.

     

    1. The NHS, Local Government and Social Care

    We are grateful that despite the privatisation of many parts of the NHS in England we still have a recognisable system and a culture of service rather than profit within our one million or so staff and their NHS organisations. We were pleased to hear the open ended funding commitment from the Chancellor at the last budget and urge that leaders within the NHS in England and the devolved countries use this opportunity to try to mitigate the underfunding over the last 10 years and implement the emergency plans that exist and calibrate them to deal most effectively with this particular viral threat. Any debates about further privatisation of the NHS needs to be taken off the agenda and let’s not use the budget money to prop up the private sector but requisition capacity if that is what is needed and compensate usage on an NHS cost basis. We want to protect the NHS from the risk that the NHS Long Term Plan proposals for 44 Integrated Care Schemes opens up the risk of US styled private insurance schemes.

     

    1. Funding for staff and facilities.

    It will of course be difficult as a result of the staffing crisis that has been allowed to drift over the past 10 years with shortages of NHS workforce of 100,000 of which 40,000 are nurse vacancies but also includes doctors and other key staff. We and our Labour Party colleagues have been reminding Tory Ministers  that it takes 10 years to train a medical specialist so you cannot whistle them up or poach them from other poorer countries. The government needs to abolish their proposed points based immigration regime and indeed the compulsory NHS insurance of £650 per adult which is a huge disincentive to come here and work in the health and social care system.

    Hospitals and other health facilities in the UK take time to plan, build and commission. We can of course learn from Wuhan in China where they built a 1000 bedded hospital in weeks! Our own war preparation in the late 1930s when industry shifted production rapidly from civilian to military supplies is another exemplar. Despite the negative impact of 10 years of Tory austerity we urge the NHS to embrace this opportunity to invest in staff, supplies and facilities needed to manage the effects of the pandemic. Creating strategic regional NHS bodies will ensure that capital and revenue resources committed from the centre are used optimally and equitable to meet population needs in collaboration with local authorities.

     

    1. Staff training, welfare and support

    Front line NHS and social care staff will need our support over this time. We must ensure that working practices protect staff as much as possible from the risks in the workplace. Training and provision of Personal Protective Equipment (PPE) is vital and employment practices will need to adapt to the changing situation. Lets not forget social care workers, dentists, optometrists and district nurses who are part of our front line. Staff will need retraining if doctors and nurses are to be diverted to unfamiliar roles as we will need A&E, pandemic pods and intensive care unit capacity to be enhanced. Sadly, we now have a significant workforce who work for private contractors as part of the Tory privatisation of the NHS. We need to ensure that they have the same employment safeguards, minimum pay levels, sick pay and the health and safety entitlements as NHS staff. This is the time to renationalise such services back into the fold.

     Patients with existing long-term conditions remain in need of continuing care as will patients presenting with new life-threatening conditions such as cancers, diabetes and circulatory diseases. NHS managers will need support to organise these different services and decisions to postpone non-urgent elective surgery to free up resources. What also makes sense is testing novel ways of supporting people digitally and by teleconferencing to reduce attendance at NHS premises. This can be rolled out for Out Patient provision as well as GP surgeries. The NHS 111 service, and other online services  and the equivalents in the devolved nations can easily be overwhelmed so pushing out good health information and advice is being done and needs to continue. The public and patient engagement has always been at the heart of our policies and can be rolled out in this emergency utilising the third sector more imaginatively.

     

    1. Vulnerable populations.

    In our assessment of what needs to be done we must not bypass the urgent needs of some of our most vulnerable populations. The homeless and rootless populations, many of whom have longstanding mental health conditions and/or substance dependency, are particularly at risk. They need urgent attention working closely with the extensive voluntary sector. Also those populations with long term conditions who will feel at risk if services are withdrawn due to staff redeployment or staff sickness need planning for. Primary care needs to be the service we support to flag up those in need and ensure that their medications and personal care needs continue to be met even if we need to involve volunteers and good neighbours to help out with daily needs such as shopping/providing meals and other tasks.

    Undocumented workers such as migrants and refugees are often frightened to use health services for fear of police intrusion. The government needs to make it clear that there will be no barriers to care for this population during this crisis and beyond.

    Social care is in need of particular attention. It was virtually ignored in the budget. This sector is at risk in terms of problems with recruiting and retaining staff as well as the needs of the recipients of care and support.. While business continuity plans may be in place there is no question that this sector needs investment and generous support at the time of such an emergency. They will be a vital cog in the wheel alongside home-based carers in supporting the NHS and wider social care system. Those most at risk seem to be the most neglected. Disabled people with care needs have received little advice and no support. Already carers are going off sick and can be replaced only with great difficulty. Those paying for their own care with Direct Payments seem to get no support at all.

    With the COVID-19 virus we are seeing that the older population and those with so called ‘underlying conditions’ are at particular risk. We must ensure that this large population do not feel stigmatised and become isolated. Rapid assembly of local support groups should be encouraged which has been referred to as ‘local COBRA groups’. Local government can play a key role in establishing local neighbourhood centres for information and advice on accessing support as we move toward increasing quarantining and isolated households. Again wherever possible the use of IT and telephone connectivity to share information and provide remote support will make this more manageable.

     

    1. Assuring universal basic income.

    Finally the SHA recognises that the economy will be damaged by the pandemic, organisations will go to the wall and staff will lose their jobs and income stream. We have always recognised that the fundamental inequalities arise from the lack of income, adequate housing and the means to provide for everyday life. This pandemic will last for months and we think that the Government needs to ensure that we have systems in place to ensure that every citizen has access to an adequate income through this crisis. We pay particular attention to the 2m part time workers and those on zero hours contracts as well as the 5m self-employed. There have been welcome changes in the timely access to the insufficient Statutory Sick Pay but this is not going to be the answer. People will be losing their jobs as different parts of the economy go under as we are already seeing with aviation, the retail sector and café/restaurants. The government needs to reassure those fearful of losing their jobs that they will stand by them during the pandemic. It may be the time to test the Universal Basic Income concept to give all citizens a guarantee that they will have enough income for healthy living. We already have unacceptable health inequalities so we must not allow this to get worse.

     

    1. Conclusion

    The SHA stands ready to support the national and international efforts to tackle this pandemic. We assert our belief that a socialist approach sees universal health and social care as an essential part of society. That these systems should be funded by all according to a progressive taxation system and meet peoples needs being free at the point of use.  We believe that a thriving state owned and operated NHS and a complimentary not for profit care sector is essential to achieve a situation where rich and poor, young and old and citizens in towns, cities and in rural areas have equal access to the best care.

    We recognise that the social determinants of health underpin our health. We agree with Marmot who reminds us that health and wellbeing is reflected by ‘the conditions that people are born, grow, live, work and age and by the inequities in power, money and resources that influence these conditions’.

    The pandemic is global and is a major threat to people’s health and wellbeing. Universal health and public health services offer the best means of meeting this challenge nationally and globally. Populism and inward looking nationalism needs to be challenged as we work to reduce the human suffering that is unfolding and direct resources to meet the needs of the people at this time.

    On behalf of officers and vice chairs

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    “Like everyone else, we feel helplessness, anxiety, and fear.”

    by Dan Robitzski / 8 hours ago

    As they try to fight the COVID-19 outbreak, medical staff in China are suffering from the seemingly endless slog of work, new cases, and the coronavirus itself.

    Nurses in Wuhan, the city where the outbreak began, are fainting on the job, developing painful rashes, sores, hypoglycemia, and psychological exhaustion — and that’s why two of them published an impassioned plea for help from the rest of the world in the journal The Lancet on Sunday.

    “While we are professional nurses, we are also human. Like everyone else, we feel helplessness, anxiety, and fear,” the authors, Yingchun Zeng and Yan Zhen, both from hospitals in Guangzhou, wrote. “Experienced nurses occasionally find the time to comfort colleagues and try to relieve our anxiety. But even experienced nurses may also cry, possibly because we do not know how long we need to stay here and we are the highest-risk group for COVID-19 infection.”

    Nearly 2,000 medical workers helping COVID-19 patients in China have been infected, and at least nine have died. Meanwhile, the nurses write that the safety measures they have to follow, like quadruple-layering gloves and constantly wearing and washing tight respirators that are giving them bedsores, are simultaneously making them sick and rendering them useless as caregivers.

    For instance, unpackaging medical supplies and giving a patient a shot while wearing four layers of latex gloves is particularly difficult.

    “Due to an extreme shortage of health-care professionals in Wuhan, 14,000 nurses from across China have voluntarily come to Wuhan to support local medical health-care professionals,” the nurses wrote. “But we need much more help. We are asking nurses and medical staff from countries around the world to come to China now, to help us in this battle.”

     

     

     

    1 Comment

     

    Make the UK the safest place world to have a baby!

    Why is the UK still not in the top ten countries for infant mortality and for maternal deaths? Why? We are a rich country. We have an established high-quality health service. Healthcare is supposed to be accessible to all. How come babies and mothers die or are badly hurt at birth? How come Black and Ethnic minority babies suffer most? Why do poor areas have worse outcomes than wealthy areas? Why is infant mortality rising? (The infant mortality rate is the number of children that die under one year of age in a given year, per 1,000 live births. The neonatal mortality rate is the number of children that die under 28 days of age in a given year, per 1,000 live births. These are both common measures of health care quality, but they are also influenced by social, economic and environmental factors). Are there fundamental problems with core policy documents like the maternity review “Better births”? These are painful questions.

    Our campaign wants real improvements for mothers and babies. This posting is not intended as a clinical paper, it is a discussion amongst activists and concerned citizens about where the problems lie. A key set of participants in this discussion are mothers who have given birth, including those who have lost babies, grandmothers and other birth partners, and women who could not conceive.

    Our campaign published our Maternity Manifesto during the election but though well shared on Facebook, it did not get into any parties’ manifesto.

    We also called a national meeting on issues in maternity care.

    What then are the factors that result in UK outcomes at birth worse than other advanced countries?

    The answers include shortage of NHS funding, staffing shortages, poor management in some hospitals, staff in fear of speaking out, some policies and procedures, disrespect towards the women carrying the baby, and, as cited in the East Kent enquiry, a lack of practical understanding by staff and by mums of the need to “count the kicks” in the latter part of pregnancy. The introduction of charges for migrant women has also caused deaths. NHS material seems to centre the cause on mothers who smoke, or who are overweight. (Now smoking in pregnancy is plain stupid, it really is, and most mums would not do so if they were not addicted. Don’t do it!). However, other countries, Greece for example, who smoke more, have better outcomes in pregnancy than does the UK. Wider problems like obesity and diabetes, and even women giving birth older, are mentioned in the literature about this. Again, the age of the mother as a factor, but this is only partly true. Giving birth older is often safer than giving birth too young. Globally it is most often young girls who die in childbirth.

    Answers may lie in the financially and emotionally vulnerable place that pregnant women occupy in our society, including poverty, violence and stress. Poverty and inequality are factors in infant mortality; “The sustained and unprecedented rise in infant mortality in England from 2014 to 2017 was not experienced evenly across the population. In the most deprived local authorities, the previously declining trend in infant mortality reversed and mortality rose, leading to an additional 24 infant deaths per 100 000 live births per year (95% CI 6 to 42), relative to the previous trend. There was no significant change from the pre-existing trend in the most affluent local authorities. As a result, inequalities in infant mortality increased, with the gap between the most and the least deprived local authority areas widening by 52 deaths per 100 000 births (95% CI 36 to 68). Overall from 2014 to 2017, there were a total of 572 excess infant deaths (95% CI 200 to 944) compared with what would have been expected based on historical trends. We estimated that each 1% increase in child poverty was significantly associated with an extra 5.8 infant deaths per 100 000 live births (95% CI 2.4 to 9.2). The findings suggest that about a third of the increases in infant mortality between 2014 and 2017 can be attributed to rising child poverty (172 deaths, 95% CI 74 to 266).” (Our bold for emphasis).

    The UK is a rich advanced country, with a long history of universal healthcare but we have rising infant mortality. “Rising infant mortality is unusual in high-income countries, and international data show that infant mortality has continued to decline in most rich countries in recent years” and “In the most deprived local authorities, the previously declining trend in infant mortality reversed and mortality rose, leading to an additional 24 infant deaths per 100,000 live births per year, relative to the previous trend“.

    Poverty is not the sole cause of high Infant Mortality though, Cuba has good outcomes equal to the UK for infant mortality. Cuba is very poor indeed and the UK is one of the wealthiest economies (sadly Cuba does less well on maternal deaths).  

    Research shows out of 700,000 births a year in England and Wales, around 5,000 babies are stillborn or die before they are a month old”. 5,000 babies each year. There have been major news stories about baby deaths in many hospitals, notably in ShropshireEast Kent and Morecombe Bay.

    Maternal deaths. The UK is not in the top ten countries with the lowest infant mortality rate, neither is it the safest place to give birth. In 2015-17“209 women died during or up to six weeks after pregnancy, from causes associated with their pregnancy, among 2,280,451 women giving birth in the UK. 9.2 women per 100,000 died during pregnancy or up to six weeks after childbirth or the end of pregnancy.” In 2016 The UK ranked 24th in the world in Save the Children’s Mothers’ Index and Country Ranking Norway, Finland, Iceland, Denmark, Sweden, Netherlands, Spain, Germany, Australia, Belgium, Austria, Italy, Switzerland, Singapore, Slovenia, Portugal, New Zealand, Israel, Greece, Canada, Luxembourg, Ireland, and France, all did better than the UK. The situation in some other countries is massively worse than here but that is no excuse. But these baby and mothers’ deaths must stop. We cannot sit back and let these deaths continue.

    Let’s be clear, the situation for women in pregnancy and childbirth is massively better than before the NHS, and is head and shoulders better than in the USA today. But maternal mortality is an issue here in the UK, and a huge issue in poorer countries, especially where women give birth without a trained professional being in attendance. Quite rightly professionals and campaigners in the UK participate in international endeavours to improve this situation. The NHS should be training and sending midwives to those countries, instead, it is recruiting midwives from poorer countries. In Europe we have cuts in healthcare through Austerity; in the global south, the same concept of cutting public services to the bone is called Restructuring.

    Why is the UK, a rich country with (almost) universal health care not doing better by its mothers and babies? Look at just this case and see the problems in the provision of maternity care;

    Archie Batten

    Archie Batten died on 1 September 2019, shortly after birth.

    When his mother called the hospital to say she was in labour, she was told the QEQM maternity unit was closed and she should drive herself to the trust’s other hospital, the William Harvey in Ashford, about 38 miles away.

    This was not feasible and midwives were sent to her home but struggled to deliver the baby and she was transferred by ambulance to QEQM where her son died. Archie’s inquest is scheduled for March. (BBC).

    We know that temporarily “closing” maternity units because they are full is a common occurrence. Women then have to go to a different hospital. Induction of labour can be halted because the unit is full. It is not a pleasant situation for mothers. Some maternity units have closed permanently, meaning mothers have to travel further for treatment, at a time when the ambulance service is under great strain (though being in labour is not considered an emergency for the ambulance service!).

    Shortage of Midwives and consequent overwork for the existing staff. The UK has a shortage of three thousand five hundred midwives. The midwife workforce is skewed towards older midwives who will retire soon.

    Gill Walton, general secretary and chief executive of the Royal College of Midwives said “We know trusts are facing huge pressures to save money demanded by the government, but this cannot be at the expense of safety. We remain 3,500 midwives short in England and if some maternity units regularly have to close their doors it suggests there is an underlying problem around capacity staffing levels.

    Training midwives is not just about recruiting new starters to university courses. There need to be sufficient training places in the Hospitals who are already working flat out, leaving little time for mentoring of students, as well as places in the Universities. Alison Edwards, senior lecturer in midwifery at Birmingham City University, who says: ‘It isn’t as simple as recruiting thousands more students as this requires the infrastructure to support it.

    ‘You need more tutors, more on-site resources and, perhaps more importantly, more mentors and capacity in placement areas – which is currently under immense strain.’ 

    One student midwife wrote about her experiences in this letter, where she described very hard work without either pay or good quality mentoring.

    The government and the NHS call for Continuity Care from Midwives. This means the same midwife or small team of midwives cares for the mother through her pregnancy, birth and postnatal period. We too believe this would be wonderful if it were possible. It is however impossible with the existing ratio of midwives to mothers. Providing continuity of care to the most vulnerable mothers is a good step. NICE have reduced this to the idea of each woman having a named midwife. One to One a private midwife company claimed to provide this but was unable to continue trading, and went bust leaving the NHS to pick up the pieces.

    Nationally the NHS is underfunded and looks set to continue so. Much of the problem comes from a long period of underfunding. We spend less than 9.8 per cent of GDP on health. Switzerland, Germany, France, Sweden, Japan, Canada, Denmark. Belgium Austria Norway and the Netherlands all spend more. That places the UK 13th in the list of high spenders on health care. The US spends 16.9 %. (although a lot of that money is diverted from patient care to the big corporations and insurance companies). The NHS was the most cost-efficient health care service in the world.

    Underfunding causes staff shortages. Some errors at birth come from staff being overworked and making mistakes.

    Some, our campaign believes, flow from fundamental flaws in government policy such as in the Maternity Review, where the pressure is on staff not to intervene in labour.

     Listen to the Mother. Some of the deaths are from women not being heeded in pregnancy and childbirth. This is backed up in reports from mothers, including some quoted in the big reviews mentioned above. However, overworked and tired staff who know labour like the back of their hand can easily stop heeding an inexperienced mother.

    Poverty kills mothers and babies. As we said above, some deaths, poor baby health, and injuries come from growing maternal poverty and ill-health. Low-income families find it hard to afford good food. Food poverty affects a staggering number of children. The charity UNICEF estimates that “2.5m British children, or 19%, now live in food-insecure households. This means that there are times when their family doesn’t have enough money to acquire enough food, or they cannot buy the full variety of foods needed for a healthy diet. In addition, 10% of these children are also classified as living in severe food insecurity (the European average is 4%) and as a result, are set to experience adverse health.”

    Studies show that;

    The Independent inquiry into inequalities in health (Acheson 1998) found that a child’s long term health was related to the nutrition and physique of his/her mother. Infants whose mothers were obese had a greater risk of subsequent coronary heart disease. Low birth weight (under 2500 g) was associated with increased risk of death in infancy and with increased risk of coronary heart disease, diabetes and hypertension in later life. Accordingly, the Inquiry recommended, ‘improving the health and nutrition of women of childbearing age and their children, with priority given to the elimination of food poverty and the reduction of obesity’. (NICE )

    A significant number of deaths of new mothers come from mental health issues that spiral out of control. Some of these will be newly developed conditions and some existing conditions made worse by pregnancy and childbirth. Mothers family and professionals must all be on the alert and intervene early. There are good ways to treat mental health in pregnancy.

    Reducing the social and economic stresses around pregnancy would also help reduce the deaths and suffering

    When Birth goes wrong it can be a dreadful experience for everyone involved. In most cases, the panic button brings in a well-drilled team of experts who can solve nearly every problem and do it calmly. At other times, it is dreadful, as described in the coverage of the birth and death of baby Harry Richford. Harry Richford was born at the Queen Elizabeth the Queen Mother Hospital in Margate in 2017 but died a week later. https://www.bbc.co.uk/news/uk-england-kent-51097200

    Sands, the baby death charity explains that there are many causes of babies dying before birth. Crucially important is that mothers are heeded when they are concerned and that everyone Counts the Kicks

     

    Maternity is not the only area of the NHS that suffers. There have been serious mistakes in NHS planning including closing far too many beds. The NHS closed 17,000 beds and now is working beyond safe bed occupancy. There are 100,000 staff vacancies. Waiting times in A and E are dreadful, as are waiting times for cancer treatment. NHS managers and the Government have taken the NHS far from the Bevan model of healthcare (for history read this).

    Press coverage. How does the press cover the NHS, and baby deaths? There are very real problems in the NHS and maternity care but the coverage in the press of these problems seems to switch on and off in strange ways, often to suit Conservative Party political requirements. The NHS and the Government are masters of propaganda and news manipulation. The public needs to learn to judge the news and to look both for actual problems and look out for bullshit and manipulation. Why was news of the arrest of the nurse from the Countess of Chester hospital headlines on the 70th Anniversary of the NHS? Why was the news of the understaffing there not given similar nationwide publicity? Why have we heard little or nothing since?

    If the government can switch the blame to the professionals in the NHS (but not their mates the high admin of the NHS), then they seem to be happy to publicise the problems. In other cases, problems are swept under the carpet.

    Professionals expect to (and do) take responsibility for their own actions. Mistakes will be made. It is impossible to go through life without some mistakes. When we are dealing with life and death mistakes can be catastrophic, even where there is no ill intent.

    Malicious action is rare.   There are the terrible cases of serial murderer Harold Shipman, and the convicted surgeon Ian Paterson who falsely told women, they had breast cancer and operated on them unnecessarily. The hierarchical system in the NHS and the lack of regulation in private hospital, which was described as “dysfunctional at almost every level” allowed that harmWe have not found such a case in maternity.

    Unintentional bad practice, however, has also harmed babies. No one went to work intending to harm in the events publicised in the Morecombe Bay Enquiry into the deaths of 11 babies and one mother. It was said that “The prime responsibility for ensuring the safety of clinical services rests with the clinicians who provide them, and those associated with the unit failed to discharge this duty over a prolonged period. The prime responsibility for ensuring that they provide safe services and that the warning signs of departure from standards are picked up and acted upon lies with the Trust, the body statutorily responsible for those services.”

    The Enquiry described what happens like this “In the maternity services at Furness General Hospital, this ‘drift’ involved a particularly dangerous combination of declining clinical skills and knowledge, a drive to achieve normal childbirth ‘whatever the cost’ and a reckless approach to detecting and managing mothers and babies at higher risk.”

    The Furness General Hospital was pushing for Foundation Trust status at the time and was not exercising the necessary supervision.

    “Maternity care is almost unique amongst NHS services: the majority of those using it are not ill but going through a sequence of normal physiological changes that usually culminate in two healthy individuals. In consequence, the safety of maternity care depends crucially on maintaining vigilance for early warning of any departure from normality and on taking the right, timely action when it is detected. The corollary is that, if those standards are not met, it may be some time before one or more adverse events occur; given their relative scarcity in maternity care, it is vital that every such occurrence is examined to see why it happened.

    So, many factors come into play in such incidents of harm to mother and baby. Professionals too can be emotionally wrecked by tragedy.

    Huge personal and professional lessons can be learned from a detailed review of cases where mistakes are made. There is a whole literature about learning from mistakes. The worst such incidents are referred to as Never Events. This is just one article about such errors but there is a whole field of research devoted to it. Serious Mistake Reviews often happen at the end of shifts, and in the worst cases, may lead to long public enquiries.

    NHS as a research organisation One of the great virtues of the NHS is the research base it offers professionals. What happens in the NHS which covers 62 million people is studied, evaluated, and researched. This is invaluable to staff and above all to patients. Sadly this research is also of interest to big business especially to those who sell health insurance and to the big corporations who have their ‘snouts’ in the NHS ‘trough’. Research for the common good is clearly different from research to make money. We see that regularly in big pharma. Cheap effective medicines do not make money for the companies. Yet the government is giving away our medical data to companies to make a profit.

    There are also “errors” that happen when everyone is following accepted procedures and protocols; “untoward events, complications, and mishaps that resulted from acceptable diagnostic or therapeutic practice”. Procedures within the NHS can be robust and well researched, and problems still occur.

    https://www.mamaacademy.org.uk/news/mbrrace-saving-lives-improving-mothers-care-2019/

    Research matters. Only by studying outcomes can these errors be revealed. A classic example is the once customary practice of episiotomy, cutting a woman to prevent tears to the perineal skin in childbirth, which is now no longer used except in an emergency. Research both formal and informal changed that practice. As another example of such research, Liverpool Women’s hospital has been involved in research about the benefits of leaving the baby attached by the cord if they are born unwell. NHS staff and other health professionals, academics and pressure groups are working hard to improve outcomes for mothers and babies. Each mothers death is reviewed in the MBRRACE-UK report

    https://mamadoc.co.uk/the-maternal-mortality-report-we-should-all-learn-from/

    Never again. The tragedy of the death of a mother and or baby is felt by that whole extended family. Most families want to know it will never happen again. Cover-ups and lies mean it will happen again, so brutal honesty is needed.

     

    The aftermath of medical treatment or neglect which causes real harm is complex. Whether the outcome is death, life long impairment, or long term physical and mental health issues, these are very significant events for all concerned.

    Campaigners in Liverpool campaign for SEN funding to be returned. 2019

    If a baby is born with life-changing impairments, the baby is left facing catastrophic difficulties and the mother and family can face major heartbreak and hardship. The huge love we have for our kids (may it long continue), whatever their issues, does not prevent the financial, housing and employment issues families with disabled children face. Nor does it guarantee the best educational opportunities, SEN is being battered by cuts. but parents and teachers are fighting back.

     

    The cost of financial “compensation” from an injury to a newborn is huge because it is life long. The cost of this “compensation” used to be carried by the government but the system changed to make hospitals “buy” insurance from a government body which is set up like an insurance company. The cost to the hospital is charged on the basis or earlier claims, like car insurance. Obstetrics make the highest claims of any section of the NHS.

    Liverpool Women’s Hospital had a huge case (not about babies) some years ago, arising from a surgeon who left many women damaged after incontinence operations. Their total bill, over 5 years, according to the Echo, was £58.8 million. “The NHS trust has been forced to pay out £58.8m in the last five years for both recent and historic negligence cases.

    The limited work we do, as a campaign, in holding the hospital to account, leads us to believe lessons have been learned by the hospital. However, in every hospital, there are pressures which could lead to problems. These pressures include financial and organisational, problems of management ethos, and the potential for bullying, the distrust by the staff of their management, and disrespect for whistleblowers.

    The NHS has gone through years of reorganisation after reorganisation. In that time the financial and government pressure has been to complete the re-organisation, or face catastrophic consequences so very many hours of admin and senior doctor time has been wasted on this process. That time could have been focussing on saving babies.

    At STP and national level, there are other problems. The NHS is intensely political. There are deep structural problems. (We believe the NHS should return to the Bevan Model of health care)

    The NHS is not only deprived of adequate funding, but it has also been forced to implement many market-based changes, including the internal market, outsourcing and commissions of services to for-profit companies. These market-based structures are expensive.

    The NHS has also seen dire staff shortages resulting from stupid decisions like removing bursaries, not training enough doctors and the hostile environment to migrant staff.

    There are moral and financial issues in all cases of such errors. The hurt to the babies is our priority.

    Baby deaths and severe injury at birth have complex roots. Though what happens in the hospital is crucial, it is not just what happens in the hospitals that matter. The stress, poverty and anxiety many mothers endure during pregnancy do sometimes affect the outcomes for the child. Many women are still sacked for being pregnant but families can rarely cope with just one wage (do fight back against sacking pregnant women!). See Maternity Action for details. Both mums and midwives can call Maternity Action for advice.

    Low pay or the dreaded universal credit can make food heating and rent all too expensive. This can lead to food poverty. Women do not yet have real equal pay but mothers have the worst pay of all  Benefits are no longer allowed for a third child. even though most claimants are working. Whether parents are working or not, every child has a right to food and shelter, be they first or 10th child. The child gets no choice!

    Not every pregnant woman is in a stable caring relationship. Housing, especially private renting, becomes more difficult when women are pregnant. Who can forget the story of the homeless woman giving birth to twins in the street? Pregnancy is often the time when domestic violence is inflicted on a woman but it is the time when women are least able to walk away. Poverty kills babies too.

    Please join us in campaigning for better outcomes for all mothers and babies in the NHS and across the globe. We want this to start a discussion, so please send us your views. and information

     

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    2 informative and extremely worrying videos from our Vice Chair, Dr Brian Fisher on the dire state of social care in England.

    Video 1: the current state of social care.

    This brief video, made for Reclaim Social Care, outlines what social care is and how it operates at the moment in England.

    https://photos.app.goo.gl/6kqUa7nbCjg2CEjt9

    Video 2: the impact of the cuts to social care:

    This brief video, made for Reclaim Social Care, outlines the impact of the cuts to social care. It ends with a plea to avoid voting Tory – sadly, that aspect is redundant now. The Tories have pledged more money for social care and that is likely to make a difference. But not enough to change things significantly on its own. And as the IFS says, austerity is “baked in” to a swathe of Tory plans.

    https://photos.app.goo.gl/W2cZz5h7WRbW9v2S8

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    Patients still make enquiries at busiest hours, despite 24/7 online access

    · University of Warwick publishes first independent evaluation of one of the main providers of online consultation platforms

    · Targeting services at younger patients and those with general administrative enquiries could be most effective

    · “In reality, patients were seeking access to health care at the same times and for the same sort of problems than they did using traditional routes.” Says supervising author.

    Patients are using online consultations in the same way they would arrange a consultation via traditional means, a new independent evaluation by the University of Warwick reveals.

    Despite this, the study identifies several opportunities to tailor online platforms to specific patient requirements and improve their experience.

    Primary care researchers from Warwick Medical School have today (26 March) published the first independent evaluation of one of the main providers of online consultation platforms in NHS general practice. Published in the British Journal of General Practice, it provides independently analysed information on the types of patients that are using online triage systems, how and when patients are using this platform, and what they think of it.

    Online triage is a system in which patients describe their problems via an online form and subsequently are telephoned by a GP to conduct a telephone consultation or arrange a face-to-face consultation. Practices aim to respond within one hour of receiving the request.

    The researchers examined routine information from 5140 patients at nine general practices using the askmyGP platform over a 10 week period. Highest levels of use were between 8 am and 10 am on weekdays (at their highest on Mondays and Tuesdays) and 8 pm and 10 pm at weekends, mirroring the busiest time for patients contacting their practice via telephone.

    Supervising author Dr Helen Atherton, from Warwick Medical School, said: “With online platforms there is an assumption that having a 24/7 ability to make contact with a general practice will cater to those who wish to deal with their health problem at a convenient time, often when the practice is shut, and that being online means they will perhaps share different problems than they would over the telephone or face-to-face.

    “In reality, patients were seeking access to health care at the same times and for the same sort of problems than they did using traditional routes. This suggests that patients’ consulting behaviour will not be easily changed by introducing online platforms. Therefore practices should be clear as to exactly why they are introducing these online platforms, and what they want to achieve for themselves and their patients in doing so – the expectation may well not meet reality.”

    The NHS Long term plan sets out that over the next five years all patients will have the right to online ‘digital’ GP consultations. The main way these are being delivered is via online consultation platforms. The online platforms claim to offer patients greater convenience and better access and to save time and workload for GPs, however there is currently a lack of independent evidence about their impact on patient care and care delivery.

    Patient feedback analysed as part of the study showed that many found the askmyGP system convenient and said that it gave them the opportunity to describe their symptoms fully, whilst others were less satisfied, with their views often depending on how easily they can normally get access to their practice, and on the specific problem they are reporting.

    The study found that two thirds of users were female and almost a quarter were aged between 25 and 34, corroborating existing evidence. The commonest reason for using the service was to enquire about medication, followed by administrative requests and reporting specific symptoms, with skin conditions, ear nose and throat queries and musculoskeletal problems leading the list.

    The researchers argue that practices should avoid a ‘one size fits all’ approach to implementing online consultations and should tailor them to suit their practice populations and model of access, considering whether it is likely to add value for their patient population.

    Dr Atherton adds: “Individual online consultation platforms are uniform in their approach, patients are not. We found that patient satisfaction is context specific – online consultation is not going to be suitable for all patients and with all conditions and that one approach is unlikely to work for everyone.

    “Practices could focus on encouraging people to deal with administrative issues using the platform to free up phone lines for other patients. It could be promoted specifically to younger patients, or those who prefer to write about their problems and not to use the telephone. Clear information for patients and a better understanding of their needs is required to capture the potential benefits of this technology.”

    · ‘Patient use of an online triage platform; a mixed-methods retrospective exploration in UK primary care’ published in the British Journal of General Practice, DOI: 10.3399/bjgp19X702197

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