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    So here we are in Week 16 of our SHA Blog about how the Johnson government is mishandling and mismanaging – except where it comes to the interests of the profit-making private sector – the COVID-19 pandemic; and why the UK is “world beating” – in terms of the highest death rate from COVID in Europe!

    Test and Trace

    The “teething problems” with the centrally designed, and privately contracted, NHS Test and Trace scheme, continues. It is a privatised system organised through the likes of Deloitte, (Deloitte is one of the Big Four accounting organisations in the world, whose business is in financial consultancy.) These private firms put the NHS logo in their own “branding” to try to build public belief, and confidence, that what they are doing is part of the NHS, and in the public’s interest, when it is a private system making lots of money for private investors: in the way that suits them best, rather than the most efficient way it could be done.  .

    It has had a huge investment of taxpayers’ money to employ 20,000 under-used telephone operators who are poorly trained in the complex field of contact tracing.  The Independent SAGE group reports that one contact tracer told them that ‘out of 200 tracers at my agency we have only had 4 contacts to call over the past 4 weeks’. Speaking to worried people and trying to elicit information about their contacts within a system which has not been able to build trust is a genuine challenge. The familiar GP practice or the local hospital and local authority – in which people really do have confidence – have in this “NHS Test and Trace scheme” had to take a back seat. (Readers will recall from previous blogs that the Independent SAGE group was set up in May to provide scientific advice independent of political pressure, after it was reported that Johnson’s “special advisor” Dominic Cummings had attended, and was believed to have influenced, the Government’s “official” Scientific Advisory Group on Emergencies. )

    Early problems have been identified in the initial design of diagnostic testing. No NHS number for instance, no occupation or place of work recorded, no ethnicity data and test results not being shared with the GP. The Lighthouse labs set up in Milton Keynes, Alderley Park Cheshire, Cambridge and Glasgow are collaborations between pharmaceutical industries (GlaxoSmithKline (GSK) and AstraZeneca), Universities in Cambridge and Glasgow, Boots, Amazon and the Royal Mail alongside the Wellcome Trust. (AstraZeneca owns Alderley Park).

    They were set up to meet the escalating government targets to get testing up to 100K (Hancock) and then to 200K (Johnson) without Ministers being clear about the strategy for testing and ensuring that results got back quickly to people and local players such as GPs and the local Public Health teams who could act. If the objective was just to get tests sent out in the mail or undertaken by Army squaddies in car parks across the country, in order to get the numbers up for the Downing Street briefings, then there was no need to worry about useful information about workplace/occupation? It is not the consortium of laboratories’ fault, as they are contributing to a national emergency, but the political leadership, which has not taken enough notice of public health professionals who have provided laboratory services and integrated themselves with NHS and local public health teams over decades. Public Health England are faced with the nightmare of quality assuring data sent to them from these laboratories.

    Workplaces

    One reason to worry is that incomplete information can lead to a delay in identifying a workplace outbreak. Returning the test result information started at Local Authority level which is not enough information on which to act. After some pressure the local teams have started to get postcode data. However noting a rise in individual cases scattered across West Yorkshire did not help public health officials pin down the common link: which was that they all worked at the Kober Meat Factory in Cleckheaton! These public health systems need to be designed by people who know about public health surveillance, outbreak management and contact tracing. It works best if the tests are undertaken locally, results go back to GPs and local Public Health teams with sufficient information to associate cases with industries, schools, places of worship, community events or food/drink outlets. This is the level of data that would help the public health team in Leicester who are under scrutiny with ‘knowledgeable’ politicians such as Home Secretary Priti Patel declaring the need for a local lockdown in the city. Speed is of the essence, too, as we know that COVID-19 is being transmitted when people do not have symptoms and is most contagious in the first few days of the illness.

    We have known from international data that meat-processing plants are high risk environments for transmission. This is clearly something to do with the damp, cool working environment, which is noisy and so workers have to shout to each other and are often in close proximity. Toilet facilities and rest areas are likely to be cramped and how often they are being cleaned an issue. Furthermore – as we have learnt from Hospital and Care Home outbreaks – how staff get to work will be important to know, too: for example, if they are bussed in together or car sharing, both of those involve being with other people in enclosed spaces.

    As in abattoirs here in the UK and in other parts of the world, jobs like this are usually undertaken by migrant workers. These workers usually live in cramped dormitory type multi-occupation residences. Low paid often migrant workers, who are poorly unionised, are particularly vulnerable to the COVID-19 contagion whether they work in US meat packing factories or in Germany or indeed in Anglesey (Wales). The 2 Sisters plant in Llangefni for instance has had over 200 workers with positive test results.

    The Tonnies meat processing factory in Germany has had more than 1500 of its workers infected and 7000 people have had to be quarantined as a result of the outbreak. This has had a ripple out effect with schools and kindergartens, which had only recently reopened, having to close again. Unsurprisingly there are stories of the factory being reluctant to share details of the staff, many of whom are Romanian or Bulgarian and speak little German.

    Contact tracing

    The importance of testing and rapid reporting of cases to local agencies was highlighted in a recent South Korean example, where a previously well -controlled situation was threatened by the finding that a series of nightclubs had been linked through one very energetic person. Tracers had to follow up 1700 contacts and be able to control the on-going chain of transmission! While South Korea, unlike the UK, has had a mobile phone app to assist contact tracing, they still depend on the local tracers to use shoe leather rather than computer software to really understand the local patch and the complex community relationships.

    The Independent SAGE group is producing useful analyses and information for us all and has been promulgating the WHO Five elements to test and trace, namely:

    FTTIS – Find, Test, Trace, Isolate and Support.

    All of these are important and the recent example in Beijing shows again how a rapid local lockdown response was used to implement FTTIS and they appear to have managed to contain the outbreak to one part of this megacity of over 20m people.

    Social distancing

    The Independent SAGE has also recently taken a line critical of the government position on social distancing. They say that the risk of transmission in the UK remains too high to reduce the social distancing guidance. They oppose the move from a 2m guidance to 1m plus and say that it risks multiple local outbreaks, or in the worse case a second wave. The pattern of continuing waves of infection has been seen in the USA, where social distancing has been poorly enforced, and in other countries where a significant second wave has occurred such as Iran.

    The Government is rightly worried about the economic impact of the lockdown and pandemic, but they are sending out mixed messages on social distancing which has led to chaotic scenes on Bournemouth beach, urban celebrations in Liverpool and street parties in many cities. In the USA it has identified the 20-44 year olds as being a group who are testing positive more frequently and we need to send the message out loud and clear that although they may not die from COVID-19 at the rate older people and those with underlying conditions, they are at risk of long term damage to their health and will transmit the virus to other more at-risk people in their families or local communities.

    The Prime Minister always wants to be communicating good news, and needs to beware that the call for more ‘bustle’ on the high streets and ramping up/turbo charging the economy carries big risks of new local outbreaks that will ensure that the Sombrero curve of infection is not flattened, but that we are condemned to live with on-going flare ups across the country.

    Ex Chancellor Kenneth Clarke tweeted recently, in the light of the situation in the UK and the flip flopping on air travel restrictions, that:

    The UK government’s public health policy now seems to be ‘go abroad on holiday, you’ll be safer there!”

    29.6.2020

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

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    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.

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

    Germany and Greece 

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

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

    Test, trace and isolate

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

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

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

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

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

    Independent SAGE

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

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

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

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

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

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

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

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

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

    When should a School Reopen?

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

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

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

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

     

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

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

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

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

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

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

    31.5.2020

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

    1 Comment

    Public meeting Wednesday June 3 – Get your ticket!

    We would like to invite you to our first virtual Zoom public meeting

    Internationalism in the Post Covid-19 World

    Wednesday 3rd June, 6pm to 8.30pm

    Speakers are: Harsev Bains, Baroness Christine Blower, Dr Kailash Chand, Jeremy Corbyn MP, Jacqui McKenzie, Murad Qureshi AM.

    Please register for this event at liberation.org.uk/event  And pass it on to friends and colleagues!

    Joint event by The Socialist Health Association and Liberation.

    Please contact Jean Hardiman Smith at admin@sochealth.co.uk for more information.

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    Death Rates in France

    Tony Cross, formerly of Radio France International (the French equivalent to the BBC World Service), reports from France in www.theravingreporter.com that the number of deaths per day (from all causes, and not just deaths in hospital) has declined from a high point of 600 a day at the beginning of April, to a lower rate than in the previous two years (see the yellow line, compared to the red and blue lines). This is probably due not only to the decline in Covid-19 deaths as a result of the lockdown, but also to the lower rate of road traffic accidents and lower air pollution from road and air traffic. The statistics come from INSEE, the French National Institute for Statistics and Economic Studies.

    Deaths from Covid 19 in the Care Sector

    Meanwhile, in the UK, Ann Bannister, Secretary of Reclaim Social Care, has just posted death figures from the Office of National Statistics covering Care Homes and Domiciliary Care.

    From March 2nd to May 1st this year, there were 45,899 deaths of care home residents, 27.3% involving Covid-19. 72.2% of Covid-19 deaths of care home residents were in a care home when they died, and the rest had been transferred to hospital. This means that over 9,000 deaths were not included in the totals reported in the press, of all the deaths from the virus, because the press was reporting only hospital deaths.

    Covid-19 was the main cause of death of men in care homes who died during the same period, while Alzheimer’s and other forms of Dementia were the main cause of death in women living in care homes, with Covid-19 in second place. However, Dementia and Alzheimer’s were also the main pre-existing condition in deaths caused by Covid-19 in both sexes.

    The statistics for recipients of Domiciliary Care 10 April – 8 May 2020 show that 3,161 clients of care in their own homes died of Covid-19, which were 1990 more than the average over three years.

    Unison North West are planning a Social Care campaign video conference on 26 May. To register email nwepoc@unison.co.uk

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    The Conference on Retroviruses and Opportunistic Infections (CROI) in Boston is the most important yearly scientific meeting for HIV doctors and the global community of people living with HIV.

    However, this year – and at the very last minute because of the new coronavirus outbreak – the organisers replaced it with a ‘virtual’ conference.

    HIV i-Base, the London-based HIV Treatment Information charity, regularly attends this conference. Simon Collins and Polly Clayden at i-Base always report on the latest scientific research, including on new drugs for both treatment and prevention of HIV.

    But importantly his year, CROI have given open access to a special session on COVID-19 and SARS-CoV-2.

    Here is Simon Collins’ report for i-Base. This includes a link to the special session which contains up-to-date information about the outbreak that can be of interest to all, and not just to people who are HIV positive:

    The special session on coronavirus at CROI yesterday is posted for open-access on the CROI website. [1]

    The 75-minute overview includes four talks and a Q&A at the end.

    A few selected key points include:

    • The highest risk of more serious illness and outcomes (risk of dying) are older age (80>70>60 years old), and having other health conditions (heart, lung/breathing, diabetes, cancer). The risk of the most serious outcomes is 5 to 30 times higher than with seasonal influenza (‘flu’).
    • Implications for people living with HIV are not currently known, other than as for the general population. One speaker included low CD4 as a possible caution. [Note: Due to lack of evidence so far a low CD4 count has not been included as a risk in the recent UK (BHIVA) statement]. [2]
    • Transmission is largely from microdroplets in air from someone during the infectious period (generally from 1 day before symptoms to average 5 days, but up to 14 days after). These can remain infectious on hard surfaces for an unknown time (possibly hours) which is why hand-washing and not touching your face is important.
    • Best ways to minimise risk of infection include washing your hands more carefully and frequently and not touching your face.
    • Soap and water is better than hand sanitisers (and more readily available).
    • Best candidate treatment (so far) is remdesivir (a Gilead compound). This has good activity against a range of viruses in in-vitro studies and is already in at least four large randomised studies.
    • Studies with candidate vaccines are expected shortly – within two months of the virus being isolated – fastest time for vaccine development.
    • The response in China after the first cases were reported was probably much faster than it would have been in the UK. This included:
      –  Within four days of the first reported cases, the suspect source was identified and closed (a seafood market).
      –  Within a week, the new virus was identified (SARS-CoV-2).
      –  The viral sequence was then shared with WHO and on databases in the public domain for other global scientists to use.
      –  Within three weeks of the first confirmed cases, Wuhan and 15 other large cities in China were shut down as part of containment measures.
    • One of the questions after the main talks asked whether SARS was now extinct. The answer explained that SARS is a bat virus, and only 50 out of about 1300 species of bats have been studied so far. So SARS is very likely still around.

    COMMENT

    Currently, the most important things for people living with HIV are:

    1. To make sure people have enough medications – including at least one month spare. If travelling where there might be a risk of quarantine, to take additional meds with you to cover this.

    2. As recommended by BHIVA, sensible hygiene precautions (hand washing and not touching your face etc). [2]

    3. Avoid or delay any non-essential or non-urgent hospital visits.

    4. Special caution for those who are older or who have multimorbidities – which are prevalent in HIV.

    References

    1. Special session on COVID-19. CROI 2020, 8–11 March 2020.
      https://special.croi.capitalreach.com
    2. BHIVA. Comment on COVID-19 from the British HIV Association. 27 February 2020.
      https://www.bhiva.org/comment-on-COVID-19-from-BHIVA
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    One on International Trade dispute settlements and the other on Social Care.

    These are not official SHA policy.

    Issues for the NHS during UK Trade deal Negotiations

    As socialists we have an almost irreconcilable set of principles

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    This article was first published in the Camden New Journal under the title, Brexit, and spectre of NHS US sell-off, on 16 May 2019.

    There is much talk at the moment about the prospect of Brexit resulting in a trade deal with the US which will sell off our NHS to American private healthcare providers.

    This fear has also been expressed by Shadow Health Secretary Jonathan Ashworth. [1] But it is critical to understand this “sell-off deal” has been under way for a long time and is fast gaining momentum, argue Susanna Mitchell and Roy Trevelion.

     

    The driver of the “sell-off deal” is Simon Stevens, who in 2014 was appointed head of NHS England, the body that controls all NHS spending. Before this, Stevens had been vice-president and CEO of the mammoth American healthcare corporation the UnitedHealth Group.

    Stevens has proceeded to “Americanise” the service through his subsequent NHS policy, based on a privatisation strategy he had outlined at the World Economic Forum at Davos in 2012. [2]

    From first to last, his NHS policy – the Five Year Forward View, the Sustainability and Transformation Plans and Accountable Care Organisations (renamed Integrated Care Programmes) that back it up, and now the 10-year Long Term Plan – have worked to import the US model into the UK.

    Unsurprisingly, the UnitedHealth Group will make major gains from this transformation. It is now the largest healthcare company in the world, with a 2018 revenue of $226.2 billion. It has many secondary companies that serve more than a hundred-million people globally. [3]

    Over the years it has been prosecuted for fraud and bad faith practices. This included limiting insurance payments to doctors, and not stating its true financial results in reports to shareholders. [4] [5]

    One of its fastest growing subsidiaries is Optum (formerly UnitedHealth UK). This is a leading information technology- enabled health services business. In February 2015, it was one of the commercial organisations approved by NHS England as “Lead Providers” to carry out the financial work of GPs.

    It is now firmly positioned in the system and ready to take away more public money. [6]

    The healthcare system in the United States is hugely more costly, and outstandingly less effective than that in the UK. In terms of funding and wellbeing, there is no rational argument for imposing it on our NHS. The only benefit it brings is increased profits for shareholders in the commercial healthcare sector.

    To take three examples, first comparing cost:

    On average, other wealthy developed countries spend about half as much per person on health as the US – in the US $10,224 compared to $4,246 in the UK. In 2017 the US federal government spent 7.9 per cent of GDP directly or indirectly on healthcare; however in total, taking into account private expenditure, the US spent a vast $3.5trillion or 18 per cent of GDP. This private sector spending is triple that of comparable countries. [7] [8]  This structure excludes many citizens from affordable health­care. Appallingly, one in four adults skipped a medical treatment in 2017 due to an inability to pay. [9]

    Secondly, from the point of view of efficacy and wellbeing, statistics are also devastating. The US has the lowest life expectancy at birth among comparable countries (US 78.6, UK 81.2). Statistics show that life expectancy for both men and women has increased more slowly in the US. It comes 12th in the global life expectancy table. [10]

    Thirdly, the US maternal mortality rate is truly shocking. It stands at 26.4 per 100,000 live births, the worst among all developed countries. [11]

    In the UK the rate stands at 9.2 per 100,000. [12] [13]

    Deaths for African-American women are three to four times higher than for white women. [14]

    The infant mortality rate is also worse. The US rate is 5.79 deaths per 1,000 live births. [15]  The UK rate is 3.8 deaths per 1,000 live births. [16]

    It is clear that if we follow the American model of healthcare it can only reduce wellbeing in the UK. Simon Stevens’ “sell-off deal” simply increases the wealth of global corporations (such as the Mayo Clinic, which has recently opened in London [17]).

    It is time that this fact was “called out” loudly and clearly. All possible measures must be taken to prevent the continuing imposition of this ineffec­tive and costly system.

    Susanna Mitchell and Roy Trevelion are members of the Socialist Health Association.
    References, some links, live at the time of writing, may not have been maintained:
    [1] BBC Question Time 25.04.2019  at 47.21 ff  https://www.bbc.co.uk/iplayer/episode/m0004hkk/question-time-2019-25042019 .
    [2] https://www.sochealth.co.uk/2017/05/25/truth-stps-simon-stevens-imposed-reorganisation-designed-transnational-capitalism-englands-nhs-stewart-player/
    [3] http://selloff.org.uk/nhs/CVforSimonStevens260516.pdf
    [4] https://www.sec.gov/news/press/2008/2008-302.htm
    [5] https://law.freeadvice.com/insurance_law/insurers_bad_faith/unitedhealth-pays-400-million-in-bad-faith-claim.htm
    [6] http://selloff.org.uk/nhs/CVforSimonStevens260516.pdf
    [7] https://www.crfb.org/papers/american-health-care-health-spending-and-federal-budget
    [8] https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#item-average-wealthy-countries-spend-half-much-per-person-health-u-s-spends
    [9] https://www.federalreserve.gov/publications/files/2017-report-economic-well-being-us-households-201805.pdf
    [10] https://www.healthsystemtracker.org/chart-collection/u-s-life-expectancy-compare-countries/#item-le_the-u-s-has-the-lowest-life-expectancy-at-birth-among-comparable-countries_2019
    [11] https://www.npr.org/2017/05/12/528098789/u-s-has-the-worst-rate-of-maternal-deaths-in-the-developed-world?t=1560004210914
    [12] https://vizhub.healthdata.org/sdg/
    [13] http://digg.com/2017/uk-birth-us-safety-comparison
    [14] https://www.huffingtonpost.co.uk/entry/elizabeth-warren-black-maternal-mortality_n_5cc0e93fe4b0ad77ff7f717b?guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAACQmWXh6QTnSJI5sjLN1KEdQCuSnVb__LEQLJAyEiK2PZwqnVABYxo500JrU24NHWCooflTZAia50H4OJ-YzSPMUqXyGODWHMGcBXUxhfVY-fau-ViM-Ly9n32SQ1vXD-SGhWXohZRVo2givDSEbM1D3TVs38R5MjmfY_5rGZXuP&guccounter=2
    [15] https://www.cdc.gov/nchs/nvss/deaths.htm
    [16]https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/childhoodinfantandperinatalmortalityinenglandandwales/2016
    [17] https://www.medcitybeat.com/news-blog/2019/mayo-clinic-oxford-university-clinic-partnershiphttps://www.medcitybeat.com/news-blog/2019/mayo-clinic-oxford-university-clinic-partnership.

     

     

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    Good integrated healthcare or neoliberal con?

    La Ribera Hospital

    The Alzira Model is named after the town in Spain where the La Ribera hospital, the first hospital using this model, is located

    Map of Spain

    The Alzira Model:

    • Goes beyond the PFI model of the building being privately operated to also include clinical services
    • Paid for by a capitation fee
    • The first contract covered only the La Ribera hospital and was signed in 1997, the hospital opened in 1999 and the contract was terminated in 2003 due to losses.
    • Replaced by second contract, which widened the remit to also manage the primary healthcare of the surrounding health area.

    The Spanish National Health System

    Spanish health system

    There are operational differences to UK NHS

    • Responsibility for healthcare has been devolved to the regions
    • Specialist care  (e.g. Children’s hospital) is covered at Health Area level
    • A health zone contains a hospital plus primary health centres. Residents are allocated to primary health centres. (No choice of GP, as in UK) Residents are referred to hospital by a GP at their primary health centre.

    The model was hailed as a tremendous success story by neoliberal groups around the world with the following claims:

    • Cheaper to deliver than traditional public sector healthcare – savings of around 25% being achieved
    • Good for patients and staff
    • Affordable for the taxpayer

    The Reality

    (a) The Spanish context

    • Labour costs in Spain: Clinical staff in public hospitals are part of the Spanish Civil Service, which has very generous pay, above OECD average, whilst working hours are less than average – if we compare to the UK NHS savings of around 20-30% can typically be made.
    • Financing by regional savings banks Prior to financial crisis their governing bodies were dominated by regional politicians – so no risk transfer. Low rates of interest charged on loans

    (b) No financial success story

    • The integrated contract was only viable because of:
    • Generous Increases in capitation fee in early 2000s
    • Low interest rates
    • Low labour costs
    • Cherrypicking and freeriding

    All of this was hidden due to poor governance systems and lack of accountability

    Further flaws

    • Very optimistic capitation fees at start
    • 1st contract failed – political coverup on re-letting
    • Wage protests
    • High staff/patient ratios
    • Additional costs of monitoring ignored
    • Many items omitted from contract
    • Recommended structures for managing PFI-style policy all missing in Spain (Specific Public/Private Partnership unit, model standardised contracts, public sector comparator, any method of project evaluation)

    Proliferation of the Alzira Model

    • Used for other integrated healthcare (i.e. hospitals and primary care) in Valencia region with similar findings
    • When used elsewhere (both in Spain/elsewhere in world), it has tended to be for hospitals only

    Implications

    Given that it’s NOT a good cost effective way of delivering healthcare, what does the usage of the Alzira Model mean?

    • A way of keeping artificially keeping debt off the public sector balance sheet?
    • A way to impose an ideological right wing view of creating a market for healthcare?

    Performative Frame

    • Superiority of private sector style techniques in delivering a better quality service
    • Linked with political will to create a market for Public/Private Partnership healthcare over the long term – shift from infrastructure (just 5% of global healthcare spend) to clinical services (lucrative and stable long term returns)
    • Increasing involvement of healthcare companies

    Conclusions

    Breakdown of Alzira model in Valencia

    Regional government changes from right wing Partido Popular to left wing coalition who scrap the policy amid corruption scandal of director of the healthcare group

    The rhetoric of success from global consultants needs to be challenged

    This was presented at our conference on Accountable Care Systems

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    What is larger than the UK’s entire economy, soaring in price, wildly profitable, the leading cause of personal bankruptcy, bankrupting the United States and a massive economic bubble that nobody has heard of yet? Healthcare in America… a modern-day gold rush is on as young Americans clamour for healthcare careers in the same way that young adults were jockeying for technology careers at the peak of the Dot-com bubble in 1999.

    The US approach to health and social care provision continues to exert defining influence on the possible futures of UK provision and at least some can see the dangers inherent in this. How can we understand developments in the US and how does this arm us to understand – and intervene in – developments in the UK?

    The US spends more on health than any other country in the world, nearly a fifth of its GDP in 2015 compared with 9.1 percent in the UK, 11.2 in Germany, 5.5 percent in China and 4.7 in India (all figures for 2014). In 2015, US health care spending reached $3.2 trillion, or $9,990 per person. Primarily, increased spending was driven by rising costs for private health insurance, hospital care, physician and clinical services. Alongside this, rising general poverty meant more people drew on Medicaid and Medicare, state health benefits for poor US citizens. The price of drugs continues its inexorable rise, rapidly soaking up state benefits which have failed to keep pace with rising health costs.

    This rising cost context of health care has seen share prices in health-related industries soar. In 2017 three vast health conglomerates were in the top 10 of the US Fortune 500 – each of them richer than former market giants such as General Motors and AT&T. Health market leader McKesson is a pharmaceutical distributor and health technology developer. Another, United Health, a health insurance provider, has over 100 million customers globally.  Health industry mergers in the US have been accelerating over the last 15 years, peaking in 2015 and 2016 in a process of what Marxist would call the centralisation of (health) capital. In 2015, the record year for M&A in the sector, total deal values were in excess of $100 billion, over a third of the total UK GDP for that year.  Mergers and Acquisitions in health industries is a worldwide phenomenon with, in the UK, M&A in the sector actively promoted.

    The global expansionist ambitions of the US health industry helps drive this trend, and capital is currently being sucked into global health industries as never before by the promise of what is known as the “Rising Billions”   Over the next five years, between three and five billion new consumers world-wide will become connected to the internet. The ‘Rising Billions’ are consumers of goods and services, but are also patients in need of medical care and medical commodities, so called ‘health customers’. Alongside the health commodities these health customers might consume, eHealth systems are areas of profitability for the health industry giants. eHealth includes things like, for example, systems of communication between health providers and practitioners and remote health monitoring, potentially useful areas of innovation. Problems arise, however, when this technology is used to enhance profit rather than service provision. For example, virtual consultations between doctors and other professionals and patients, another growth area, bring the possibility of doctor ‘call centres’ advising patients from anywhere in the world steps closer radically changing doctor-patient relationships and health professionals roles and status.

    This technologically-driven approach to health and social care is already evident in the UK. For example, Jay Strickland, director of Southwark Council’s Adult Social Care department quoted in the Financial Times  extols the virtues of using motion detectors to replace care workers in older people’s homes: ‘We could pop in at lunchtime to see someone…[But at] five past one, she could be on the floor. So there’s no real value to this.’ Once a motion detector system of monitoring patients has been embraced, then there’s no need for monitoring staff to be in the same borough or city, or even country. Again, a call centre approach is implied here, perhaps with a smaller care staff on standby locally to attend in a crisis in this neoliberal ‘Just in Time’ approach to health care delivery.

    A key driver behind the avalanche of UK legislation over the last five years is the aim to construct a legislative framework in which new, privatised, joint institutions of health and social care can be developed. Twenty three so-called ‘vanguard sites’ have been tasked with exploring new, population-based market-oriented for profit models for local health services. Multispecialty Community Provider (MCP) and Primary and Acute Care System (PACS) vanguards are aiming to integrate NHS services and social care. The MCP care model is described as a ‘new type of integrated provider’ which aims to combine the delivery of primary care and community-based health and social care services. Importantly, this will include providing ‘some services currently based in hospitals, such as some outpatient clinics or care for frail older people, as well as diagnostics and day surgery’.   In other words MCPs are vehicles for shifting some NHS provision into the Independent Sector for private capital to run at a profit.  PACS are non-hospital based private health and social care provision, seemingly expanded versions of MCPs. The Kings Fund says of PACS:

    Under this new care model outlined in the NHS five year forward view, a single entity or group of providers take responsibility for delivering the range of primary, community, mental health and hospital services for their local population, to improve co-ordination of services and move care out of hospital.

    While some vanguards continue to use informal partnerships, commissioners and providers in many areas are putting in place more formal governance arrangements – in some cases describing the new arrangements as integrated care organisations (ICOs) or accountable care organisations (ACOs) or systems. In April 2017 this direction of travel was taken to its logical conclusion when health leaders in Manchester’s NHS and social care commissioners offered a tender of £6 billion over ten years for one organisation to provide all ‘out of hospital’ health and social care provision. Their tender document sets out plans for ‘local care organisations’ to provide all non-acute services – including social care – across the city. The LCO will hold a single 10 year contract to provide services for a population of around 600,000 people. Meanwhile, neighbouring Stockport’s vanguard project, which is somewhere between a MCP and a PACS, is being developed without a competitive process. The standard MCP model set out by NHS England incorporates primary, community, mental health and social care services, but leaders in Stockport are looking to expand this to establish a privately-run health conglomerate also providing hospital services including the emergency department, acute medicine and frail elderly care. Clearly, the care models can be moulded to the needs of the local authority, so long as they are focussed on releasing more of the state health sector to private profit.

    This commitment to a qualitatively greater amount of funding in one tranche to the Independent Sector comes very swiftly on the heels of the first experiment in this direction, when Circle Health took on the running of Hinchingbrooke Hospital in Cambridgeshire. The contract to run the hospital was supposed to last from 2012 for 10 years and was worth £1bn. Circle announced its intention to quit after less than three years saying the contract was “unsustainable”. In September 2015 the Care Quality Commission found that patients were being neglected at the hospital, that hygiene was inadequate, and that staffing problems were affecting care.  Clearly, practical lessons will have been learnt from this total failure. However, the key one won’t have been – that the failure is a consequence of attempting to run health and social care to previous standards of delivery for profit. As the disasterous privatisation of the social care sector in the UK over the past twenty years has clearly shown, this is not possible. The problems at Hinchinbrooke and the problems of the social care sector were not caused by ‘inefficiencies’ or ‘poor execution of service’ but by the US-inspired health provision for profit model itself.

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    I am just writing this as me. It isn’t going to be the most perfect piece of prose, partly because the information has come from my husband/carer and because I still feel the fear whenever I think about it. My brush with co-payments was traumatising for me, my husband and could have had very serious consequences – including death.

    I live with a rare, and potentially fatal condition. It has been what they call “brittle” from the beginning. Nevertheless, I am well insured and of course carry all necessary documents for health treatment in an EU country. What could possibly go wrong??

    Early one morning while on holiday in an EU country I started to feel nauseous. This is a warning sign of a crisis. The nausea progressed to projectile vomiting, then voiding, as my temperature plummeted and I began to lose consciousness. My husband phoned the local health centre. They spoke English and he fully explained the danger – left too long my organs will shut down, and the end game is potentially death.

    The first words spoken were – “that will cost you 180 euros. “OK” said husband, but he was not at all confident in any system that could put the money first.

    “Bring her down to the centre” were the next words down the phone.

    “But she is unconscious and covered in sick” said hubby, “I can’t just put her in a taxi”.

    “We don’t do home visits” was the response.

    “I don’t know the system”, said my husband, “I can’t bring her anywhere, what do I do?”

    Well it might seem obvious, but my husband was panicking

    “Phone an ambulance”.

    Hubby did, and the ambulance came, but the co-payment fiasco didn’t end there.

    The ambulance people were caring and somehow got me downstairs and into the ambulance.

    We then proceeded to go past at least one gleaming private hospital, slowly down some narrow country roads, and well out of town to the nearest public hospital.

    I was off loaded.

    Alone with me in a room, hubby was then asked for another co-payment. “just go to the desk”. Imagine if it was your loved one, and you were asked to leave them in a crisis, and alone.

    The doctor came and told him to hurry, go to the front of the queue as an emergency, as she wanted to start treatment urgently. Hubby ran.

    Once back he could talk about my medical history, allergies and so on. The doctor was knowledgeable, efficient and kind. It doesn’t take long to bring me round from a dangerous situation, and I can usually get home in the NHS in around 6 to 8 hours, but even so, I was told to get a taxi probably a bit earlier than I would have needed/wanted in the UK.

    Going home the taxi driver treated us to a very informed chat on how this was a trojan horse and the end of their public healthcare system. A few days before we had a taxi driver talk on TTIP and chlorinated chicken.

    If anyone is tempted to think we would do it differently under the current model of defunding the NHS, just think of the brilliant success of the co-payment systems we have already.

    The Care System has always been co-payments for the less poor. I will not say the rich, as demands for some contribution are made to many we would not consider that well off. The situation is dire: abuses of human rights, starvation diets, neglect; the list goes on. There are repeats of the TV programme “Waiting for God”. Not even the wealthy can ensure they are not being herded and milked for the benefit of the shareholders. It is the law.

    Then there is dentistry. I was warned years ago that dentistry was the pilot for the NHS direction of travel by a totally distraught dentist, who felt his patients no longer came first, and the less well-off would be excluded. Hubby has paid £600.00 for dentures (just a couple) under the NHS system. They are not fit for purpose. Treatment is basic now, and in my town people are often seen with big gaps and rotten teeth. The old pull it out by using the door trick has even re-appeared. It is tempting to go private if you have the money, and friends have paid thousands to private dentists, though they are against the concept.

    Co-payments will have the most terrible impact on the sick, disabled and poor. They will be excluded, frankly, so the worried well can have blue fitted carpets and no queuing. It will fix the NHS in the same way as taking those truly needy cohorts out and shooting them would also fix it – just it’s more acceptable/less obvious.

    I have not heard a single person as a patient under the co-payment scheme who isn’t well off express that they liked it. Quite the opposite, and I work with healthcare staff and academics in the US and Australia. They know it puts their lives on the line.

    Like dentistry a “reasonable” co-payment will soon start to look like quite a chunk of your money – loads more than we all first thought. And for what? This was posted on our SHA Website and I’ll repeat it here:

    NHS Dental Care Faces a Severe Collapse

    One of the health concerns neglected by the NHS is dentistry regardless of the fact that teeth matters as much as any other part of our body. As revealed by the British Dental Association in September 2016, the NHS had to bear a cost of £26m when around 600,000 people in a year made nugatory appointments with GPs over dental issues. Though this statistic has resulted in ridicule, yet in all honesty, it is the government, not its citizens, who should be embarrassed.

    It is the NHS bills that are drawing patients away from the official government system and driving them toward GPs for their dental problems. As indicated by the BDA’s new analysis, this practice might soon outclass government financing as the main revenue source for NHS dentistry.

    The NHS charges for dental services were first instituted in 1951 to bring down the demand. The BDA has named these charges as “health tax”, which veil actual trims in the service and debilitate the patients most needing care. Due to the incurred charges, about 1 of every 5 patients has deferred treatment as per the official findings.

    The government funding for the NHS has been cut down by £170m since the Tories first made it to No 10, and it is hoping that patients should constitute the shortage. In 2016, dental charges were climbed by 5%, and they are anticipated to take the same hike even this year too. Considering the 16 years of time, it is assumed that majority of the NHS budget for dentistry will be financed by patients instead of the central government. But what is the use of the NHS if it is not a free service at the required time, and treatment isn’t according to one’s need but ability to pay?

    Children are entitled to avail free NHS dentistry – but even they are being pulled down by the government as it is unable to meet the demand and offer enough dentists. Earlier in 2016, a letter was signed by more than 400 dentists exhorting that dental care in Britain is falling to the levels of “third world”. According to them, the NHS dental system in England is ill-equipped for the purpose. These crises are of grave nature; about 62,000 people mostly including children turn out to be at the hospital each year due to tooth decay; half of the adults haven’t been to a dentist for the past two years; and one of every seven kids hasn’t gone to a dentist since the age of eight.

    People in Britain are already paying higher bills for fundamental care, and add a bigger sum of a dental budget by submitting these charges than their correlates in the devolved countries – systems of which have become less dependent on charge income throughout the recent decade. To deal with this gap, the BDA is sending information posters to more than 8,000 NHS dentists all through England to help picture patients’ feedback on the eventual fate of the charge.

    When dental charges were made a part of the NHS in 1951, Nye Bevan who was the formulator of the NHS resigned from the service in protest. Today, after sixty-five years, the service is damaged by inadequate investment, exaggerated charges, and a shortage of dentists. There is a genuine need to form a government-funded NHS dentistry which wouldn’t rip off the patients. However, as of yet, we are going in the other direction of which the consequences will be borne by lower-income Britons.

    Co-payments in health to me sound very much like the position refugees are suffering under this government according to the latest briefing by Asylum Matters. I have approached them to ask to reproduce the paper and recommendations, and been given the go ahead. This will follow shortly.

    Finally: Imagine:

    You have a heart attack in a local park. You and your partner set off in the ambulance only to discover that you must pay, and your wallets and cards are locked up at home. Precious time is lost chasing the money. Your partner is scared you will die when they are away getting the plastic.

    You just gave every bit of spare funding you had for the youngest child/grandchild to access university for 3 years, and then you get cancer (or another serious and maybe longer-term condition). It is might be difficult to fund all these co-payments to your GP and specialists. It is not worth a blue carpeted half empty waiting room. Under the current defunding you won’t get that anyway. I have loads of co funding horror stories from the USA.

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    Cheered up by last week? The last few weeks have given us a respite from a seemingly endless wave of victories by populists and the right: after a miserable 2016, we have seen the radical right narrowly defeated in the Austrian presidential election, heavily defeated in the second round of the French presidential election and in the legislative vote, in decline in Germany and locked out of government in the Netherlands. And did I mention a hung parliament in the UK?

    Brexit bus

    It might be nice to relax and go back to critiquing neoliberalism, but we should not. The populist radical right is still a force to worry about for four reasons.

    First, these electoral victories are not so impressive as they might look. In electoral terms, these votes are still scary. Only in the context of 2016 should we be glad that over forty percent of the French and Austrian electorates have voted for candidates from the darkest areas of the right.

    Second, the right is directly wielding a lot of power. The radical right is in government or close to it in a number of smaller European countries. Trump is president. Despite much wishful thinking, he is likely to be president until January 2021. The UK is still likely to be governed by the Conservatives… partnering with the Democratic Unionists, a party of the radical right that has benefited until now from the refusal of the UK media to pay attention to Northern Ireland.

    Third, the right shapes agendas. There is an alarming coincidence between the manifestos of UKIP and the manifesto that gave the Tories one of their highest-ever vote shares in the last election. The French even have a word for it: Droitisation, or the way the far right pulls the moderate right and even the center-left towards it, aping its arguments in an effort to get its voters. Theresa May’s whole campaign is a nice example of that. But Jeremy Corbyn, who broke with convention on so much, didn’t break with the increasingly nativist tone of politics on Brexit or immigration control.

    Fourth, as the last two years have shown, politics after a decade of financial crisis isn’t easy to predict. Parties and party systems across the West have been losing stability for decades, social democratic parties have been eroding and the center-right becoming less centrist while the populist radical right parties grow.

    Political scientists have written much about the populist radical right, which I review in a new article (free). The populist radical right has three characteristics. It is populist, siding with the people’s common sense over elite knowledge. It is nativist, believing there is a nation that needs defending. And it is authoritarian, expressing love and respect for authority. In the UK, that means UKIP and the DUP as well as some solid fraction of the Conservative party.

    This is basically a toxic brew from the perspective of any likely reader of this blog. Populism is affirming since it relies on arguments anybody can understand. Authoritarianism is both popular in its own right and easy to trigger with, for example, scare stories about migrants.

    Nativism, finally, can lead to “welfare chauvinism”, or what Alexandre Afonso calls “fake socialism”: not a neoliberal platform of cutbacks, but rather a generous and very exclusive, nativist welfare state. Think a well funded NHS that you can only use if you provide two forms of ID proving you legally reside in the UK. Trump, Le Pen, and May all campaigned on platforms with a strong element of welfare chauvninism.

    Fortunately, there is not a lot of research showing that the populist radical right in office actually pursues welfare chauvinist policies. For a long time, the research found that they ran on welfare chauvinist themes and then enacted classic right-wing cutbacks (which is what you would expect of parties with a strong base in small business people who are notoriously hostile to regulation and welfare states). More recent research has found that in systems where they enter government in coalition, such as Austria or Belgium, they achieve little and what they achieve is in restricting access to benefits- more chauvinism, but not more welfare. The main reason or that is coalition government, which tempers the policy effect of any given party. The newest research seems to show that they also cut back less on welfare budgets relative to more conventional right parties. So: lots of chauvinism, not so much welfare.

    In other words, the potential of welfare chauvinism is not being exploited, or at least consistently translated into policy. Trump is a particularly extreme example. After running as a welfare chauvinist candidate (whose logic pointed to a fully funded NHS for white people), he is promoting a Tea Party agenda that will be devastating to, in particular, working class rural whites above fifty who are a key part of his support. May talked a good welfare chauvinist game until people saw the Conservative manifesto, which was chauvinist without the welfare.

    As the Canadian writer Jeet Heer noted of the unexpectedly good Labour result, it “looks like you can get young people, minorities, and white working class in a coalition if you offer them something.” That is a niche worth filling. Social Democratic parties exist to fill it, and collapsed after instead becoming unconvincing catch all parties. The populist radical right remains a threat, but if it empowers social democrats to actually pursue social democracy, then the long run outcome might be positive.

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