Blog

  • Categories
  • Category Archives: Health Inequalities

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

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

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

     

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


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

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

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

     

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

     

    DIGITAL WORKING IS TRANSFORMING CARE

    Opportunities

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

    Challenges:

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

    Actions:

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

     

    SHIFTING TO PROACTIVE WORK WITH COMMUNITIES

    Opportunities

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

    Challenges:

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

    Actions:

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

     

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

    These have been thrown into sharp relief through the pandemic.

    Opportunities

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

    Challenges

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

    Actions

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

     

    PRIMARY CARE AND LONG-TERM CONDITIONS INC COVID

    Opportunities

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

    Challenges

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

    Actions:

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

     

    RELAXATION OF RULES HAS BEEN HELPFUL

    Opportunities  

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

    Challenges

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

    Actions

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

     

    FUNDING, TRAINING AND STAFFING

    Challenges

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

    Actions:

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

     

    STAFF SAFETY IN THE TIME OF COVID

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

     

    PRIMARY CARE BUILDINGS

    Challenges:

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

    Actions:

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

     

    BOOSTING DEMOCRACY IN THE NHS

    Challenges

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

    Actions

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

     

    ADVANCED CARE PLANNING

    Opportunities

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

    Challenges

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

    Actions:

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

     

    SOURCES:

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

     

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

     

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

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

     

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

     

    CONTRIBUTORS

    Dr Onkar Sahota

    Dr Duncan Parker

    Dr Joe McManners

    Dr Robbie Foy

    Dr Brian Fisher

     

    CONFLICTS OF INTEREST

    Dr Fisher:

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

    Leave a comment

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

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

    Lonely Ministers

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

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

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

    What is the strategy?

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

    Led by the science?

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

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

    Test, Trace and Isolate (TTI)

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

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

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

    Auditing misuse of public funds

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

    BAME communities and COVID

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

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

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

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

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

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

    7.6.2020

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

    2 Comments

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

    The impact of the pandemic on inequalities more generally and the implications for policy and plans going forward

    Key messages

    • The pandemic has hit us when we have already seen health inequities widen
      • 10 years of austerity have disproportionately affected the least affluent and the most vulnerable
      • Life expectancy has plateaued and inequalities in mortality have widened in recent years. The gap in healthy life expectancy at birth is about 19 years for both males and females.
      • Spending constraints between 2010 and 2014 were associated with an estimated 45,000 more deaths than expected: those aged >60 and in care homes accounted for the majority
      • There has been a systematic attack on the social safety net. Services have been cut disproportionately in more deprived areas with a clear North South divide, and there are higher rates of poverty in the Devolved Administrations who have limited powers to mitigate the impact of poverty. Child poverty has increased to over 4 million children
    • The COVID19 pandemic is having major impacts on health, through direct and indirect effects, summarised the in diagram below

    Source: Douglas et all, BMJ April 2020

    • The pandemic strategies are not clear across the UK and do not adequately recognise the unequal direct and indirect impacts.
      • The epidemic is at different stages in different communities and has caused more deaths in dense urban and more deprived areas.
      • It can be seen as multiple outbreaks. These are affecting the most vulnerable people inequitably, such as those in institutional settings, prisons and migrant detention facilities, homes with multiple occupancy, and households that are overcrowded or contain multiple generations.
      • A policy of managing the virus rather than aiming for suppression, may result in repeated surges, local outbreaks and lockdowns which could exacerbate the impact on health and further widen health inequities
      • The centralisation of data and decision-making has meant that approaches cannot be matched to the needs that only the regional and local level will know well enough and in real time
    • There is a consensus that the COVID19 pandemic has a major potential to widen health inequities,
      • As can be seen from the diagram above, the health impacts are likely to have differential effects on different groups of people, in particular:
        • Those most vulnerable to the infection: such as older people, BAME people, those living in enclosed settings
        • Those on low incomes or living with financial insecurity
        • Vulnerable families: for example, those at risk of domestic violence, those who are poorly housed, children at risk of abuse or neglect
        • Those at risk of social isolation
        • Vulnerable groups: for example, the homeless, people with disabilities, undocumented migrants
        • High vulnerability and institutional settings where outbreaks can occur rapidly.
        • This pandemic has made us focus on older people, and the young are paying a high price for protecting the old. Impacts on the young will have more long-lasting impacts on health inequities
        • Inadequate public health expenditure and ‘shrinking the state’ disproportionately affect poorer people including our BAME communities. More ‘austerity’ to ‘pay for’ the pandemic is not an option as austerity widens the health inequalities that lead to disproportionate mortality due to direct and indirect impacts of COIVD19
    • Deprivation: people living in more deprived areas are more likely to die from COVID19
      •  ONS analyses have shown that the age-standardised mortality rate of deaths involving COVID-19 in the most deprived areas of England was 55.1 deaths per 100,000 population compared with 25.3 deaths per 100,000 population in the least deprived areas. In Wales, the most deprived areas had a mortality rate for deaths involving COVID-19 of 44.6 deaths per 100,000 population, almost twice as high as the least deprived area of 23.2 deaths per 100,000 population.
      • The Kings College Symptoms tracker found that COVID-19 prevalence and severity became rapidly distributed across the UK within a month of the WHO declaration of the pandemic, with significant evidence of urban hot-spots, which tend to be more deprived areas.
      • The openSAFELY cohort study used national primary care electronic health record data linked to in-hospital COVID-19 death data, which is the largest cohort study in the world, examining 17 million primary care records. This showed a gradient from least deprived to most deprived, adjusted for age, sex and risk factors, so that people living in the most deprived quintile have a risk of 1.75 that of people in the least deprived

    Hazard ratio for in hospital COVID19 death (adjusted for age/sex/risk factors

    IMD quintile of deprivation
    • Unequal impacts
      • People living in more deprived areas are more likely to be exposed to COVID19:
        • Population density and overcrowding: urban poverty
        • Occupational exposure: more likely to be key workers and less likely to be able to work from home
        • Vulnerable groups e.g. homeless, refugees and asylum seekers, substance misusers
      • People living in more deprived areas are more likely to die when they get sick with COVID19:
        • They develop multiple co-morbidities at younger age (people in the most deprived areas get sick 10 years younger than the most affluent)
        • Equity of access to quality health and social care mitigates this, but has become eroded as austerity has hit services in the poorest areas most
        • They are more likely to also be from BAME groups
    • We have evidence on what works to reduce inequities in health
      • We know what causes inequities in health outcomes. The WHO Commission on Social Determinants of Health in states that inequities are caused by the conditions in which we are born, grown, work and live. There is now a large body of evidence from expert reports on health inequalities from academic as well as government sponsored reviews (Black and Acheson) for the past 40 years.
      • We know what works to tackle inequities in health: this can be usefully summarised by Sir Michael Marmot’s six policy areas for action:
        • Give every child the best start in life
        • Enable all children, young people and adults to maximise their capabilities and have control over their lives
        • Create fair employment and good work for all
        • Ensure healthy standard of living for all
        • Create and develop healthy and sustainable places and communities
        • Strengthen the role and impact of ill-health prevention
      • No strategy: the UK government has not prioritised health inequalities, and England has had no health inequalities strategy since 2010, although devolved nations have policies within the constraints of their powers.
      • But we have assets: We have seen how individuals and communities are resilient, and this has been amply demonstrated in their amazing response to this public health crisis. We should be following Prof Sir Michael Marmot’s advice: “Our vision is of creating conditions for individuals to take control of their own lives. For some communities this will mean removing structural barriers to participation, for others facilitating and developing capacity and capability through personal and community development”

    Conclusions:

    1. There are already major inequities in health outcomes in the UK, and these have been getting worse
    2. COIVD19 is disproportionately killing the less affluent and those in vulnerable groups
    3. There is a very high risk that the indirect impact of COVID19 will worsen health inequities through well-known mechanisms.
      • Greater vulnerabilities: for example, the higher prevalence of co-morbidities and complex multi-morbidities, ethnicity, disability
      • Higher exposure: for example, through occupations, overcrowding, enclosed settings, multi-occupancy households
      • Less access to resources to protect against economic and financial impacts
      • Less access to quality public services

    Actions

    • Commit to a long-term inequalities’ strategy with a multi-faceted approach building on previous Labour success 1997-2010. This should be even more ambitious, to tackle the commercial/ structural determinants of health, and to create healthy communities and places: it should reduce reliance on less effective individual behaviour change strategies, and include the intersectionality of disadvantage
    • Decentralise data and decision-making for COVID19 to better allow resources and control measures to be matched to need
    • Focus on elimination of transmission of COVID19 high risk settings, for example social care and health service facilities, prisons and migrant detention facilities, homes with multiple occupancy, and overcrowded or intergenerational households
    • Redistribute wealth: Maintain social protection measures as long as required and then in the longer term: implement Universal Basic Income and a Green New Deal with an economy based on need not profit. Ensure proportionate universal allocation of resources o Prioritise children: ensure safeguarding/ tackle domestic violence/ prevent unwanted pregnancies/ action to ensure healthy pregnancy outcomes/ push for childhood vaccinations programs to continue/ get children back to school as safely as possible
    • The NHS and social care should be always provided by need and not ability to pay: the state is a protective factor against unequal exposures to health determinants, as a provider, enabler and employer
    • Build and nurture the grassroots movements that have blossomed during the pandemic, and establish community oriented primary care to empower communities to create healthy communities

    Sources

    • Watkins J, Wulaningsih W, Da Zhou C, et al Effects of health and social care spending constraints on mortality in England: a time trend analysis BMJ Open 2017;7:e017722. doi: 10.1136/bmjopen-2017-017722
    • https://bmjopen.bmj.eom/content/7/11/e017722

    Posted by Brian Fisher on behalf of the Policy Team.

    Leave a comment

    BASHH (The British Association for Sexual Health and HIV) reports significantly reduced service capacity during the coronavirus pandemic. They are monitoring this with an ongoing survey. Here is the most recent set of results dated 21 April 2020. You can click through to read the full results on the link below or on the BASHH site.

    The British Association for Sexual Health and HIV (BASHH) are running an ongoing survey during the coronavirus pandemic to understand how sexual health services are being impacted and where pressures are emerging.

    The most recent set of results found that service capacity has been significantly reduced with 54% of sites closing in recent weeks, and the majority of respondents (53%) stating they had less than 20% capacity for face-to-face services. Staffing levels have also dramatically shifted to cope with COVID-19 provision, with a drop in available staffing of around half compared to the baseline figures. At the time of responding, members said that 38% of staff had been redeployed and 17% were shielding, isolating or are ill.

    The survey results show that vulnerable populations are particularly at risk during this time, with almost 1 of 5 respondents saying they were only able to offer limited, or no care at all, to this group. Other challenging areas appear to be delivery of routine vaccinations (54% unable to provide) and provision of LARC as preferred contraception (54% unable to provide). 9% said they were unable to maintain PrEP provision.

    A new round of the survey will be circulated in the near future to help identify any changing trends and to provide latest insights which will be shared with national health leaders. Huge thanks to all members for their invaluable contributions so far.

    To see the full results from the first round of the survey click here.

    Leave a comment

    Many migrants, refugees, and people with insecure immigration status in the UK will be particularly at risk during Coronavirus, due to lack of or restricted access to council services, healthcare, and housing.

    JCWI, Migrants Organise, and Medact have put together a short guide for Mutual Aid groups to consider how best to support at risk migrants. Please share this far and wide!

    https://docs.google.com/document/d/11cKMCy08ebN-lJQsP1jvsTcSfwC6YeE8FYrmAZCoZ1w/mobilebasic

     

    Some resources and information from the guide

    Docs Not Cops health rights advice

    • Advice from NHS 111, and treatment in a GP surgery or A&E department, are always free
    • There is no charge for examinations or tests to find out if a person has coronavirus.
    • There is no charge for hospital treatment for confirmed coronavirus

    For more information, contact docsnotcops@gmail.com and jamesskinnner@medact.org. 

    Doctors of the World

    • Free helpline for healthcare advice to people, regardless of immigration status: 0808 1647 686 from 10am to 12 midday, Monday to Friday
    • Coronavirus (COVID-19) advice for patients in 45 languages, produced in partnership with the British Red Cross. Download here: https://www.doctorsoftheworld.org.uk/coronavirus-information/#

     

    Changes to asylum and immigration process during COVID-19

    • Check updates here and here
    •  No Recourse to Public Funds Network have up to date information on changes to NRPF rules during COVID-19 here

     

    Leave a comment

    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

    Leave a comment

    While we welcome the £5bn emergency fund for the NHS and other public services and the open ended commitment made by the Chancellor that the government will provide whatever the NHS needs to meet the challenge of COVID-19; we are concerned to point out three big issues on sustaining an NHS, social care and protecting all workers including those in the gig economy.

    The Chancellor re-iterated the discredited election manifesto statements about 50,000 more nurses while we know that there are already 43,000  funded nurse vacancies. He repeated the mantra about 50 million more GP appointments while recruitment of young doctors to become GPs remains poor and it is not clear how this can be achieved in the short term. He reiterated the discredited election slogan about 40 new hospitals. Both staffing promises ignore the fact that it is not only money that is needed – the legacy of austerity cannot be reversed by a cash injection alone – training a GP/medical specialist takes 10 years. Turn the tap off for 10 years and turn it back on expecting accolades is not good enough.

    We are very concerned too about the immigration health surcharge, which is being increased to £624 per person. The NHS needs to continue to ethically attract health workers into our country for training and service. The surcharge will apply to EU citizens from January next year. This health surcharge is a serious disincentive and opens another pathway for Tories to introduce insurance charging into the NHS. The cost of collection as with all insurance schemes will be prohibitive.

    Social care has been ignored. Everyone involved knows that we should be investing in health and social services and even Jeremy Hunt who presided over NHS austerity is on record as saying that this is a glaring omission in the budget. You need to invest in health and social care and the budget is silent on social care. The budget statement of 8,700 words mentions social care twice only and the manifesto commitment of £1bn/year for 5 years seems to have been lost. Local government leadership role has been ignored such as their role in housing, childcare and social support in communities. The attention given to cars, roads, potholes, red diesel and fuel tax does not signal that the other existential emergency on climate change is being addressed.

    Finally we welcome the steps taken to move entitlement to SSP to day one but worry that the 111 service is already over stretched and should not have the burden of certification forced on them. The health and wellbeing of those who are not eligible for SSP, such as the estimated 2m part time and zero hours workers and the 5m self-employed is inadequately protected: the ESA is probably too small a compensation. Many will feel they have to continue to work, putting their own health and that of their families at risk.

    The SHA campaigns for health and social services to be free at the point of need and to be funded by general taxation. We know that the 10 years of Tory austerity has damaged the fabric of our NHS and we need to invest in capital and training of staff with confidence in long term growth and sustainability. In a modern society the social care services need to be an integral part of our system and should be planned together with joint investment. This budget has missed an opportunity to make this change.

     

    On behalf of the Officers and Vice Chairs

    1 Comment

    It is truly shocking that life expectancy has stalled in England, and for poorest women it has fallen.  The Marmot Review: 10 years on[1] published this week, shows us in detail how we have failed to improve on most of the indicators that were highlighted in the original review[2] 10 years ago. It points out that this can be clearly linked to the lack of implementation of those evidence-based recommendations.

    The report looks at five of the six domains that were used in the 2010 report:

    1. Give every child the best start in life
    2. Enable all children, young people and adults to maximise their  capabilities  and  have  control  of  their lives
    3. Create fair employment and good work for all
    4. Ensure a healthy standard of living for all
    5. Create and develop healthy and sustainable places and communities
    6. Strengthen the role and impact of ill health prevention

    It is interesting that they chose not to look at the sixth domain, on the grounds that plenty has been written on this area since 2010, and review was not necessary. This will ensure that there is no opportunity for Government to respond with messages about what it done in this domain, while evidence shows this to be the least cost-effective approach, and hence should have been lowest priority for policy and action.

    We know that the top priority should be our children and young people. It is very worrying that infant mortality has increased in the poorest families, that child poverty has increased and now stands at over 4 million. It shows how tax and benefits changes have been deeply regressive, pushing many families into the poverty trap. Knife crime is more common in those areas where youth services have been cut the most. A positive finding is that poor children appear to thrive better in poorer areas than in richer ones: either they are more socially excluded and stressed in affluent areas or that children and education services are doing something right in more deprived areas.

    Income is a massively important determinant of health. This report highlights how work is good for health only if it is good quality work. So, although employment has increased, this isn’t enough for people to feel the benefits. The report notes that the average weekly earnings at 2015 prices were £502 in September 2019, only £5 higher than in 2008. The UK is one of only five of the 35 OECD countries where the purchasing power of the average wage has fallen since 2008. Since 2008 there has been a large reduction in benefits available for working age people and children. This, together with the rise in housing costs, has been the driver for huge increases in food bank use. The most deprived households would now have to use over 70% of their disposable income on food if they wanted to follow the Eatwell guide for healthy nutrition.

    The report highlights social cohesion throughout, and describes forgotten communities:

    “there are   more   areas   of   intense   deprivation   in   the   North, Midlands   and in southern coastal towns than in the rest of England, whilst other parts of England have thrived in the last ten years, these areas have been left ignored. Since 2010 government spending has decreased most in the most deprived places and cuts in services outside health and social care have hit more deprived communities the hardest”

    We welcome this report. It confirms the SHA conviction that austerity kills and that the policies of the Conservative-led governments since 2010 have directly led to a heavy burden of increased mortality, ill health and misery that is largely carried by the poor. The most effective actions should have been to address the wider determinants of heath rather than individual behaviour change. Polices have in fact done the opposite of this, including the Government Prevention Green Paper a year ago. This report shows how investment for most things that affect the wider determinants of health has instead been reduced in more deprived communities.

    It would be of interest to compare the data collected here with similar analyses in the other devolved nations which have attempted to mitigate the impact of UK wide austerity policies from Westminster.

    Prof Sir Marmot says:

    ‘If health has stopped improving, it’s a sign that society has stopped improving. When a society is flourishing, health tends to flourish’

    The SHA realises that there is a very powerful lobby that will undermine this report and all the other emerging evidence, for political reasons.  We know that this report will be challenged by those who support right wing policies, and its conclusions ignored by those with an agenda that doesn’t believe in equity.

    We must do all we can to reach agreement again on what a flourishing society looks like. We must change and strengthen our democracy to be more accountable to the multiple views in our communities. The report says

    “Our vision is of creating conditions for individuals to take control of their own lives. For some communities this will mean removing structural barriers to participation, for others facilitating and developing capacity and capability through personal and community development”

    And as socialists, we believe that the state does have a crucial in protecting and improving the health of its people. For the last 10 years, our Government has been actively undermining the wellbeing of all but the most affluent.

    [1] The Marmot Review; 10 years on, Institute of Health Equity http://www.instituteofhealthequity.org/the-marmot-review-10-years-on

    [2] Fair Society, Healthy Lives, 2010 Institute of Health Equity http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review

    Leave a comment

    The Marmot Review 10 years on is being launched today, and is making headlines

    Key messages:

    • Over the last decade health inequalities have widened overall, and the amount of time people spend in poor health has increased since 2010.
    • #Marmot2020 confirms an increase in the north/south health gap, where the largest decreases were seen in the most deprived 10% of neighbourhoods in the North East, and the largest increases in the least deprived 10% of neighbourhoods in London.
    • The 10-year on review discounts the theory that the slowdown in life expectancy increase can be solely attributed to severe winters or flu.

    You can see the report here

    Follow twitter tag #Marmot2020

     

    Kathrin

    Leave a comment