Category Archives: Mortality

Measures of mortality andt heir significance

I sent this letter to the Scottish First Minister and health spokesperson with the PQs attached and and copied it to Welsh First Minister and Health spokesperson.

21 March 2020

Dear Nicola and Jean,

I am writing as a public health physician who is increasingly concerned about the apparent failure to implement fundamental public health measures to address the COVID-19 outbreak – specifically, community contact tracing and testing – and about what seems to be one of the knock-on effects of this failure, namely the blanket closure of schools.   

Tracing and testing of contacts, isolation and quarantine are the classic tools and approaches in public health to infectious diseases. According to the WHO, they have been painstakingly adopted in China in response to the COVID-19 outbreak, with a high percentage of identified close contacts completing medical observation; and they have been strongly recommended by the WHO for other countries.

In England, there are a lack of data – contact tracing appears to have been adopted only initially. According to modelling conducted by the authors of one of the papers published by the government yesterday, ‘The Efficacy of Contact Tracing for the Containment of the 2019 Novel Coronavirus (COVID-19) (Keeling et al.) they expect that it would enable the outbreak to be contained :
“Aggregating across all individuals and under the optimistic assumption that all the contact tracing can be performed rapidly, we expect contact tracing to reduce the basic reproductive ratio from 3.11 to 0.21 – enabling the outbreak to be contained (figure 2). Rapid and effective contact tracing can therefore be highly effective in the early control of COVID-19, but places substantial demands on the local public-health authorities.”

The basic reproductive ratio, R0, is a standard epidemiological construct for understanding the epidemic potential of an infection; the higher the ratio, the more difficult it will be to control its spread. Ideally, R0 should be 0. If R0 is less than 1, an infected person will transmit the infection to less than one other person, and so the epidemic potential is critically reduced. On the basis of this modelling, if contact tracing is not being rigorously conducted now, the possibility of critically reducing the epidemic would be missed. The Keeling paper when taken together with the New York academics Shen et al  critique  raises serious questions about the validity of  Prof Fergusson’s  model (whose apocalyptic numbers were was used by the Westminster government to justify its approach.)  

I am truly concerned that contact tracing, testing, quarantine and isolation have not been exhaustively carried out before taking the blanket decision to close all schools. I have sent the opposition spokespeople for health at Westminster some suggested PQs that my colleague Peter Roderick and I have drafted, which I attach.

It is important to note that many areas in Scotland and elsewhere have a low number of cases and so at this stage by taking an area approach to vigorous and meticulous contact tracing and testing it should be possible to contain the disease – in Singapore, the BBC reports that the army has been called in to help with this. This would in time, with other measures, allow local areas on a school-by-school basis to safely consider reopening – and uphold each child’s right to education.

One of the major differences in this outbreak is that the outbreak is being managed centrally rather than being coordinated centrally, with insufficient foot soldiers on the ground. In England local authorities and Directors of Public Health cannot tailor responses to the local situation and are subject to central policy decisions. My colleagues in public health in local authorities say they have received very little information. This, combined with the devastating cuts to community-based communicable disease control and the changes wrought by the HSC Act 2012 which carved out public health from health services in England and then further fragmented communicable disease control by removing it to PHE have created a perfect storm.

I urge the Scottish government immediately to institute a massive centrally-coordinated, locally-based contact tracing and testing programme; and to discuss with local authorities, health boards, trade unions, public health and communicable disease control experts, schools and colleges and universities how this tried-and-tested classic approach would, with other measures, enable the blanket school closure decision to be modified in favour of a locally-based strategy.    

Scotland has been a pioneer for public health measures –it is important to reassert its expertise.
 
Yours sincerely,
Allyson Pollock

Professor Allyson Pollock, Professor of Public Health, Faculty of Medical Sciences, Newcastle University



Suggested draft PQs to the Secretary of State for Health and Social Care on contact tracing and testing

Summary

Contact tracing, testing of contacts and isolation are the classic tools and approaches in public health to infectious diseases. They have been adopted in China in response to the COVID-19 outbreak, and have been strongly recommended by the WHO. In England, there is a lack of data – contact tracing appears to have been adopted only initially, whilst the authors of one of the scientific papers published by the government today state that they expect that it would enable the outbreak to be contained.  

China

In February 2020, 25 experts from China, Germany, Japan, Korea, Nigeria, Russia, Singapore, the US and WHO undertook a 9-day Joint Mission on COVID-19 to China.
It stated the following on contact testing:

“China has a policy of meticulous case and contact identification for COVID-19. For example, in Wuhan more than 1800 teams of epidemiologists, with a minimum of 5 people/team, are tracing tens of thousands of contacts a day. Contact follow up is painstaking, with a high percentage of identified close contacts completing medical observation. Between 1% and 5% of contacts were subsequently laboratory confirmed cases of COVID-19, depending on location.

For example:
• As of 17 February, in Shenzhen City, among 2842 identified close contacts, 2842 (100%) were traced and 2240 (72%) have completed medical observation. Among the close contacts, 88 (2.8%) were found to be infected with COVID-19.

• As of 17 February, in Sichuan Province, among 25493 identified close contacts, 25347 (99%) were traced and 23178 (91%) have completed medical observation. Among the close contacts, 0.9% were found to be infected with COVID-19.

• As of 20 February, in Guangdong Province, among 9939 identified close contacts, 9939 (100%) were traced and 7765 (78%) have completed medical observation. Among the close contacts, 479 (4.8%) were found to be infected with COVID-19” (pp.8/9).

During the second stage of the outbreak, “[m]easures were taken to ensure that all cases were treated, and close contacts were isolated and put under medical observation” (page 15).

It is not clear from the report whether all contacts were tested, though they were apparently quarantined. Contacts have been both tested and quarantined in Singapore, where the army has been called in to help with tracing, according to the BBC.

In considering next steps for other countries, the report states (emphases added):
“3. Much of the global community is not yet ready, in mindset and materially, to implement the measures that have been employed to contain COVID-19 in China. These are the only measures that are currently proven to interrupt or minimize transmission chains in humans. Fundamental to these measures is extremely proactive surveillance to immediately detect cases, very rapid diagnosis and immediate case isolation, rigorous tracking and quarantine of close contacts,and an exceptionally high degree of population understanding and acceptance of these measures.

Achieving the high quality of implementation needed to be successful with such measures requires an unusual and unprecedented speed of decision-making by top leaders, operational thoroughness by public health systems, and engagement of society.

Given the damage that can be caused by uncontrolled, community-level transmission of this virus, such an approach is warranted to save lives and to gain the weeks and months needed for the testing of therapeutics and vaccine development. Furthermore, as the majority of new cases outside of China are currently occurring in high and middle income countries, a rigorous commitment to slowing transmission in such settings with non-pharmaceutical measures is vital to achieving a second line of defense to protect low income countries that have weaker health systems and coping capacities. The time that can be gained through the full application of these measures – even if just days or weeks – can be invaluable in ultimately reducing COVID-19 illness and deaths. This is apparent in the huge increase in knowledge, approaches and even tools that has taken place in just the 7 weeks since this virus was discovered through the rapid scientific work that has been done in China.”

The mission recommended countries outside China with imported cases and/or outbreaks of COVID-19 to “[p]rioritize active, exhaustive case finding and immediate testing and isolation, painstaking contact tracing and rigorous quarantine of close contacts” (page 21).
England

Blogs by PHE CEO (Duncan Selbie) and PHE’s Deputy Director, National Infections Service (Nick Phin) in mid-February state that contact tracing was being undertaken:
“PHE now has a very extensive and complex contact tracing operation underway with health protection teams around the country diligently talking to people that might have been in close contact with carriers of the virus to assess their risk, provide advice and ultimately prevent further spread.”
“So far in the UK we’ve seen a small number of novel coronavirus cases.  At the moment we undertake contact tracing to prevent the infection spreading further. Contact tracing is a fundamental part of outbreak control that’s used by public health professionals around the world.”

There was no statement that those traced would be tested, isolated or quarantined, and apparently this would be done only if the contact developed symptoms:
“When we get in touch with a contact we provide them with advice on what to do if they become unwell or develop certain symptoms.  This way they can speak to the right health expert, so that the right advice can be given and right action taken.
If we believe a contact is at higher risk of infection they may be asked to self-isolate, remaining in their home and staying away from work, school or public places and we contact them daily until they can be given the all-clear.
If the person being monitored does develop symptoms, we would test them and provide them with specialist care if they have the novel coronavirus.”
There is also an implication in Nick Phin’s blog that as more cases develop, less contact tracing might be undertaken (emphasis added):
“Our experts have considerable experience at using contact tracing to prevent and contain outbreaks and to keep the public safe.

However, it does involve a lot of resources so as part of our comprehensive approach to tackling novel coronavirus in the UK, we’re putting extra resources into our contact tracing efforts. If the virus becomes established in the UK then we mayneed to move to a different phase of the response which focuses less on containment – but we are a long way off that.”

Concern has been expressed about the UK’s approach to contact tracing and testing – see, for example,  Martin Hibberd, professor of emerging infectious diseases at the London School of Hygiene and Tropical Medicine, quoted in The Guardian on 12/3/20 as saying that “the UK’s response ‘has clearly not been sufficient’. He and other experts called for much more extensive testing and tracing of the contacts of those diagnosed with Covid-19”.

The government published today the scientific evidence supporting its COVID-19 response. According to modelling conducted by the authors of one of the papers published, entitled ‘The Efficacy of Contact Tracing for the Containment of the 2019 Novel Coronavirus (COVID-19) (Keeling et al.) :
“Aggregating across all individuals and under the optimistic assumption that all the contact tracing can be performed rapidly, we expect contact tracing to reduce the basic reproductive ratio from 3.11 to 0.21 – enabling the outbreak to be contained (figure 2). Rapid and effective contact tracing can therefore be highly effective in the early control of COVID-19, but places substantial demands on the local public-health authorities.”

The basic reproductive ratio basic reproductive ratio, R0, is a standard epidemiological construct for understanding the epidemic potential of an infection; the higher the ratio, the more difficult it will be to control its spread. Ideally, R0 should be 0. If R0 is less than 1, an infected person will transmit the infection to less than one other person, and so the epidemic potential is critically reduced. On basis of this modelling, if contact tracing is not being rigorously conducted now, the possibility of critically reducing the epidemic would be missed.  

We have not been able to find any data on contact tracing, the testing of contacts, isolation or quarantine in any part of the UK, and have not been able to find any PQs on the subject so far (despite the hundreds already tabled).

Draft PQs (1) and (2) below are therefore aimed at obtaining those data for England.

Draft PQ (3) directly addresses the government’s response to the expectation of the Keeling et al. paper published today.

Draft PQ (4) has been prompted by personal knowledge and conversations with other public health professionals, and concern that public health expertise in infectious diseases and in disease control more generally has been disappearing in local areas. 

Draft PQ (5) is wider than testing of contacts, but cost may very well be a factor that might have contributed to a lack of testing, and so we have suggested framing the question more broadly.

Draft PQs


(1) To ask the Secretary of State for Health and Social Care if he will specify, by local authority area, the contact tracing that is currently underway in England in relation to those who have been, or are suspected as having been, infected or contaminated with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), including (a) the number of personnel carrying out such tracing and (b) the number of close contacts (i) identified and (ii) traced.

(2) To ask the Secretary of State for Health and Social Care if he will specify, by local authority area, the number and percentage of close contacts of those who have been, or are suspected as having been, infected or contaminated with the severe acute respiratory syndrome coronavirus  2 (SARS-CoV-2), who (a) are undergoing testing (b) have tested positive and (c) have been isolated or quarantined.

(3) To ask the Secretary of State for Health and Social Care whether he is ensuring rapid and effective contact tracing in relation to COVID-19, in light of the authors of the Keeling et al. study entitled ‘The Efficacy of Contact Tracing for the Containment of the 2019 Novel Coronavirus (COVID-19) published by the government on 20thMarch 2020, stating that “we expect contract tracing to reduce the basic reproductive ratio from 3.11 to 0.21 – enabling the outbreak to be contained”; and if not, why not.

(4) To ask the Secretary of State for Health and Social Care if he will publish the latest data for the numbers of (a) consultants in communicable disease control and (b) community infection control nurses, and c) their location by local authority area.

(5) To ask the Secretary of State for Health and Social Care if he will specify (a) the public bodies and/or (b) the companies which are carrying out the tests for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and explain the sensitivity and specificity of each test and their cost .
 
Allyson Pollock, Professor of Public Health, Newcastle University
Peter Roderick, Principal Research Associate, Newcastle University
20/3/20

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20/03/2020

 

OPEN LETTER TO THE PRIME MINISTER FROM THE SOCIALIST HEALTH ASSOCIATION

Dear Mr Johnson,

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

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

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

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

  1. You are placing staff at risk

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

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

  1. You are placing patients at risk

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

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

  1. You are placing communities at risk

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

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

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

This pandemic is likely to add to that grotesque toll.

  1. You are placing the NHS at risk

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

  1. You are placing Social Care at risk

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

  1. You are placing democracy at risk

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

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

 

WE EXPECT YOUR GOVERNMENT TO:

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

 

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

 

Chair SHA

Dr Brian Fisher, London

Vice-chairs SHA

Dr Tony Jewell

Tony Beddow, Swansea

Norma Dudley, London

Mark Ladbrooke, Oxford

Secretary

Jean Hardiman Smith, Ellesmere Port

Treasurer

Irene Leonard, Liverpool

Co-Chair KONP

Dr Tony O’Sullivan, London

 

Co-signatories

Dr John Carlisle, Sheffield.

Terry Day, London

Carol Ackroyd, London

Corrie Louise Lowry, Wirral

Caroline Bedale, Oldham

Hazel Brodie, Dumfries

David Taylor-Gooby, Newcastle

Peter Mayer, Birmingham

Dr Alex Scott-Samuel, Liverpool

Dr Jane Roberts, London

Dr Judith Varley, Birkenhead

Vivien Giladi, London

John Lipetz, London

Jane Jones, Abergavenny

Dr Kathrin Thomas, Llandudno

Dr Louise Irvine, London

Dr Jacky Davis, London

Dr Coral Jones, London

Dr Nick Mann, London

Dr John Puntis, Leeds

Brian Gibbons, Swansea

Anya Cook, Newcastle,

Alison E. Scouller, Cardiff

Punita Goodfellow, Newcastle upon Tyne

Parbinder Kaur, Smethwick

Gurinder Singh Josan CBE,  Sandwell

Jos Bell, London.

Steve Fairfax Chair SHA NE, Newcastle upon Tyne

 

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

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COVID-19 Pandemic

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

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

 

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

 

  1. A global crisis

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

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

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

 

  1. The public health system

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

 

  1. The NHS, Local Government and Social Care

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

 

  1. Funding for staff and facilities.

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

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

 

  1. Staff training, welfare and support

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

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

 

  1. Vulnerable populations.

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

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

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

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

 

  1. Assuring universal basic income.

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

 

  1. Conclusion

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

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

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

On behalf of officers and vice chairs

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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

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

by Dan Robitzski / 8 hours ago

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

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

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

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

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

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

 

 

 

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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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Archie Batten

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Studies show that;

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

 

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Responding to the third tranche of inspections from Her Majesty’s Inspectorate of Fire and Rescue Services, Matt Wrack, Fire Brigades Union (FBU) general secretary, said:

On the national view

“This tranche of reports are a complete indictment of the government’s dangerous complacency over the risk of fire, flooding, and other hazardous incidents. Austerity has ravaged our fire and rescue service, leaving residents in many areas at risk. In Gloucester, the inspectorate are clear that changes are needed ‘urgently’, but politicians and fire service management elsewhere must not rest on their laurels.

“With no national standards and no national infrastructure coordinating fire and rescue service policy, residents inevitably face a postcode lottery of fire safety.

“While fire service bosses must be responsible for any failings, so too should the politicians who have starved them of funding, resources and boots on the ground. Our service is collapsing – it’s plainly unsustainable.”

On Grenfell

“The inspectorate’s verdict that London Fire Brigade’s senior management has been slow to learn from the Grenfell Tower tragedy will make worrying reading for firefighters, who have faced unfair criticism while others, including those in government, have no been held to account. It will also be deeply concerning for the Grenfell community and all of London.

“Grenfell must be a turning point for UK fire safety – anything less is completely unacceptable. The inquiry’s vital recommendations must be implemented quickly in London, but they also must be implemented in every fire and rescue service in the country.”

On equality and culture

“It’s shameful that not enough is being done enough to improve equality and diversity in our service. Progress has all but flat-lined under this government – and a severe lack of recruitment and the scrapping of equality targets is largely to blame. We need to recruit more firefighters – and we need to make sure they reflect the communities they serve.

“We are also deeply concerned about toxic bullying and harassment from management in many fire and rescue services. Firefighters give their all to keep the public safe – it’s disgraceful that certain fire service bosses have thanked them with intimidation. We urge any firefighter affected to contact their FBU representative.”

Notes:

The FBU is the trade union representing the overwhelming majority of firefighters in the UK and serves as the professional voice of firefighters and the fire and rescue service. The union is a core participant in the ongoing Grenfell Tower Inquiry.

The FBU’s initial response to the publication of the Grenfell Tower Inquiry phase one report is available here: https://www.fbu.org.uk/news/2019/10/30/fbu-response-grenfell-tower-inquiry-phase-1-report

The FBU launched its Grenfell: Never Again campaign on the second anniversary of the fire, with five demands: 1) the removal of all flammable cladding; 2) retrofitting sprinklers wherever a risk assessment deems necessary; 3) ensure a strong, democratic voice for tenants; 4) reverse the cuts to firefighter numbers and fire safety officers and; 5) create a new national body to oversee the fire and rescue service. For more information, please see here: www.fbu.org.uk/grenfell-never-again

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A major fire at a Travelodge in Brentford, London, today saw more than 100 firefighters respond.

Matt Wrack, FBU general secretary, said:

“This fire is yet another sign of this government’s utter failure to get to grips with our fire safety crisis. Two years on from Grenfell, there has still been no comprehensive programme testing building materials.
“The approach so far has been the agonisingly slow removal of one particular kind of cladding, but that barely scratches the surface.
“The Tory manifesto made no new policy proposals to tackle the fire safety crisis – just more of the same indifferent inaction. They have slashed the fire and rescue service and could not even bring themselves to mention it in their manifesto. Their record is nothing short of shameful.
“We need to bring together firefighters, government, tenants, and the fire safety industry to properly implement the Grenfell inquiry recommendations and get to grips with this crisis before we have another tragedy.

Media contact: Joe Karp-Sawey, FBU communications officer

joe.karpsawey@fbu.org.uk

Notes

The FBU recently called for a forum of all those needed to drive through sweeping changes to UK fire safety, writing to representatives from the government and shadow cabinet, the London Fire Brigade, the National Fire Chiefs Council, the Mayor of London, the Local Government Association, the first ministers of Scotland, Wales and Northern Ireland, fire safety bodies and the Grenfell community. For more information, please see here: https://www.fbu.org.uk/news/2019/11/25/firefighters-call-forum-implement-grenfell-inquiry-recommendations

The FBU is the trade union representing the overwhelming majority of firefighters in the UK and serves as the professional voice of firefighters and the fire and rescue service. The union is a core participant in the ongoing Grenfell Tower Inquiry.

The FBU’s initial response to the publication of the Grenfell Tower Inquiry phase one report is available here: https://www.fbu.org.uk/news/2019/10/30/fbu-response-grenfell-tower-inquiry-phase-1-report

The FBU launched its Grenfell: Never Again campaign on the second anniversary of the fire, with five demands:

1) the removal of all flammable cladding;

2) retrofitting sprinklers wherever a risk assessment deems necessary;

3) ensure a strong, democratic voice for tenants;

4) reverse the cuts to firefighter numbers and fire safety officers and;

5) create a new national body to oversee the fire and rescue service.

 

For more information, please see here: www.fbu.org.uk/grenfell-never-again

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Health inequalities persist and grow in the UK. Differences in morbidity and mortality add to rising public concerns about household poverty and children’s health and development. Current attempts to redefine and find new national lower measures for poverty in the UK when current measures show increases, talk endlessly about getting more information about poor people and their lives and involving them in defining the problems. This blog is about how the language used itself diverts attention from the real underlying issues, such as why, in the rich UK, are personal and public resources so badly distributed by government or the labour market that anyone is left without sufficient to choose an acceptable conventionally inclusive and healthy lifestyle. Whatever the role of freedom of choice in people’s lives, which is a basic premise of our marketised consumerist society, it follows that no one should have too few resources to exercise it as others do.

Today’s problems are constant reminders of what Sir Douglas Black brought to wider public and political awareness as long ago as 1977. His report concluded that “poverty remains the chief cause of disease, and it is a factor which is beyond the immediate control of medicine”. ‘Disease’ here means all forms of ill-health, and the poverty referred to is not only that of the individual household lacking adequate disposable resources (mainly cash incomes) to be free to make its own healthy choices of food and socially-inclusive lifestyle, but also the lack of the collective resources of decent housing, health and care, children’s services, education, public transport, opportunities for adequately paid work and other collective means of enabling and empowering people to take a recognised part in their society over time. These are matters that Sir Donald Acheson’s report on Inequalities in Health reiterated in 1998 and others repeatedly have since then.

Public expenditure on and availability of all of these collective as well as individual resources at the levels needed to prevent deprivations and health inequalities has been considerably reduced by deliberate government ‘austerity’ policy since 2010. It is just possible that the politicians who devised and maintained these anti-statist policies were unaware of the health consequences of their pursuit of austerity; at any rate, if not culpably ignorant and oblivious, they seem to disregard the reports which increasingly make the connections between their policies and the consequent growth in a wide range of social evils including health inequalities. Beyond a little fire-fighting in crisis situations the current political response is too often to focus on or even blame the victims, suggesting for instance that they wouldn’t be so unhealthy if they’d made the right lifestyle choices compatible with their resources. The current government does not acknowledge that the resources are inadequate for such choices.

The obvious problem of inadequate resources and incompatible objectives, such as eating or heating, can’t be answered as long as we focus only on people in poverty and their own reports. The language we use to talk about the problems (the discourse, to use the technical jargon) not only distorts our focus on underlying causes but actually closes off some options for policy action, and this is being deliberately promoted for ideological reasons by some of the people involved. It’s part of the bigger story of attitudinal manipulation widely discussed in political circles, but it’s relevant in many other fields as well, and it affects social scientists as well as other publics. That’s why the current discourse matters when we discuss health problems.

First, a note about the social science technical aspects. The discourse reflects the currently accepted explanatory paradigms, the self-consistent system of concepts and theories which any scientific system uses to structure its approaches in ways which make it seem like ‘common sense’ not needing to be questioned. That’s why to make sense of what’s happening now, we need to review,  brutally briefly, the succession of dominant poverty paradigms since the 19th century. The traditional paradigm was acceptance of class-based social stratification, given its authority by the dominant social order or even by religious beliefs, in which poverty was the way of life of the lowest layer of society, in terms of squalor and exclusion. Dividing poor people into the ‘roughs’ and the ‘respectables’, many well-off people assumed this was a matter of individual choice even if the system was immutable. But the earliest systematic attempts by such pioneers as Seebohm Rowntree showed the poorest people lacked adequate resources even for physical efficiency. He designed an artificially low ‘primary poverty’ budget to show it was inadequate for real life, but even so it was criticised for superfluity.

This generated the second dominant paradigm in this field, poverty defined as and measured by household incomes below artificial minimum subsistence budgets. In the 20th century this generated an academic industry of competing prescriptions for variants of what the lowest level of living for poor ‘othered’ people could be, some allowing for minimal social participation expenditure as well or targeted on ‘healthy living’. Against this, during the 1930s, Sir John Boyd Orr argued that instead of prescribing minimum budgets for the lowest level of living at which people didn’t show nutritional deficiency symptoms, researchers should study empirically at what minimum levels of income households actually achieved optimum levels of nutrition. This generated lively scientific and professional association arguments for years. In the post-war period, the sociologist Professor Peter Townsend argued that if households were to be studied for sufficient spending on adequate nutrition, this applied even more strongly to adequacy of their resources for social participation. He suggested that seriously lacking resources for participation in conventional lifestyles was the conceptual definition of the social phenomenon of poverty, identifying its cause in the structure of resource distribution and pointing to a more appropriate measure of poverty than normative budgets based on the natural science measures of nutrition and health alone.

This third paradigm thus raised the question of whose standards of adequacy of resources and life choices were to be applied to distinguish normally inclusive lives from poverty. Should they be the experts’ prescriptive (normative) views about healthy diets and lives, or the population’s views about inclusive lifestyles (though research experts are needed to discover empirically what they are)? The question of whose and what standards were to be applied, and the levels of various resources needed to enable inclusive lifestyles, became a matter for the poverty research industry, but some policy-oriented researchers (and many politicians) found it hard to accept the shift from expert to ordinary people in defining what an inclusive lifestyle and adequate resources might be. Some of this was caused by manifest confusion between the social science question of what levels and standards of resources were needed for social inclusion, adequacy, as defined by the whole population, and the completely different political question of what governments asserted ‘the taxpayer’ could afford for social security claimants.

A larger problem, one which is rarely admitted openly but colours all such arguments, is the ancient class distinction between living standards Good Enough for Us, We the People, or sufficient for Them, the Poor. Evidence from social surveys and focus groups shows that when they ask about what levels of living are needed for poor people to escape poverty, participants offer more restrictive views than when they are asked about what all of ‘us’ need to live a minimally decent inclusive life in society. If the word ‘poverty’ is used in the question, responses often ‘other’ the victims as ‘them’. Thus although the currently dominant paradigms may succeed in dominating discourse to squeeze out previous ones, the older ones may leave persistent residues in common thought. Today’s focus on poor people’s lives which avoids the social and economic structures within which they occur harks back to the traditional paradigm of class divisions.

This is no accident. It shows that it’s not only traditional social distinctions but ideology, how power should be used politically, which influences the discourse. The chief distinction is between the traditional conservative view that different minimum standards are naturally hierarchical since in that ideology each class has its ranked position and unequal status and the decent minimum may vary accordingly. By contrast, the socialist egalitarians argue that the minimally adequate inclusive lifestyle standards should apply to everybody. This reflects the recognition that conventionally inclusive lifestyles may remain unequal in many respects but everyone within them has sufficient resources to make choices and still be recognised as included or healthy. Inequalities remain but are no longer caused by a serious lack of resources, and are therefore not a poverty problem even if they are some other. For instance, assessing the promotion of ‘go private and get better service’ in the NHS then depends on whether the standard quality of services in this essential collective resource demonstrably meets the ‘good enough for us all’ expectations or whether it reflects a ‘NHS good enough for those who don’t have resources to make choices’ conservative austerity perspective.

The focus of all the public argument right now against this background is the people in poverty as defined by the current paradigm, as people whose “resources are so seriously below those commanded by the average individual or family that they are, in effect, excluded from ordinary living patterns, customs and activities” (Townsend 1979). Why then do some anti-poverty organisations welcome more intensive study of people in poverty — “to fight poverty, we must first understand more about those in its grip” (The Guardian 17.9.18). This focus dominates much media framing of what to do about poverty. Even if the scope is broader, it’s the counterpart of studying malnutrition in terms of why don’t poor people eat greens instead of junk food. In terms of the old analogy of pulling drowning people out of the river downstream, it’s asking why don’t they swim, and planning to teach them better, instead of asking why did they fall in upstream — or even who keeps pushing them in. The article quoted calls on policy makers to use this focus “to help alleviate poverty in Britain”. But why not work to abolish it? The answer must lie on the political right where alleviating poverty is philanthropic and OK, while policy to abolish it is political and ‘lefty’.

A discourse which focuses obsessively on the characteristics and experiences of people in poverty is a bit like first aid. Victims must of course be relieved, even if at that stage no account is taken of causes. But overall in the health field much more attention is rightly focused on prevention even while state funding is restricted. The danger of the discourse focusing only on victims is that it normalises acceptance of ill-health and alleviation (the conservative stance) instead of emphasising attention to its preventive ‘clean water’ of adequate resources. ‘Poverty porn’ attracts many television viewers and normalises ‘othered’ lifestyles whose deprivations and deviances are enforced. It’s a modern version of visiting Bedlam three hundred years ago. Of course ‘those who experience it are best able to describe it’, a perspective long emphasised by for instance community workers and mental health service patients (not forgetting victims of oppressive social security, as illustrated by ‘I, Daniel Blake’). But this is not the same as the shift to claiming that the ‘voices of the poor’ should be the principal source of valid evidence on how to abolish it. This would be like acknowledging that sick patients are the best guides to what their symptoms feel like, and then claiming their reports as scientific analysis of causes. Cholera patients report fever and diarrhoea, not polluted water supplies. A neglected factor in this well-meaning emphasis on victims’ accounts is the implication that people who aren’t suffering can’t understand it, or even that they lack empathy, which is used to discredit critics who look beyond symptoms to causes.

The more the current discourse emphasises focus on people in poverty, the more it distracts from discussion of preventive measures, especially when these are discussed in terms of government policy instead of the foundations of good health. But to avoid policy argument as “not our business” gives covert support to ideological opposition to structurally redistributive policies, not the foundations of social policy for health and social security of resources for everyone. Evasion of those issues is discourse closure on prevention. Preventing poverty and health inequalities sounds good, but when it means trying to change the behaviour of victims without increasing their access to relevant individual and collective resources to adequacy levels, it’s dishonest.

Poverty prevention is not the only subject closed off by discourse focusing primarily on the lives of people in poverty. In this world of inequalities, there doesn’t seem to have been interest in studying how far statistically normal individual variability in health experience overlaps with health inequalities which themselves correlate with variations in levels of individual or household power over resources and the availability of collective resources. No one expects the normal range to be dependent on resources alone, so we need research to establish what its contribution is. The ‘Money Matters’ research by Kerris Cooper and Kitty Stewart (JRF 2013; 2015) showed that (contrary to some conservative lobby groups’ claims) money indisputably does matter and others showed the causative networks by which it does. Regrettably the project failed to proceed to ask, ‘and if money matters, then how much money matters?’ If we are to have effective preventative policies to abolish poverty as well as alleviating it, then we need to know what the evidence suggests that bit of the anti-poverty target is.

There is no theoretical reason (except perhaps in some neo-liberal economic or politically reactionary fantasies) why anyone in UK society should have too little power over resources to be able to make healthy choices without detriment to their conventionally decent socially-inclusive lives. Discourse matters because when it focuses only on poor people’s health it closes off the bigger problem of those structural inequalities which also damage everyone’s social health.

 

 

Author.

John Veit-Wilson is Emeritus Professor of Social Policy of Northumbria University and guest member of Sociology at Newcastle University. He is author of Setting Adequacy Standards: How governments define minimum incomes (Policy Press 1998) and was poverty consultant to the Joseph Rowntree Foundation’s Money Matters research programme. He was a founding member of the Child Poverty Action Group in 1965.

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Life tables 1841 -2011

The first English Life Table was based on data collected around the census year of 1841 and gave female life expectancy as 42 and male as 40.[1] By the sixth table, in 1891, life expectancy for women in England and Wales was 48 and for men 44. Many people lived longer than this, but so many babies died in their first year of life that it brought the average down. Public health reforms during the 1890s meant that by 1901 life expectancy was 52 for women and 48 for men.[2] Four years each, gained in just ten years. The turn of the century brought a dramatic drop in infant and childhood mortality as sanitation and living standards improved. By 1921 women were expected to live to 60 and men to 56. Eight years each, gained in just twenty years. By 1951 women’s life expectancy was 72 and men’s 66. Women gained 12 years to men’s ten over this thirty-year period as a result of better maternity care, partly due to the new NHS, and a higher proportion of women being non-smokers. This rise, of more than a year every three years, took place despite war, rationing and austerity.

Improvements slowed in the 1950s. Most of the easy victories had been achieved. In 1956 the Clean Air Act was passed, four years after the Great Smog caused excess deaths that Harold Macmillan tried to blame on influenza.[3] By 1971 life expectancy for women was 75 and for men 69. Three years more each, achieved in twenty years. In the 1970s the rate of improvement in life expectancy accelerated again. Social progress in that much maligned decade meant that despite cutbacks in healthcare and public services in the 1980s under Margaret Thatcher, by 1991 women were living to 79 and men to 73. Four years each, achieved in twenty years.

Over the next twenty years, men caught up a little with women: since more men smoked there were more male smokers who could give up. By 2011 women were expected to live to 83 and men to 79. In those twenty years women gained three years and men five. The six-year gap that had opened up by 1951 was back to four.

Since 2011, under David Cameron and Theresa May, life expectancy has flatlined. The latest figures, published by the Office for National Statistics in September, are for the period 2014-16. Women can now expect to live for 83.06 years and men for 79.40 years.[4] For the first time in well over a century the health of people in England and Wales as measured by the most basic feature – life – has stopped improving. Just as Macmillan had done, the government initially tried to blame the figures on flu deaths. But as the years have passed and life expectancy continues to stall it has become clear that flu isn’t the culprit. The most plausible explanation would blame the politics of austerity, which has had an excessive impact on the poor and the elderly[5]; the withdrawal of care support to half a million elderly people that had taken place by 2013; the effect of a million fewer social care visits being carried out every year; the cuts to NHS budgets and its reorganisation as a result of the 2012 Health and Social Care Act; increased rates of bankruptcy and general decline in the quality of care homes; the rise in fuel poverty among the old; cuts to or removal of disability benefits. The stalling of life expectancy was the result of political choice.

The first to be affected were elderly women living alone in the poorest parts of the UK. Their areas had been targeted by the last Labour government for interventions aimed at improving health. All those schemes were cancelled in the years after 2010. By 2016 cuts in welfare spending, especially those affecting older pensioners, had been linked to a rise in deaths. Public health experts writing in the British Medical Journal called for an inquiry, but the government refused.[6] Instead officials continued to claim that ‘recent high death rates in older people are not exceptional.’[7] An even higher rise in the death rate was recorded for Scotland, but again there was no serious response.[8] By July 2017 Michael Marmot’s Institute of Health Equity was linking NHS cuts to the rise in deaths among those with dementia and to faltering life expectancy.[9] A paper I co-wrote with researchers at Liverpool, Glasgow and York connected the rise in mortality rates with delays in discharging elderly patients from hospital because appropriate social care was not available.[10] The Financial Times reported that the slowdown in life expectancy had cut £310 billion from British pension fund liabilities, and these figures included only a few pension schemes.[11]

Life expectancy for women in the UK is now lower than in Austria, Belgium, Cyprus, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Liechtenstein, Luxembourg, Malta, the Netherlands, Norway, Portugal, Spain, Sweden, and Switzerland.[12] Men do little better.[13] In almost every other affluent country, apart from the US, people live longer than in the UK, often several years longer and the best countries are pulling away. Between 2011 and 2015 life expectancy rose by a year in both Norway and Finland.[14] It rose by more than a year in Japan, despite the Japanese already having the highest life expectancy in the world.[15]

Extra deaths now projected to occur every year in the UK from 2016 to 2058, by ONS – 2016-based projection as compared to the 2014-based projection

 Extra      Cumulative       Time Period

‘in year’

deaths

39,307             39,307             2016 – 2017

25,668             64,975            2017 – 2018

27,246             92,221            2018 – 2019

28,521             120,742          2019 – 2020

29,581             150,323          2020 – 2021

307,031           457,354          2021-2030

 246,302           703,656          2031-2040

 178,483           882,139          2041-2050

17,310             882,139          2050 – 2051

17,463             899,602          2051 – 2052

17,582             917,184          2052 – 2053

17,650             934,834          2053 – 2054

17,600             952,434          2054 – 2055

17,404             969,838          2055 – 2056

17,050             986,888          2056 – 2057

16,524             1,003,412       2057 – 2058

Source – calculated directly from ONS tables of expected deaths by age and year.[16]

In the UK official projections have now been altered because of the tens of thousands of people who have died earlier than expected. If you subtract the latest ONS figures from the figures published two years ago, you can see that a further one million earlier deaths are now projected in the next forty years (the ONS itself doesn’t publish this number – it is shown in the table above).[17] What has happened is no longer being treated as a decline; it is the new norm. On 26 October the Office for National Statistics announced that it estimates that, by 2041, life expectancy for women will be 86.2 years and for men 83.4. Both figures are almost a whole year lower than projected in 2014.[18]

Superficially this might appear a small adjustment that will only have an effect many years in the future. But its implications are huge.[19] Already in the year from July 2016 to June 2017 an additional 39,307 people have died. Seven per cent of them were people between 20 and 60: almost 2000 men and 1000 women. Well over four-fifths of the premature deaths projected by the ONS will be of people who are now in their forties and fifties.

These extra deaths are not linked to more migration to the UK: the ONS now projects less in-migration. They are not due to a rise in births: the ONS now projects lower birthrates. They are simply the result of mortality rates having risen in recent years.[20] The ONS believes this will have a serious effect on life expectancy and population numbers for decades to come. It does not say why the change has happened or even point out how exceptional it is.

The UK government accepts that air pollution, a reversible cause, results in 40,000 premature deaths a year.[21] There are complaints and headlines about that, but not about the fact that there were almost 40,000 more deaths than expected in the year up until June 2017. It is projected that there will be an extra 25,000 deaths between July 2017 and June 2018; an extra 27,000 in the year after that, more than 28,000 extra deaths in the 12 months after that, then another 30,000 (see table above). And on and on and on, and still the government has given no explanation.

Whatever has happened has happened in a country where the official statisticians feel they can only point out in the seventh note[22] attached to a press release that some figures have been adjusted. It is not difficult to guess the likely cause of the sudden deterioration in the health of the nation. If we do not address the policies that have caused these changes, the ONS projections will become reality.[23]

References

[1] ONS (2015) How has life expectancy changed over time? London: ONS, September 9th, https://visual.ons.gov.uk/how-has-life-expectancy-changed-over-time/

[2] Dorling, D. (2006) Infant Mortality and Social Progress in Britain, 1905-2005

In: Eilidh Garrett, Chris Galley, Nicola Shelton and Robert Woods (eds), Infant Mortality: A Continuing Social Problem: A volume to mark the centenary of the 1906 publication of Infant Mortality: A Social Problem by George Newman. pp 223-228, available here: http://www.dannydorling.org/?page_id=2442

[3] Dorling, D. (2014) Why are the old dying before their time? How austerity has affected mortality rates, New Statesman, February 7th, https://www.newstatesman.com/politics/2014/02/why-are-old-people-britain-dying-their-time

[4] ONS (2017) National life tables: England and Wales 2014-2016 released on September 27th 2017: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/datasets/nationallifetablesenglandandwalesreferencetables

[5] Loopstra R, McKee M, Katikireddi SV, Taylor-Robinson, D, Barr B and Stuckler D. (2016) Austerity and old-age mortality in England: a longitudinal cross local area analysis, 2007–2013. J R Soc Med;109: 109–116.

[6] Hawkes N. (2016) Sharp spike in deaths in England and Wales needs investigating, says public health expert, BMJ; 352: i981.

[7] Hawkes N. (2013) Recent high death rates in older people are not exceptional, says Public Health England. BMJ 2013; 347: f5252.

[8] Dorling, D. (2016) The Scottish Mortality Crisis, The Geographer (Newsletter of the Royal Scottish Geographical Society), Summer, pp.8-9, http://www.dannydorling.org/wp-content/files/dannydorling_publication_id5595.pdf

[9] Marmot, M. (2017) Marmot Indicators Briefing, Embargo: 0001hrs Tuesday 18th July, London: Institute of Health Equity,  http://www.instituteofhealthequity.org/resources-reports/marmot-indicators-2017-institute-of-health-equity-briefing/marmot-indicators-briefing-2017-updated.pdf

[10] Green, M.A., Dorling, D., Minton, J., and Pickett, K.E. (2017) Could the rise in mortality rates since 2015 be explained by changes in the number of delayed discharges of NHS patients? Journal of Epidemiology & Community Health, Online First: 2nd October 2017 doi: 10.1136/jech-2017-209403

[11] Combo J. Life expectancy shift ‘could cut pension deficits by £310bn’, The Financial Times, 2017 [updated 4 May 2017; cited 2017 8 August]. Available from: https://www.ft.com/content/77fa62fe-2feb-11e7-9555-23ef563ecf9a.

[12] Eurostat (2017) File: Life expectancy at birth, 1980-2015 (years), Brussels: Eurostat, http://ec.europa.eu/eurostat/statistics-explained/index.php/File:Life_expectancy_at_birth,1980-2015(years).png

[13] Ibid.

[14] Ibid.

[15] Otake, T. (2017) Continuing streak, Japan leads world in life expectancy, WHO report says, The Japan Times, May 17th, https://www.japantimes.co.jp/news/2017/05/17/national/science-health/continuing-streak-japan-leads-world-life-expectancy-report-says

[16] ONS (2017) National Population Projections: 2016-based statistical bulletin, London:ONS, Oct. 26th, https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/bulletins/nationalpopulationprojections/2016basedstatisticalbulletin

[17] To calculate these figures yourself you need to download the principal variant projections of 2014 and 2016 based by single year of age from here: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/datasets/z1zippedpopulationprojectionsdatafilesuk

[18] ONS (2017) National Population Projections: 2016-based statistical bulletin, London: ONS, October 26th,https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/bulletins/nationalpopulationprojections/2016basedstatisticalbulletin#changes-since-the-2014-based-projections

[19] For the UK, at is makes up just under 1% of the global population, the implications are on the same order of magnitude as Sen’s findings of 1990 for the world but about the future, not the past: Sen, A. (1990) More Than 100 Million Women Are Missing, New York: The New York Review of books, December 20th, http://www.nybooks.com/articles/1990/12/20/more-than-100-million-women-are-missing/

[20] Dorling, D. (2016) Public Health was declining rapidly before the Brexit vote Public Sector Focus, July/August, pp.20-22, http://www.dannydorling.org/?page_id=5639

[21] Roberts, M. (2016) UK air pollution ‘linked to 40,000 early deaths a year’, BBC News (Health) February 23rd, http://www.bbc.co.uk/news/health-35629034

[22] ONS (2017) Note ‘7. Changes since the 2014-based projections’, London: ONS, https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/bulletins/nationalpopulationprojections/2016basedstatisticalbulletin#changes-since-the-2014-based-projections

[23] There are numerous examples of where projections have not held true in future because people react to the projections and ten improve things before all the harm projected to occur if we can on as usual, can occur. See: Dorling, D. and Gietel-Basten, S. (2018) Why Demography Matters, preliminary details are here: http://www.dannydorling.org/books/demography/

First published by the London Review of Books

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Preparing for the end of someone’s life; be it our own or a loved one’s, is possibly the hardest thing we will have to do. Aside from decisions you have to make, you may need to draw up different documents, and discuss your or your loved one’s final wishes. Final arrangement also need to be discussed, like whether or not you wish to be buried, interred in a mausoleum, or cremated and then turned ashes into a living memorial diamond.

No one knows when death will come and break the calm and happy life.

However, it does get easier when you are willing to start the process long before the time ever comes. This gives you plenty of time to decide on the available courses of action instead of when the actual time comes, making it easier on the loved ones left behind. They will know what the final wishes were, have all the documents in order, and there shouldn’t be any surprise decisions to make because all the final arrangements have already been made.

Final Decisions

When it comes to final decisions, it’s safe to say that not all situations can be accounted for, but having had some prior conversation should make those decisions more bearable. Almost everything can be planned for and this listing is not meant to be all inclusive.

Here a few things you need to discuss with your loved ones to prepare yourself for end of life.

Health Care

While no one expects to pass on while in a hospital or nursing home, it would be prudent to find out what the protocol is for them in your area. While they are prepared to handle such events, knowing what will happen, helps you make appropriate arrangements in the event that you disagree with something.

Use of Hospice

This option is a god send for some, and a burden for others. While those whom work in the hospice industry are typically trained to help and aid both the family and those whom are terminal, it forces mindsets that can be quite hard to swallow. Again, being prepared for what should be done in these instances goes a long way.

Medical Procedure

Confer with loved ones what your beliefs are for medical help. While not quite the same as what health care protocols involve, make sure loved ones know and understand if and why there is a DNR in place, or how long to wait and under what circumstances they are to pull the plug on life support.

Important Documents

There are a number of different documents that should be accessible when the worst starts to happen. Documents like a living will, medical information release, and power of attorney, will prove quite useful. Provided that each set of documents is kept up to date, there shouldn’t be much in the way of added stress.

Each country will more than likely have their own version of the following documents, and this listing is not exhaustive to the number of documents you can have, or should. Please consult your doctor and lawyer long before you ever have to worry about this situation.

Living Wills

Living wills are legally binding and speak on your behalf for your end of life care. They do so when you are unable to do so for yourself. They also minimize confusion or added stress on your loved ones by pointing out what your final medical wishes are, such as a DNR or DNI orders. If you talk with your doctor about your wishes, they can draw up your DNR and DNI orders and have them in your medical file for you without the need for a living will.

Medical Information Release

Due to the nature of medical care, it is important that you have a legally binding release of information or you may find yourself unable to get information. This can extend to medical insurance policies; so it would be wise to have one should the need arise. A legally binding release of medical information allows those designated by you to receive information about your condition and prognosis as well as deal with the insurance company if needed.

Power of Attorney

A power of attorney is quite important and it will allow a person you designate to operate on your behalf when you are unable to do so; for a great many things. While a general power of attorney form encompasses a very broad range of things, you can also be quite specific in who can do what where, and how.

Final Wishes

These are more of a personal nature, and should be discussed at length with your family. In most countries, it may be customary to hold a funeral and a wake, but it may not be quite what you want. Things to consider for your final wishes include how you want your remains handled, specific instructions for the family, and how you would like to be remembered, such as turning your cremated remains into an ever-lasting diamond.

Turning ashes into diamonds and setting it on memorial jewellery become new trends to commemorate a beloved.

Your religious beliefs and life beliefs will play a large portion of this, and can only be carried out if your family knows about it. Otherwise, you will be left with what they think is best at the time. Most family members will gladly follow your last wishes if they know them, so be candid with them and what it is that you would like done when the time comes. Then, they can be assured that what they are doing will make you happy in the afterlife.

Final Arrangements

Almost all of your final arrangements will be cost intensive. You may want to be buried in the back yard under your favorite tree with your favorite book; but there may be laws in place that would prohibit such actions. There are also many laws in place about the spreading of ashes. Please research your area’s laws on the matter before making a final decision.

Cremation

Probably the second most opted form of final rest, cremation reduces the need to purchase a plot at a graveyard or within a mausoleum. Ashes can be kept and quietly displayed at home, or used for living memorials for the remainder of the family. Turning ashes into memorial diamonds can provide loved ones with a unique and special way of keeping someone they’ve lost close by.

Burial

Typical burial is quite possibly the most common form of a final resting place. However, along with the costs of conducting a funeral, you will need to weigh in the cost of a casket and burial plot. Often, a burial plot can be purchased years in advance, but bear in mind that you must read the fine print for the grounds you wish to be laid to rest in.

Entombment

If you feel that being in a graveyard is not to your liking, you can also look into being interred at a mausoleum. While you will still have to purchase a plot, it offers a more accessible way for your family to visit over a grave.

Graveyard – another home to return.

Final Thoughts

Being prepared means knowing what to do in any given situation. Preparing for a loved one’s or your own demise is never at the top of our priority list. But, it is far easier to prepare for long in advance before we may ever enter that typical stage of our lives.

The final decisions one must make are hardest to make when you are not able to. Hospitals and nursing homes may have their own protocols that they must follow to be within legal limits. Hospice services may not always be an option, as they can be costly and lengthy while we struggle to retain life. We may or may not want specific medical procedures carried out on us or our loved ones, so it must be discussed at length.

Have as much documentation readily available when the time comes for your loved ones. This way, they will be able to administer your wishes as you wish. Do not get caught in a position where you are unable to legally know what your medical status is, or deal with other agencies like the insurance company or bank.

Your final wishes and final arrangements should be discussed long before you get to that bridge. There are many options that are available, such as memorial diamonds made from ashes of your loved ones that can be added alongside the customary burials or cremations. Remember that the more prepared you and your loved ones are, the more likely it is that your wishes will be respected and carried out.

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