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    Measures of mortality andt heir significance

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

    The Westminster Government announced on May 10th that:

    “As a result of the huge efforts everyone has made to adhere to strict social distancing measures, the transmission rate of coronavirus has decreased. We therefore anticipate, with further progress, that we may be able, from the week commencing 1 June, to welcome back more children to early years, school, and further education settings. We will only do this provided that the five key tests set by the government justify the changes at the time, including that the rate of infection is decreasing. As a result, we are asking schools, colleges, and childcare providers to plan on this basis, ahead of confirmation that these tests are met”

    We believe that the 5 tests will not be fully met by June 1st and that this announcement was premature. This decision has been taken without transparency about the evidence that has been used on the direct and indirect health impacts. We now see French schools having to reclose.

    We also believe that the Government should have attempted to agree a consensus with Local Authorities and Teaching Unions before announcing a country wide directive around schools in general. The announcement has left schools without clear expectations, without a structure for managing this. We understand that many Local Authorities and schools will now have to seek the skills and information to figure this all out themselves. We believe that this uncertainly will lead to decisions that could adversely affect the health of children, teachers, families, and vulnerable people in their communities. We do not want a repeat of the mistakes in respect of care homes.

    In addition, it breaks the consensus across the four nations in the UK and shows little regard for regional variation or for impacts on inequities in health outcomes for everyone, and educational outcomes for children. Educational opportunities are a powerful determinant of long-term health outcomes.

    The SHA believes that the education sector has been systematically under-resourced and discouraged by this Government since 2010 under austerity, which leaves many schools with insufficient staff, increasing class sizes and inadequate environments that are less able to meet the stringent conditions to enable them to open as safely as possible in such a short timescale.

    We believe that the Government should have considered the following:

    1. How risks would be minimised, and benefits maximised:
      1. In the school environment, such as through safe distancing, handwashing, and other logistic measures to minimise transmission of COVID19, where staffing levels may not be sufficient and school buildings are not always suitable. Children use their bodies to learn.
      2. To children, in particular those in deprived neighbourhoods, in vulnerable groups, children from BAME families, and those with special needs. There is no clarity on alternative arrangements that could have been much more robust to safeguard, and to ensure their nutrition, learning and emotional needs. This should not rely on schools to provide these solutions now
      3. Allowing for the full autonomy of schools and their local authorities within their safeguarding obligations on an area basis
      4. To other groups, such as teachers, communities, and vulnerable groups, and weigh these against the benefits and risks to the wider society
    1. How harm would be minimised, and benefits maximised:
      1. To children who may be missing education which is likely to have a long-term impact on those from more deprived neighbourhoods and those who are less likely to have received equitable support at home
      2. To children who become infected, including asymptomatically and to their immediate household and contacts
      3. To the wider community, especially those that have had a high incidence of COVID19 and remain at high risk of further outbreaks and resurgences. These have disproportionately affected more deprived communities and those with a high proportion of BAME people
    2. How the overall public health response would support this move:
      1. How potential school outbreaks would be identified and managed in the absence of a fully functioning test/ treat/ isolate programme, particularly as some businesses are reopening at the same time.
      2. How schools will be supported by local public health services unless further resources and decision-making powers are decentralised to allow a robust and appropriate and rapid local multi-agency response

    The SHA believes that this decision has been reached without a clear rationale on the benefits and risks, and without demonstrating that the 5 key tests have been met:

    Test one: Making sure the NHS can cope

    Test two: A ‘sustained and consistent’ fall in the daily death rate

    Test three: Rate of infection decreasing to ‘manageable levels’

    Fourth test: Ensuring supply of tests and PPE can meet future demand

    Fifth test: Being confident any adjustments would not risk a second peak that would overwhelm the NHS

    We would add a Sixth: A fully functioning test/ treat/ isolate programme

    The SHA believes that the decision has been reached without sufficient consultation with key stakeholders and before the 5 tests have been fully met. In addition, the National Education Union has set 5 tests specific to educational settings, and we support their belief that in many areas these have not been met.

    We expect a more supportive response from the Dept for Education including investment into online learning and into a revived Sure Start model.

    The SHA believes that schools should be reopened at the right time but that the Government should make the best efforts to ensure that there is a consensus for when this should happen based upon relevant expert input rather than political pressure.  This has clearly not been achieved, as it has been in other countries that have gradually opened schools.

    We encourage Local Authorities and Academy Trusts to follow the example of LAs such as Liverpool, Haringey, North of Tyne, Hartlepool, and Brighton – and devolved governments in Wales, Scotland, and NI – in making it clear that they will not reopen schools until they feel it is safe.

    Sources

    Actions for schools during the coronavirus outbreak updated 18th May. Department of Education for England

    https://www.gov.uk/government/publications/covid-19-school-closures/guidance-for-schools-about-temporarily-closing

    NEU five tests for Government before schools can re-open

    https://neu.org.uk/neu-five-tests-government-schools-can-re-open

    ONS figures reveal 65 COVID-related deaths in education workforce

    https://schoolsweek.co.uk/ons-figures-reveal-65-covid-related-deaths-in-education/

    Which occupations have the highest potential exposure to the coronavirus (COVID-19)? ONS May 11th https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/employmentandemployeetypes/articles/whichoccupationshavethehighestpotentialexposuretothecoronaviruscovid19/2020-05-11

    Coronavirus (COVID-19) related deaths by occupation, England and Wales: deaths registered up to and including 20 April 2020 May 11th https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesofdeath/bulletins/coronaviruscovid19relateddeathsbyoccupationenglandandwales/latest

    https://www.tes.com/news/coronavirus-doctors-back-teachers-fears-over-schools-reopening?fbclid=IwAR2JD0Np1x_lgG49xo1Hig4T9ozNto36vsG09Ue-mvAtMrTvhWVyegtphBE

    Prof John Edmunds

    https://www.theneweuropean.co.uk/top-stories/john-edmunds-tells-lords-decision-to-re-open-schools-is-political-1-6660526?utm_source=Twitter&utm_medium=Social_Icon&utm_campaign=in_article_social_icons

    Prof Devi Shridhar, Professor of Global Public Health, Edinburgh Uni &  Ines Hassan.

    https://www.theguardian.com/commentisfree/2020/may/20/british-schools-science-children-education-testing-tracing

    https://www.newschain.uk/news/young-children-will-still-socially-distance-school-health-chief-says-8334

    Schools re-close in France after 70 new Covid cases following re-opening  6-11yr classes. NB. French schools starting age is 6 not 3.

    https://www.independent.co.uk/news/world/europe/coronavirus-france-school-cases-reopen-lockdown-a9520386.html

    Comparative school age starts

    https://data.worldbank.org/indicator/SE.PRM.AGES

    NB. Denmark is also 6 and easier to manage s/d. long term impacts of formal learning too soon

    https://www.newscientist.com/article/mg22029435-000-too-much-too-young-should-schooling-start-at-age-7/#

    Formal learning in early years linked to criminality in teens

    https://www.res.org.uk/resources-page/the-impact-of-school-starting-age-on-teenage-criminality–evidence-from-denmark-.html

    Posted by Brian Fisher on behalf of the Policy Team.

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

    The government ‘s centralised programme in England for testing and tracing – and the use of outsourcing

    1. Key messages:

    • The Government has not yet passed the five tests it set itself for easing lockdown
    • The government said that it would only consider easing lockdown once the country has passed five tests. One of these tests [TEST 5] is “confidence that we can avoid a second peak of infection that overwhelms the NHS”
    • The Devolved Administrations and many scientists and public health professionals doubt whether or not we have “passed this test” They doubt we have the capacity to detect and respond to local surges in infection or control outbreaks as lockdown is eased – and that a second or even third peak of infection will occur. Policy is diverging across the UK with mixed messaging to the public and a high risk of losing a coherent and effective strategy of suppression.
    • To manage our “exit “from lock down we need to be able to recognise new cases when they occur, test and isolate people who are infected, trace and test their contacts – and to have the flexibility resource and leadership to organise responses at a local level.
    • Other countries in Europe are using phased lifting of measures, across regions and settings. The EU Roadmap states that “the lifting of measures should start with those with a local impact and be gradually extended to measures with a broader geographic coverage, taking into account national specificities. This would allow to take more effective action, tailored to local conditions where this is appropriate, and to re-impose restrictions as necessary, if a high number of new cases occurs (e.g. introducing a cordon sanitaire)” For example, why would there be a relaxation of control measures in dense urban areas with crowded public transport at the same time as some parts of the UK that have had no new confirmed cases for 18 plus days and some areas with very few cases? We need detailed stats and maps by district council of all new cases by area of residence over time (at a more granular level than unitary authorities) The Orkney Western isles and Shetland remain in lock down when they have had no cases for 18, 21 and 32 days respectively and when a cordon sanitaire could be put in place
    • Integrated response In order to lift measures while retaining control of the virus, we must identify cases rapidly, isolate and contact trace: so testing is crucial but we must have the ability to test the right people and to rapidly act on the results

    o Prevention of new cases is always better and much cheaper than critical care. Investment in hospitals to respond to COVID19 has been absolutely necessary but will always have less impact on population level health outcomes than control measures.

    o The UK has an excellent public health and primary care system, both of which have been eroded and underfunded in the last 10 years. There are skills and knowledge and capability in these that would provide an effective and efficient response to moving through the next phases of the pandemic, if invested in. However, both these sectors have been excluded and marginalised to the detriment of their local communities

    o For a “test, trace and isolate “ system of control and response to outbreaks to be effective, data must be shared and agencies need to work together at national , regional and local level , coordinate and integrate their response if it is to be effective .No one agency has the knowledge , skills, or resources to do this on their own – and Whitehall in particular needs to recognise that central control is bound to fail.

    o Capacity for testing should provide real time data to help monitor community transmission, link with contact tracing systems and enable local authorities to function autonomously, as well as part of a national response to this pandemic.

    o Much of the infrastructure for testing commissioned by the Government has been led centrally – much of it has been established from scratch. The original drivers for increasing testing capacity were to:

        1. Allow NHS staff to be released back to work on the front line and
        2. respond politically to the growing criticism about the UKs track record on testing o The plight of care homes and the huge death toll from COVID 19 in those institutions is a classic illustration of the failures, which result from over centralization and reliance on hierarchical control and power. This example also illustrates the potential of local government and effective leadership to understand and respond quickly to local circumstances, to innovate, and to “stitch systems “together and make them work.
    • Outsourcing in England Rather than invest or expand our existing laboratory system Ministers chose instead to outsource the provision of testing for COVID 19 in England. They used special powers to bypass normal tendering and award a string of multimillion pound contracts for delivering and processing tests to private companies such as Deloitte, Randox laboratories [£ 133 million] and involved big pharma companies such as GSK, Roche and AstraZeneca and university research teams in creating mega or “ Lighthouse “ labs. These organisations:
      1. Provide swab tests on hospital patients and COVID tests run by NHS labs and Public Health England.
      2. Collect swabs from NHS workers, social care staff and other key workers at 50 drive -in centres and 70 mobile units, which are processed and reported on through a network of 3 mega “lighthouse “ labs
      3. Send out home testing kits for eligible persons with coronavirus symptoms, aged 65 or over, or who cannot work from home
      4. Offer an “on -line portal “through which CQC registered care homes [65 +] can order test kits
      5. Issue serology and swab tests for ONS surveillance and research studies
    • Together Government claims that they can offer 100000 tests a day.

    o However when backlogs develop, they tend to operate as separate “ silos” as illustrated when 50000 tests were sent to the US rather than workload shared between them.

    o More importantly, this testing system does not provide or allow access to test data by local organisations or Public Health England.

    o More than half of tests by May12th have been done by outsourced companies and results are “disappearing into a black hole” A Health Service Journal analysis on May 13th said that recent government testing figures “suggests that in recent days around two thirds of tests have taken place under the commercial lab scheme, for which the data is not available locally. This includes more than 7,000 positive test results in the past three days, and tens of thousands over recent weeks”.

    o Most tests [except for care homes] are demand led, random in nature, and requested by individuals from a wide catchment area. As such, they do not provide useful information for detecting spikes or patterns of infection in a particular geographical area, local “hot spots” or for managing outbreaks. Furthermore, test data are not completely post coded nor are they analysed at a sub-regional or local authority level, local authorities and PHE have found it difficult to get hold of these data.

    • Real time analysis and assessment of infection

    o The Government proposes to establish a Joint Biosecurity Centre with an independent analytical function which will

    o a) provide real time analysis and assessment of infection outbreaks at a community level and collect a wide range of data to build a picture of COVID-19 infection rates across the country – from testing, environmental and workplace data to local infrastructure testing (e.g. swab tests)

    o b) have a response function that will advise on the overall prevalence of COVID-19, identify specific actions to address local spikes in infections, in partnership with local agencies and guide local actions through a clear set of protocols based on the best scientific understanding of COVID-19, and what effective local actions look like.

    o We welcome the commitment to ensure that the Joint Biosecurity Centre [JBC] works closely with local partners. We would like some input into the design of the data platform, as well as discussion about rights of data contributors to access all data sets, which are held.

    o We do not believe that the JBC should have a response function, which “guides local actions surges through a series of protocols. “

    o Lessons from the 2009 H1N1 pandemic about over centralisation and hierarchical control – delays, rigidity, lack of autonomy to act, failure to listen and respond to local intelligence need to be learnt.

    Once again, they have outsourced this analytical function to a large number of private sector organisations. The strategy states that NHS England and NHS improvement have total control over access to all NHS test data will guide and inform the COVID 19 response during lock down – but so far they have not consulted local authorities or PHE about the proposal to create this JBC or involved them in the design, access and linkage to this data store. NHS England has created difficulties and even stopped local agencies from having access to important data sets, such as 111 calls.

    o Contact tracing: Contact tracing at scale can help reduce onward transmission during release from lockdown, if properly resourced by skilled people and well organised. It is unclear how their trace and track system will be integrated with the testing system.

    We are concerned that the Government has

      1. outsourced the call centre to SERCO given its previous track record [breast cancer catch up]
      2. believe that one hour of training as call handler will be sufficient to run this online and phone based contact tracing system,
      3. place so much reliance on an experimental App for contact tracing.
      4. recruited insufficient skilled contact tracers to impact on the “R” number, not made sufficient effort to recruit people with experience of contact tracing e.g. EHOs or retired professionals to the clinical team.

    The government states that for its test and trace system to work, several systems need to be built and successfully integrated. These include:

        • widespread swab testing with rapid turn-around time, digitally-enabled to order the test and securely receive the result certification;
        • local authority public health services to bring a valuable local dimension to testing, contact tracing and support to people who need to self-isolate;
        • automated, app-based contact-tracing through the new NHS COVID-19 app to (anonymously) alert users when they have been in close contact with someone identified as having been infected;

    Conclusions

    o The Testing and Tracing infrastructure which the government has commissioned has been largely been outsourced to private sector organisations and very centralised

    o As such it is a “quick fix which is poorly designed and ill equipped to support the next stage of controlling this pandemic and involving the many agencies which need to play their part as lockdown are eased.

    o The considerable investment which has been made in these new “ temporary “ structures should be channelled over the next 2 to 3 years into building a more robust, flexible , resilient and multilevel , public health and primary care systems , capable of responding to pandemics in the future.

    Sources

    Posted by Brian Fisher on behalf of the Policy Team.

     

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    The Battle of the Surcharge – won

    Finally, last Friday, the Government announced it was going to remove the surcharge that overseas NHS staff have to pay for using the service they themselves work for. This follows two years of campaigning by unions such as Unison and Unite, which between them represent over 600,000 nurses, student nurses, midwives, doctors, health visitors, healthcare assistants, paramedics, cleaners, porters, catering staff, medical secretaries, clerical and admin staff and scientific and technical staff, who are either employed by the NHS or by other organisations which provide NHS services.

    Only last Wednesday at Prime Minister’s Question Time Johnson told MPs that the extra raised £900m needed for the NHS. This has been challenged by the Institute of Fiscal Studies which put the sum at a tenth of that – £90 million. But that is irrelevant to this argument, which is that none of the overseas staff should ever have had to pay to use the NHS. The Government could focus instead on making all the big multinationals pay the taxes they avoid, just for a start.

    Unite national officer for health Colenzo Jarrett-Thorpe said: “Of all people, Boris Johnson should appreciate the wonderful and dedicated work of NHS health and social care professions, including the two non-UK nurses he singled out for particular praise in his fight for survival against coronavirus.

    Who is Dominic Cummings?

    He is not actually the Prime Minister, but appears to many to play the role of ventriloquist. He is not an MP or an elected representative of any kind. His official title is Senior Advisor to the Prime Minister, with an office in Downing Street. But he has succeeded in getting the British Public angry, which neither Boris Johnson, nor Matt Hancock, nor indeed any other member of the Government, has managed to do on anything like the same scale.

    What he has done was to behave as though the Government’s lockdown rules (which he proposed in the first place) did not apply to him, when many of us have not seen children, grandchildren and other loved ones for weeks, and too many have not even been able to say goodbye to those who were dying. And he is still refusing to admit to any wrong doing: “I think I behaved reasonably”. Up and down the country people are calling on him to resign – including more than 20 Tory MPs by Wednesday, 44 by Thursday morning with 61 criticising him. The numbers are still growing – and one Government minister has resigned over it.

    Cummings was responsible for the Brexit slogans “Get Brexit Done” and “Take Back Control”; for the campaign bus that said “We pay £350 million to the EU. Vote Leave and give it to the NHS instead” (which many of us knew was never going to happen, but some people were taken in by); for the offensive, enormous posters that said Turkey (population 75 million) was going to join the EU (implying 75 million Turkish people would be moving to Britain); and broke electoral law over spending limits, for which the campaign was fined £70,000. But not till the voting was over. The BBC website this week pointed out that Cummings was also held in contempt of Parliament for not responding to a summons to appear before, and give evidence to, the Culture, Media and Sport Select Committee. He also managed Johnson’s election campaign 2019, and is obviously very useful to the man who became Prime MInister, coming up with catchy slogans, launching a campaign against the Labour “heartlands” and advising Johnson how to handle public relations. David Cameron, a previous Tory PM, is widely quoted on twitter as saying Cummings was a “career sociopath”, while others have called him a narcissist on social media. As I am not a qualified psychiatrist I couldn’t possibly comment.

    Meanwhile a man called Craig Murray is a career diplomat, whose last job was as British Ambassador to Uzbekistan. He stood as an Independent in Blackburn in the 2005 General Election, opposing Jack Straw, then Foreign Secretary. And now he writes a blog in which he has drawn attention to Cummings’s presence in Castle Barnard on 12th April (allegedly testing his eyesight) which just so happens to be where the pharmaceutical giant, GlaxoSmithKline (GSK), has one of its 18 UK premises: an important research and manufacturing site. (See  https://www.craigmurray.org.uk/archves/2020/05/why-barnard-castle/ 24.05.20).

    Mary Wakefield, Cummings’s wife, who is editor of The Spectator,  published an article on 23rd April describing how ill Dominic had been for 10 days, with high fever, muscle spasms and difficult, shallow breathing. But on 5th April he was seen in his Father’s garden in Durham. On 12th April they were seen at Barnard Castle. On 14th April Cummings was back at work in London. On 14th April GlaxoSmithKline and Sanofi announced their collaborative agreement. On 19th April he was spotted again in Durham, though he has denied that he was there then. The former chancellor Sajid Javid was quoted in The Guardian (28.05.20) as saying the journey was not “necessary or justified”.

    Returning to Craig Murray, he further points out that GSK have been fined on more than one occasion for illegal behaviour eg fined £37.6 million in 2016 for bribing firms not to produce generic drugs. As a result the NHS would have had to pay more for these drugs, as generic drugs are cheaper than branded ones.

    GSK currently has 37 new medicines and 15 vaccines in development, according to its website. Its global HQ is in Brentford, Middlesex – you pass it if you drive into London on the M40, just before the turn-off for Kew. So a bit more handy for Cummings to get to from his own home, but also a bit more public. (GSK has 18 facilities in Britain and many more worldwide – offices, research labs and production facilities).

    On 14th April, 2 days after Dominic Cummings was seen in Barnard Castle, it was announced by GSK and the French firm Sanofi, which also makes vaccines, that they had signed a deal to develop and manufacture a Covid-19 vaccine. We all want that, don’t we? The long term solution to Covid-19 is a vaccine, just as measles, another viral illness that in the USA was serious enough for 48,000 people to need hospital treatment, resulted in 4-500 deaths and 1000 people developing encephalitis per year before the vaccination programme started in 1963.

    So why was Dominic Cummings not shouting about this development from the rooftops? It would, of course be illegal to use insider knowledge to buy up shares in the firms before their value on the stock market went up with the announcement of a potential vaccine for coronavirus. And indeed it might be a complete coincidence that he was nearby shortly before the announcement.

    Sanofi has developed an antigen based on recombinant DNA technology[1], which allows it to make a genetic match to proteins that occur on the surface of the coronavirus. They have called this the Spike (S) protein COVID-19 antigen[2]. The DNA sequence which encodes this antigen has been combined into the DNA of the baculovirus expression platform[3]. Sanofi has received some funding and collaboration from the US Biomedical Advanced Research and Development Authority (BARDA[4]).

    GSK will contribute its pandemic adjuvant (auxiliary) technology to the collaboration, so more vaccine doses can be produced. An adjuvant is used with the vaccine to stimulate the immune system, so that the vaccine is more efficient and longer lasting, and less of it is needed for each dose. This is an advantage when making enough vaccines to treat a pandemic.

    The firms have entered a Material Transfer Agreement to enable them to start working together immediately, with details to be firmed up in the following few weeks.

    BARDA’s website says its “mission is accomplished through successful public-private partnerships with industry to share risk, improve efficiency and accelerate development all while sustaining a marketplace that guarantees continued access to countermeasures vital to our national security.” “Our” here refers to the USA. It is not clear what advantage the USA intends to gain over the collaborative work of a British and a French firm, or whether Britain, France or indeed any other country with a serious outbreak of Covid-19, will be sharing in this.

    Cummings listed his goals as “Get Brexit done then Arpa” in a whatsapp profile mentioned on the BBC website on Monday. ARPA is the Advanced Research Projects Agency set up by the USA in 1958, which led to Silicon Valley. It is not clear what Cummings meant by this. It is clearly not a UK version of Silicon Valley – which has already been tried with variable longer term success eg in the science based firms around Cambridge, and in Silicon Glen in Scotland. But he might have in mind something like the US Cooperative Research and Development Agreement (CRADA), which was established in 1984 to encourage collaboration between firms and public sector research organisations or state agencies, and which has enabled firms to make money out of public sector research.

    An example of the CRADA was the anticancer drug taxol, or Taxol®[5], which has been very successful in treatment of ovarian, breast and other cancers, but for which patients must pay twice: first through their taxes which paid for the research supported by the National Cancer Institute and other public bodies, and second in the high prices charged for the drug, since the firm producing it (Bristol Myers Squibb, BMS) was allowed to charge a similar price to that of other anticancer drugs, which had not necessarily received public funding. Remember that in the USA patients will have to pay the cost of the drugs themselves or – if they have insurance – their insurance companies will; while the NHS will have to pay those prices for taxol imported here. There were three Congressional Hearings on this and related issues, but they did not lead to any difference in the legal status of the product or the property rights of the firm.

    Collaborative alliances have been a phenomenon in high tech industry, especially IT and biotechnology, since the early 1980s. Despite the risks of opportunistic behaviour by partners, the number of technologies and specialist fields in which firms need to keep up to date in order to innovate, has encouraged such relationships, though these have often ended in merger or acquisition, followed by new alliances in new specialisms.

    If a vaccine is successfully developed and prevents further outbreaks of flu-like conditions from this or other coronaviruses, and is available at an affordable price, then governments will consider any collaboration to have been a success. We have yet to see how the research will progress, and exactly what relationship the US government – which has contributed to the cost – or the UK or French governments – in whose countries GSK and Sanofi have their headquarters – will have to the firms in the collaborative alliance, let alone what benefit will accrue to people in other countries.

    From Vivien Walsh (Greater Manchester)

    [1] Recombinant DNA is what you get when segments of DNA from different sources are joined together. Recombinant technology = genetic engineering, which can be used to make eg human insulin, used to treat diabetes instead of the earlier treatment with insulin from cattle and pigs.

    [2] An antigen is a substance that can stimulate an immune response, ie activate the body’s infection-fighting white blood cells (lymphocytes).

    [3] A baculovirus is an insect virus. Recombinant baculoviruses can accommodate multiple “foreign” genes or large segments of “foreign” DNA. The baculovirus expression platform is used to generate recombinant proteins in insect cells at high production levels.

    [4] BARDA was established in the USA in 2006 during George W Bush’s Presidency. It is part of the Health and Human Services Office of the US Assistant Secretary for Preparedness and Response, which in turn was created the same year by the Pandemic and All Hazards Preparedness Act in the wake of Hurricane Katrina, to aid the USA in responding to chemical, biological, radiological and nuclear (CBRN) threats, to pandemic influenza (PI) and to emerging infectious diseases (EID). BARDA supports the transition of vaccines, drugs, and diagnostics from research to advanced development and consideration for approval by the Food and Drug Administration (FDA) and inclusion into the Strategic National Stockpile. BARDA’s support includes funding, technical assistance and core sevices, ranging from a clinical research organisation network to Centres for Innovation in Advanced Development and Manufacturing, and a fill-finish manufacturing network. To date, BARDA has supported 42 FDA approvals for products for products addressing CBRN, PI and EID threats. (From the various websites of the organisations mentioned)

    [5] Taxol was a natural product, extracted from the bark of taxus brevifolia, the Pacific Yew, which at the time could not be patented. It was developed by a huge network of researchers in the public sector and funded by US taxes plus the firm Bristol Myers Squibb, which manufactured and marketed it. To secure the intellectual property, BMS was allowed to trademark the name taxol in 1992, a name first given to the molecule by the chemist Monroe Wall in 1967, who first discovered its activity against cancer at the Research Triangle Institute in North Carolina.

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

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

    Key messages

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

    Source: Douglas et all, BMJ April 2020

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

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

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

    Conclusions:

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

    Actions

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

    Sources

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

    Posted by Brian Fisher on behalf of the Policy Team.

    Leave a comment

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

    The impact of the pandemic on BAME populations and the implications for policy and plans going forward

    1. Key messages:

    • Data collection, transparency and presentation are not good enough:

    o There is concern about inaccurate, incomplete and selective data. All official bodies should adhere to the Code of Practice for Statistics

    o Ethnicity data is not collected in many countries: in the UK for many years there has been a call for greater ethnic monitoring in routine health data and the fact that the ONS had to go back to census data and interpret current health statistics from these assumptions exposes the problem

    o Ethnicity is complex and aggregating all minorities together obscures the true picture

    o Data has sometimes been presented in misleading ways: for example, the death rate for COVID-19 in Black men has been stated as over 4 times the average, without explaining that adjustment for confounding factors such as age and deprivation would change this o Data on occupation is not well collected or presented

    • BAME people are more likely to die of COVID19

    o ONS analysis of COVID-19 related deaths by ethnic group, England and Wales: 2 March 2020 to 10 April 2020, showed:

    o Adjusting only for age: Black males are 4.2 times more likely to die from COVID-19 than White males, while Black females are 4.3 times more likely to die from COVID-19 than White females.

    ■ However, after statistical adjustment for multiple factors (region, rural and urban classification, area deprivation, household composition, socio-economic position, highest qualification held, household tenure, and health or disability) this showed that black males and females are 1.9 times more likely to die from COVID-19 than the White ethnic group. Males of Bangladeshi and Pakistani ethnicity are 1.8 times more likely to die; for females, odds of death are reduced to 1.6 times more likely. Individuals from the Chinese and Mixed ethnic group have similar risks to those with White ethnicity

    o The openSAFELY cohort study used national primary care electronic health record data linked to in-hospital COVID-19 death data, which is the largest cohort study in the world, examining 17 million primary care records. This found other ethnicities were more likely to die than white British people, even after adjustments for age, sex and other risk factors

        • Hazard ratios for ethnicities relative to white British were:
        • Mixed 1.64
        • Asian or Asian British 1.62
        • Black 1.71
        • Other 1.33
      • The study suggests that the higher prevalence of medical problems such as cardiovascular disease or diabetes among BAME people, or higher deprivation, is only a small part of the excess risk, and that further research should look at occupational and household exposures

    o In the United States, there is a more marked difference between black Americans and other ethnic groups: For each 100,000 Americans (of their respective groups), 40.9 Blacks have died, along with about 17.9 Asians, 17.9 Latinos and 15.8 Whites. If Black Americans had died of COVID-19 at the same rate as White Americans, at least 10,000 more Black Americans would still be alive.

    • BAME people are more vulnerable through unequal exposure to all the impacts of the pandemic

    o A higher proportion of many minority groups are of working age and therefore affected by the shutdown, they are more likely to be in lower paid, insecure work and in financial insecurity o Bangladeshis, black Caribbeans and black Africans also have the most limited savings to provide a financial buffer if laid off. Only around 30% live in households with enough to cover one month of income. In contrast, nearly 60% of the rest of the population have enough savings to cover one month’s income.

    o In London, BAME workers are much more likely to be key workers,

        • In 2019, 12% of all workers in the UK were from ethnic minority groups, increasing to 34% in London. A greater share of the London population are from black and minority ethnic groups.
        • Workers from an ethnic minority group represent a similar share of all key workers at 13% for the UK as a whole and a greater share at 42% in London. In rest of the UK, similar proportions are in key and non-key worker roles

    o Analysis of occupation and deaths by the ONS showed that there were 2,494 deaths involving the coronavirus in the working age population (those aged 20 to 64 years) of England and Wales up to 20 April 2020. People from BAME communities are more often working in the highest risk occupations:

        • Men working in the lowest skilled occupations had the highest rate of death with 21.4 deaths per 100,000 males (225 deaths); men working as security guards had one of the highest rates, with 45.7 deaths per 100,000 (63 deaths).
        • Men and women working in social care, a group including care workers and home carers, both had significantly raised rates of death with rates of 23.4 deaths per 100,000 males (45 deaths) and 9.6 deaths per 100,000 females (86 deaths).
    • BAME health and social care workers appear to have higher rates of death

    o Although the ONS analyses did not show a higher rate of death among healthcare workers in general, it appears that of those who have died, a very high proportion are from BAME communities.

    o An analysis of 106 workers, identified from many publicly available sources, who had died of COVID related cause up to April 22nd showed that 63 % of cases were of BAME background, and 53% were not born in the UK, which is much higher than the proportion of BAME in the whole workforce. No intensive care nurse or doctor has died, the deaths appear to occur in other patient facing groups of professionals

    Deaths in BAME health workers to April 22nd 2020

    Nurses and midwives Healthcare support workers Doctors and dentists
    Number 35 27 19
    BAME; % 71 56 94
    BAME workforce; %* 20 17 44

    Source: adapted from Tim Cook, Emira Kursumovic, Simon Lennane Health Service Journal 22 April 2020

    • CONCLUSION:

    o Ethnicity data is not collected in many countries, and where it is, differences suggests that genetic factors are less important than the wider determinants of health

    o There are multiple reasons, the most likely seem to be the first two:

        1. Higher exposure: a higher proportion of BAME people are in low paid front line key worker roles, with likely lower access to PPE and other protective measures
        2. Multi-family and intergenerational households, therefore likely to have greater household transmission
        3. Lower socioeconomic status: there is higher mortality in deprived areas as a whole
        4. Higher prevalence of co-morbidities, especially for CVD, diabetes, renal conditions, obesity and complex multi-morbidities
        5. Greater vulnerability to economic and financial impacts
        6. Structural and institutional racism underlying all the above. This can lead to higher levels of persistent stress leading to physical and mental poor health, exacerbated by lower access to services that can mitigate these effects
    • Actions

    o Call for an independent inquiry into ethnicity and mortality from COVID19

    o Improve data collection and analyses: ethnic monitoring should be part of death registration.

    o Make work safe during COVID19; workplaces should be risk assessed, with the inclusion of ethnicity as a risk factor like the NHS is doing, and include those in insecure employment fields, the self-employed and the gig economy

    ■ Key workers with high risks linked to ethnicity should be

          • withdrawn from the riskiest work or
          • should be protected with adequate PPE and multiple other protection measures in workplaces
          • prioritised for testing

    o Decentralise data and decision-making for COVID19: the implementation of measures that aim to control the virus should be decentralised to Local Government led by the Director of Public Health, to ensure that they are sensitive and appropriate for the local communities o Housing: measures should be introduced to improve housing quality and reduce higher risks of household transmission in multi-generational households

    o Community assets: listen to community leaders and nurture grassroots community action that can build on resilience in the long term

    o Address the intersectionality of ethnicity with deprivation: social protection measures for those BAME individuals and groups most vulnerable to financial insecurity, for example Universal Basic Income

    o Commit to a long-term inequalities’ strategy with a multi-faceted approach building on previous Labour success 1997-2010. More ambitious, to tackle the commercial/ structural determinants of health, and on healthy communities and places: reduce reliance on less effective individual behaviour change strategies, and include the intersectionality of disadvantage

    Sources

    o Evidence mounts on the disproportionate effect of COVID-19 on ethnic minorities Tony Kirby, The Lancet Respiratory Medicine May 8th

    https://www.thelancet.com/pdfs/journals/lanres/PIIS2213-2600(20)30228-9.pdf

    o Coronavirus (COVID-19) related deaths by ethnic group, England and Wales: 2 March 2020 to 10 April 2020 Office for National Statistics may 7th

    https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/ar ticles/coronavirusrelateddeathsbyethnicgroupenglandandwales/2march2020to10april2020

    o https://github.com/miqdadasaria/nhs covid deaths/tree/master/figures

    o OpenSAFELY: factors associated with COVID-19-related hospital death in the linked electronic health records of 17 million adult NHS patients. Posted May 7th 2020 https://www.medrxiv.org/content/10.1101/2020.05.06.20092999v1

    o BAME COVID-19 DEATHS – What do we know? Rapid Data & Evidence Review May 5, 2020,

    The Centre for Evidence-Based Medicine

    o https://www.apmresearchlab.org/covid/deaths-by-race

    o Revealed: the NHS’ plan to protect BAME staff from covid-19, HSJ May 6th https://www.hsj.co.uk/workforce/revealed-the-nhs-plan-to-protect-bame-staff-from-covid- 19/7027571.article

    o Black and minority ethnic workers make up a disproportionately large share of key worker sectors in London COVID-19 chart series 7 May 2020 Health Foundation https://www.health.org.uk/chart/black-and-minority-ethnic-workers-make-up-a- disproportionately-large-share-of-key-worker

    o Coronavirus (COVID-19) related deaths by occupation, England and Wales: deaths registered up to and including 20 April 2020 Office for National Statistics May 11th https://www.ons.gov.uk/releases/covid19relateddeathsbyoccupationenglandandwalesdeaths registereduptoandincluding20thapril2020

    o Exclusive: deaths of NHS staff from covid-19 analysed By Tim Cook, Emira Kursumovic, Simon Lennane Health Service Journal 22 April 2020

    o Covid-19 and BAME deaths: A call for action Mark Ladbrooke SHA Blog May 12th https://www.sochealth.co.uk/2020/05/12/covid-19-and-bame-deaths-a-call-for-action/

    o Are some ethnic groups more vulnerable to COVID-19 than others? The Institute for Fiscal Studies Deaton Review 1 May 2020 https://www.hsj.co.uk/exclusive-deaths-of-nhs-staff-

    from-covid- 19-analysed/7027471.article

    https://www.ifs.org.uk/inequality/chapter/are-some-ethnic-groups-more-vulnerable-to- COVID-19-than-others/

    Posted by Brian Fisher on behalf of the Policy team.

    Leave a comment

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

    Too slow to act

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

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

    Protect the NHS

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

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

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

    The Privately owned Social Care sector

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

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

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

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

    Follow the money

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

    Test, trace and isolate (TTI)

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

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

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

    Game changers – and what is the game?

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

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

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

    Palantir

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

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

    Conclusion

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

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

    24th May 2020

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

    2 Comments

    Dear friends (including many joining in recent weeks)

    Corona Confusion: lies, deceit, trickery and failure

    The shocking and rising UK death toll from the pandemic is now the highest in Europe.

    Wirral, where most DONHS activists are based, is one of the country’s worst-affected boroughs.

    Yet the scale of the heartbreaking human tragedies which result was not inevitable. The crisis has been made worse – and the number of deaths has been multiplied – by the failure of the government to act promptly and adequately in response.

    Their evident incompetence, their arrogant dismissal of criticism, and their litany of lies, deceit, trickery and failure are appalling. The long list below represents a shameful catalogue*.

    What is to be done?

    Well, we’re starting by inviting you to a rally. Yes, it’s a Zoom meeting** which we know many of you are using for social and serious reasons at this time. It’s easy to add to your device and to use.

    The rally will be on Wednesday 3rd June from 7:00pm. We have invited several guest speakers. Professor Allyson Pollock  and Professor John Ashton have confirmed and other names will be announced.

    We are expecting a large attendance so interaction is inevitably limited. But please submit any question for our speakers by email (to the address below) by 27th May at the latest.

    More details and confirmation will be sent over the next two weeks.

    Please visit (from midnight tonight) https://www.eventbrite.co.uk/e/corona-confusion-lies-deceit-trickery-and-failure-defend-our-nhs-tickets-105310370152

    Keep safe

    On behalf of Defend Our NHS

    defendournhswirral@gmail.com

    ………………………………………………………………………………………………………………………………………………………..

     

    • For anyone who still thinks the Johnson government and predecessors have been doing a good job just take a moment to read this. It is an augmented version of a Facebook post by Ray Harris https://www.facebook.com/ray.harris.7946

    The arrogance and incompetence are truly horrifying. This information should be shared widely.

    • 2011 Cameron adviser Mark Britnell, who was appointed to a “kitchen cabinet” advising the prime minister on reforming the NHS, tells a conference of executives from the private sector that future reforms would show “no mercy” to the NHS and offer a “big opportunity” to the for-profit sector.
    • 2012 Andrew Lansley’s Health and Social Care Act is passed with the support of the coalition government. It effectively abolishes a national health service replacing it with a confused jigsaw of clinical commissioning groups (CCGs) and financial regimes and what are now 42 ‘integrated care systems’.
    • The ‘efficiency’ measures of US management consultancy corporation McKinsey and various ‘market-led’ measures are imposed on flailing CCGs.
    • 2014-19 Local authority public health budgets are slashed by 35%. And the 10 most deprived areas in England are hit with nearly 15% of all these cuts.
    • 2016 is the year that Jeremy Hunt lies about and alienates the junior doctors, provoking a series of strikes against the imposition of unsafe working practices.
    • AND the government buries the warnings about the implications of a pandemic from their Exercise Cygnus.
    • The re-disorganisation of the NHS continues apace – with the programme of STP (renamed ‘slash, trash and privatise’ by campaigners) accelerating during the crisis which follows.
    • 2016-2020 UK government stockpiles containing protective equipment for healthcare workers in the event of a pandemic fall in value by almost 40% over six years.
    • December 31st 2019 China alerts WHO to new virus.
    • January 23rd 2020 Study reveals a third of China’s patients require intensive care.
    • January 24th Johnson misses first Cobra meeting.
    • January 29th Johnson misses second Cobra meeting.
    • January 31st The NHS declares first ever ‘Level 4 critical incident’ Meanwhile, the government declines to join European scheme to source PPE.
    • Early February it’s claimed by the Times that Cummings tells a meeting it was all about “herd immunity, protect[ing] the economy and if that means some pensioners die, too bad”
    • February 5th Johnson misses third Cobra meeting.
    • February 12th Johnson misses fourth Cobra meeting. Exeter University publishes study warning the coronaviruscould infect 45 million people in the UK if left unchallenged.
    • February 13th Johnson misses conference call with European leaders.
    • February 14th Johnson goes away on holiday. Aides are told keeps Johnson’s briefing notes short or he will not read them.
    • February 18th Johnson misses fifth Cobra meeting.
    • February 26th Johnson announces ‘Herd Immunity’ strategy, announcing some people will lose loved ones. Government document is leaked, predicting half a million Brits could die in ‘worse case scenario’
    • February 29th Johnson retreats to his country manor. NHS warns of ‘PPE shortage nightmare’. Stockpiles have dwindled or expired after years of austerity cuts.
    • March 2nd Johnson attends his first Cobra meeting, declining another opportunity to join European PPE scheme. Government’s own scientists say over half a million Brits could die if virus left unrestrained. Johnson tells country “We are very, very well prepared.”
    • March 3rd Scientists urge Government to advise public not to shake hands. Johnson brags about shaking hands of coronavirus patients.
    • March 4th Government stops providing daily updates on virus following a 70% spike in UK cases. They will later U-turn on this amid accusations they are withholding vital information.
    • March 5th Johnson tells public to ‘wash their hands and business as usual’
    • March 6th Health secretary Hancock says he has talked to supermarkets to safeguard food supplies.
    • March 7th Supermarkets say Hancock is lying.
    • March 7th Johnson joins 82,000 people at Six Nations rugby match.
    • March 9th After Ireland cancels St Patrick’s Day parades, the UK government says there’s “No Rationale” for cancelling sporting events.
    • March 10th-13th Cheltenham race meeting takes place. More than a quarter of a million people attend.
    • March 11th 3,000 Atletico Madrid fans fly to Liverpool.
    • March 11th Cummings asks technology CEO and business leaders in a Downing Street meeting to share skills and talent with the government in order to tackle the coronavirus pandemic.
    • March 12th Johnson says banning events such as Cheltenham will have little effect. The Imperial College study finds the government’s plan is projected to kill half a million people.
    • March 13th The FA suspends the Premier League, citing an absence of Government guidance. Britain is invited to join European scheme for joint purchase of ventilators, and refuses. Johnson lifts restrictions of those arriving from Coronavirus hot spots.
    • March 14th Government is still allowing mass gatherings, as Stereophonics play to 5,000 people in Cardiff.
    • March 16th Johnson asks Britons not to go to pubs, but allows them to stay open. During a conference call, Johnson jokes that push to build new ventilators should be called ‘Operation Last Gasp’
    • March 19th Hospital patients with coronavirus are returned to care homes in a bid to free up hospital space. What follows is an explosion of virus cases in care homes.
    • March 20th The Government states that PPE shortage crisis is “Completely resolved”. Less than two weeks later, the British Medical Association reports an acute shortage of PPE.
    • March 23rd UK goes into lock-down.
    • March 26th Johnson is accused of putting ‘Brexit over Breathing’ by not joining EU ventilator scheme. The government then state they had not joined the scheme because they had ‘missed the email’
    • March 27th Both Johnson and Cummings admit to developing COVID-19.
    • April 1st The Evening Standard reports that just 0.17% of NHS staff have been tested for the virus.
    • April 3rd The UK death toll overtakes China.
    • April 5th Johnson admitted to St Thomas’s Hospital.
    • April 5th 17.5 million antibody tests, ordered by the government and described by Johnson as a ‘game changer’ are found to be a failure.
    • April 7th Johnson is moved to intensive care with coronavirus. He later says the NHS saved his life. Subsequently it is revealed he was not using a ventilator but extra oxygen, a solution not applied universally.
    • April 10th FT reports that private clinics in the UK selling COVID-19 testing kits insist they are still able to source supplies, despite complaints from the government that shortages have prevented testing being rolled out more quickly.
    • April 16th Flights bring 15,000 people a day into the UK – without virus testing.
    • April 17th Health Secretary Matt Hancock says “I would love to be able to wave a magic wand and have PPE fall from the sky.” The UK has now missed four opportunities to join the EU’s PPE scheme.
    • April 21st The Government fails to reach its target of face masks for the NHS, as it is revealed manufacturers’ offers of help were met with silence. Instead millions of pieces of PPE are being shipped from the UK to Europe.
    • April 23rd-24th Government announces testing kits for 10 million key workers. Orders run out within minutes as only 5,000 are made available.
    • April 24th The Guardian reveals that Cummings, and a data scientist he worked with on the Vote Leave campaign for Brexit are on the secret scientific group advising the government on the coronavirus pandemic.
    • April 25th UK death toll from coronavirus overtakes that of The Blitz.
    • April 28th Hancock says “Of course care homes have been a top priority right from the start.  We’ve strengthened the rules around what happens in care homes and tightened infection control, also making testing available throughout the care centre I think is incredibly important as we’ve ramped up the availability of testing.”
    • April 28th A third of all coronavirus deaths in England and Wales are now happening in care homes
    • April 29th NHS England (London) sneak out a letter accelerating the integrated care system. Their‘Journey to a New Health and Care System’ states that over the next 12-15 months they hope to keep public engagement to a bare minimum.
    • April 30th Johnson announces the UK has succeeded in avoiding a tragedy that had engulfed other parts of the world. At this point, the UK has the 3rd highest death toll in the world.
    • May 1st The Government announces it has reached its target of 100,000 tests – They haven’t conducted the tests, but posted the testing kits.
    • May 4th It is now clear that Deloitte, KPMG, Serco, Sodexo, Mitie, Boots and the US data mining group Palantir have secured taxpayer-funded commissions to manage COVID-19 drive-in testing centres, the purchasing of personal protective equipment (PPE) and the building of Nightingale hospitals.
    • May 5th The UK death toll becomes the highest in Europe.
    • May 6th Johnson announces the UK could start to lift lock-downrestrictions by next week.
    • May 7th Guardian columnist writes that “outsourcing the coronavirus crisis to business has failed – and NHS staff know it”.
    • May 16th Hancock says that “right from the start we’ve tried to throw a protective ring around our care homes.” This is categorically untrue. Care homes were left without testing. Without contract tracing. Without PPE. Without support.
    • May 19th On ITV Piers Morgan once again accuses a cabinet minister, talking about testing, of ‘lying through her back teeth’ to BBC viewers.
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    Vested interest alert – yes I’m claiming that word back – I come from a family of school staff, teachers, TAs, school governors. The dedication and hard work of all school staff, caretakers, cleaners, cooks, governors have shown for the safety, education, well-being, in many instances feeding, their pupils throughout this crisis has been extraordinary.

    I am totally dismayed at any criticism. Staff have the well being and safety of their pupils at their very heart. Their views on the total opening of schools and the views of their representatives have to be totally respected. The issue is complex. In Liverpool, the elected City Mayor has chosen not to open schools on June 1st as a safe-guarding issue as this wonderful city is still reeling from a high rate of infection. Questions are being asked as to why Mayor Joe Anderson has taken this stance when schools in Denmark, led by our sister party, are opening. Joe has never said Liverpool can’t open its schools, he has said when it’s safe to do so and only then. Each local authority has its own characteristics, not only in terms of levels of this dreadful pandemic, but the physical nature and age of its school buildings, levels of deprivation, staffing, the amount of public funding available and not available, the differing needs of its pupils. Country by country comparison is far too simplistic. This is an educational, health and societal issue.

    We all want all our children back in school and we are most worried about our most vulnerable, where home-schooling in a cramped flat with no outdoor space is stretching our children’s educational and physical and mental health well-being. I have family members with differing views – what I do know is that they are taking decisions based on local circumstances and always with the education and health of their pupils and staff foremost in their thinking. What is clear is that our health and education services, so starved of resources in this dangerous and false economy of austerity, especially in cities like Liverpool, have to be funded properly based on demographic need. I sincerely hope this Government remembers that but I fear not. Is it safe to open schools to children other than those of key workers or classed as vulnerable? There will always be risk – the question is how to reduce it. We must now learn from other countries – transmission from children to adults, children returning to schools in Italy presenting with multisystem inflammatory syndrome weeks after exposure.

    The UK did not have community testing, contact tracing and isolation early. Surely the question is are schools safe enough to open? Which means we need information and monitoring at a local level, the amount of new cases locally and rates of transmission. Local data should be driving policy and assuming a date for the entire country is ideologically rather than data driven. We need to get children back into education, but a locally managed data driven approach has to be the only way. Prioritising testing over a date. Listening to our teaching staff and our unions.

    For Liverpool in present circumstances – I’m with Joe.

    Theresa Griffin Labour MEP North West 2014-2020

    Member SHA

    1 Comment

    The crises in health and social care are rightly at the forefront of people’s anger about the government’s lack of preparation for an inevitable pandemic, as we now face with Covid-19. People are dying unnecessarily. An integral element, simmering under the surface, is the fragmentation of public health nutrition services that should provide food security within our communities so vulnerable people are kept in good nutritional status. Yet even before this crisis there was an estimated 3 million malnourished people, with an aging population this will increase, and 8 million people in food insecurity. As lockdowns began, research from the Food Foundation estimated 3 million households were already experiencing hunger. Inequalities underpin the right to life in this crisis: mortality rates for people living in deprived areas are double that for those in less deprived areas, and interlocks with ethnicity. Some highlight ‘obesity’ but is not the problem food and health inequalities? Poverty underpins people’s lack of access to foods of good nutritional quality. Rising poverty levels are driven by erosion of welfare state and neoliberal restructuring of our economy through deregulation, precarity and low pay. Child poverty has increased by 100, 000 over the past year with around 30% of all children living in poverty. Food poverty is increasing and requires structural change not short term solutions. To protect child health and meaningfully tackle poverty a host of fiscal steps are urgently required to enable families to buy food, such as basic living income and immediate action to increase welfare. This does not remove the need for a food security system that ensures a basic level of socially acceptable nutrition is available for all; that includes universal free school meals and hot meals for older people. Public health nutrition is more than just food. It’s about ‘social’ nutrition: the infrastructure of community resources that enable people to eat together and to collectively care.

    The networks of care within our communities have broken down as the infrastructure providing services and civil spaces have closed. There is little research that documents how the spending cuts and restructuring within public health has impacted public health nutrition. However, research is underway that aims to inform the inevitable public enquiry on Covid-19. As socialists, we need to go further and give a call to action to stop further privatisation and charitisation of PHN. Fundamentally, the interests of private industry and charity conflict with the welfare state. Despite the altruism of many involved, these organisations cannot meet current or future needs which will increase in the looming economic depression. They cannot enable the voices of those who are suffering in our communities.

    Privatisation of PHN began under New Labour as food companies were brought into public health policy. From the 2000s non-NHS providers entered PHN. Local government spending cuts and austerity hit prevention budgets including nutrition-based, child weight management and life style interventions. Cuts to nutrition-related services are broadly felt because nutritional health is cross-departmental involving education, community engagement, adult and children and young people’s services and a range of professions including health visiting. Nutrition was embedded in the Sure Start programme. Since 2010, 1000 children centres have closed as £1 billion has been cut from budgets. The number of community centres, lunch clubs and meals on wheels for the elderly has been decimated. In this crisis, the role of schools in feeding children has shown their centrality in community life. Yet there are barriers due to privatisation that limit a strategic approach. For example, in most neighbourhoods, schools have the only industrial kitchens capable of preparing and distributing foods to large numbers of people. Yet access to these is mostly controlled by private food companies, including multinationals, that hold the catering contracts. So, in many ways communities are isolated, disconnected from power and the resources to enable local solutions. Social theorists argue that ‘austerity localism’ brought cuts, disempowered local communities creating distrust and disconnect with local government. Community involvement is further limited by democratic deficits that are created by material constraints and lack of structural mechanisms. All this suggests that it will be harder for public health to connect with communities and understand the scale of their need. While not supporting the authoritarian Chinese State, community engagement was integral to the Chinese response.

    Responsibility for public health nutrition lies with local government who have enlisted third sector organisations (TSOs), social entrepreneurs, and food industry to construct the state’s food aid response in this emergency. From a dietetic standpoint, it is concerning that food banks can distribute foods that may unintentionally cause harm. For example, food banks only need warn of potential allergens, if they are set up as a business.  Food banks can distribute infant formula. This is risky  for example, for vulnerable families with complex needs and should not be the responsibility of food banks. It suggests a lack of a cross-departmental strategic approach that links with professionals such as nutritionists and health visiting teams.  Providing food at the general level of need is also problematic. The voluntary sector has strategic limitations in its ability to scale up according to need. In London, developing a strategic approach has been spearheaded by NGOs at City level, and boroughs through food action alliances. The food alliances are networks of non-state and non-industry providers, involving a range of activities such as food banks, food growers, community kitchens – supermarkets- fridges. They connect with local government through their public health departments. As crisis hit, they quickly turned their energies to organising emergency food aid. Phenomenal efforts are being made to scale up to meet increased demands. However, they face barriers. For example, many TSOs are involved in competitive processes to win and maintain local government contracts. Funding is often short term; a precarious situation for TSOs. In this crisis they need to collect evidence for ‘sustainability’, that is, to secure future funding.

    Despite the existence of resilience structures at regional and borough levels, strategies to meet increased food needs were not apparent. Indeed, there was little national food strategy (Lang, 2020). In London, as the crisis unfolded new charitable funding streams emerged. Four weeks into the crisis, the owner of London’s free newspaper, Evening Standard, and son of Russian oligarch intervened to feed ‘vulnerable’ Londoners through a new charitable alliance. This centralises food surplus supplies and distribution across boroughs. This role of charities is legitimised by London’s Mayor, albeit likely unintentionally. This upscaling of charities to deliver such large-scale logistical challenges raises concerns about the future direction for PHN.

    Altruism continues with the emergence of new food banks, food project social entrepreneurs and the Mutual Aids. With roots in 19th Century social welfare based on fraternalism not paternalism, these are today on the one hand wonderful, inspiring acts of solidarity but what will they become? There are many questions to consider: Do they adopt a public health perspective that considers inequalities including class and ethnicity or are these individual acts of charity and kindness? What is the class composition of the Mutual Aids? Will there be unintended consequences? Within communities, will they bridge or increase class divides and inequalities? Do they provide uniform and equitable support?  Do they contribute to food democracy within our communities? How are they accountable?

    These and other new solidarity networks enter into the terrain of unevenly shared and disjointed public health resources. Across London, a postcode lottery in public health nutrition pre-dates this Covid crisis. For example, eligibility for free school meals depends on the political priorities of local councils as well as government policy. Universal free school meals (UFSM) for all primary age children are provided in only 4 of the 33 boroughs. This includes children in families with no recourse to public funds (NRPF). Their temporary access to FSM during this crisis will be withdrawn as schools reopen. A cruel, intentional political act belonging to the ideology of hostile environment; socially divisive among young children teaching them that ‘others’ are undeserving and go hungry. What will Labour councils do when the onus for feeding children with NRPF returns to them?

    The differences between and within boroughs is seen at the level of schools. Schools take different approaches with some providing food for all children in-need and others based on FSM eligibility. Seven weeks since its introduction, the government’s voucher scheme that replaced FSM continues to be problematic, adding to the suffering of families; some schools are bypassing with their own voucher systems. Schools are filling the gaps but cannot do so as a cross-borough strategic approach due to privatisation. In contrast to London, New York took a pan-city approach with 400 public schools providing food for all adults and children in-need.

    Despite incredible efforts, TSOs, have made it clear they cannot fulfil the function to feed ALL in need:    ‘There is not enough free food or volunteer capacity to feed all economically vulnerable people through local authority and charitable means’. Instead they argue that central government should provide the financial means to enable everyone to buy food that meets their nutritional and cultural needs. From an ethical view it is irresponsible that central government assigns responsibility to local authorities and TSOs without giving the resources to carry out responsibility. It is well established that emergency food aid systems need to be nationally co-ordinated strategies. The UK government’s use of the armed forces for food distribution to the 1.5 million shielded clinically extremely vulnerable people, is recognition of the level of strategic organisation that is needed. It shows that only central government has the resources and therefore responsibility to feed ALL people in-need, across all vulnerabilities. It is not possible for this to be a function of TSOs. How do TSOs and local government decide ‘vulnerability’ without interlocking socially divisive ideas of ‘deserving’ and ‘undeserving’ poor? These are political decisions. Solving hunger takes political will (Caraher and Furey, 2018).

     

    The politics of privatisation and charitisation are felt most strongly on the frontline by the community food activists some engaged for decades in fighting to hold their communities together. One such leading activist and mother, Maya in South London, said

    I’m tired of fighting, fighting, fighting”. Yet she remains on the frontline running the local food bank/social supermarket. She says: diets will slump in areas like this … people use social supermarket but can’t get the foods children want … fresh fruits and vegetables have short shelf life ..we have to respond to new issues that come along …the hidden people that now come out who are in extreme poverty. While caring for her community she comments on new oppression by powerful borough groups and lack of accountability: people are going crazy with this food thing … there’s a lot of money around food …all they want to do is help the ‘poor’ people … they’re doing deliveries, taking selfies and putting it on twitter …  some people are stepping on our heads… others are cashing in on it.” On a part-time London living wage, she finds her own living standards are slipping backwards.

    What will emerge from this crisis? Local authorities will soon be planning their recovery processes. With depleted and finite funds will we see a redefining of ‘vulnerable’; a new means testing for referrals to emergency food aid? We are facing a long recession/depression with increased food poverty, malnutrition and hunger. This is potentially on an unprecedented scale. How will the increased charitisation together with ongoing cuts impact the public health infrastructure and jobs? Who will be providing food for public health? These are important questions for all of us in PHN whether Director of Public Health or unpaid community food bank worker. How we tackle feeding EVERYONE in-need is not just a practical question but a basic ethical one concerning food rights and health equity that requires reconnecting with our communities and schools for grassroots participation in decision-making. Enabling participation requires tackling the material conditions, of work and physical food environments, that underpin health inequalities.

    A weak public health nutrition infrastructure, including diminished community services, contributes to undernutrition, reduced immunity, more illness, more hospital visits. Pre-Covid estimates showed  £200 million could be saved in health and social care spend if greater attention is paid to caring for the nutritional status of vulnerable adults. This would contribute to the inequality seen in the distribution of Covid-19 death rates. Our right to nutritious food is essential to enable our rights to good health and longevity free from illness. To make this a reality, for all, will require fiscal measures that guarantee universal basic living income, that integrates food costs, as well as massive investment in communities and public health nutrition. One among many lessons for how we plan for food and health resilience in times of crisis, is to meaningfully, democratically involve our communities and workforces on the ground.

    Sharon Noonan-Gunning, Registered Dietitian, PhD in Food Policy.

    Caraher M., Furey, S. (2018) The Economics of Emergency Food Aid Provision: A Financial, Social and Cultural Perspective. Palgrave Macmillan. London.

    Lang, T (2020) Feeding Britain: Our Food Problems and How to Fix Them. Pelican Books.

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

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

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

    All the other political parties have opposed this surcharge.

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

    Vivien Walsh, Manchester

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    Introduction

    This is the tenth SHA weekly blog on the COVID-19 pandemic. We are at an interesting phase of the pandemic when we are moving from Response to Recovery and uncertain how to navigate the tricky waters without the charts and the data dashboard to guide us.

    We have a government that was ill prepared for the pandemic and has been playing catch up from the early days of denial, then delay and a too early departure from building local systems of community testing, tracing and isolating. We are beginning to hear of possible COVID-19 cases in the UK and neighbouring European countries emerging before Xmas so the virus could have been around longer than we have thought. Even so we wasted precious weeks in February and then had the damaging delay between the 10th March to the 20th March, when lockdown proper started during which time the viral spread had been exponential. We now note that England has one of the highest rates of excess deaths of the 24 European countries analysed by Euromomo.

    Game changers

    The government have, in the turmoil, grasped at ‘game changers’ such as the so called home based antibody blood spot test which was scientifically unproven and nevertheless succeeded in getting the Government to buy 3.5m on ‘spec’. We need to know how much Taxpayers money was wasted on that contract and demand a greater scrutiny on such wild contracts without basic safeguards.

    The next ‘game changers’ were the treatments such as chloroquine, which Trump was allegedly pushing on the NHS to treat Prime Minister Johnson. Again these drugs have been shown to be ineffective and potentially harmful treatments. The US Federal Drug Administration (FDA) issued a caution against its use in COVID-19 on the 30th April! There are other drugs being trialled such as remdesivir and favipiravir and some show promise but need properly conducted clinical trials and not be pushed out too soon by politicians anxious to grab a game changer. Remember the risk of Thalidomide, which was used in early pregnancies with disastrous consequences. We have seen with HIV/AIDS that therapies can be successful in controlling a viral disease but the process takes time and effectiveness trials and safety are paramount.

    The other ‘game changer’ is the vaccine which has always been a long shot because there have never been vaccines developed for Coronaviruses such as SARS or MERS. Other viruses such as HIV have also proved impossible to develop a vaccine for and remember each year the Influenza virus ‘flu jab’ immunisation contains three variants which experts assess are the most likely to be circulating during the coming winter months. The effectiveness of the Influenza vaccine is much less than others such as measles in the highly effective MMR vaccine. Furthermore while there are hopeful signs of successful vaccines being developed and some moving into human trials very early on there needs to be clarity about the time these trials take and the manufacturing process as well as mounting an effective vaccination programme. It is not part of the immediate pandemic control measures and with preventive vaccines you need to be very sure of safety as well as effectiveness. We know how the anti vaxxers mislead the public about risks of vaccination and do not want to damage the high uptake of vaccines across world populations.

    Matt Hancock has during his time as SoS for Health and Social Care promoted digital solutions to many NHS issues including promoting companies who in effect were competing as privateers with NHS primary care (Babylon Health). His latest ‘game changer’ application will be the apps being trialled in the Isle of Wight and others elsewhere to assist in contact tracing.  Big players Apple/Google stand ready with their apps to step in! Of course countries like South Korea, Taiwan and Singapore have been using such apps for months and have shown the benefit they confer in the process of Test, Trace and Isolate which the UK government abandoned on March 12th.

    It does seem unbelievable that South Korea has not been subject to lockdown and using testing, tracing and isolation has only had 262 deaths from COVID-19 by the 17th May with a population of 51m people. Their epidemic started several weeks before us and it is not clear what attempts the UK government has made to properly understand their system and learn from it.

    Local Authorities and Public Health

    Local Authority public health capacity has been reduced over the 10 years of Tory austerity and the public health grants reduced in the period leading up to the pandemic. While the Directors of Public Health, through their national body the Association of Directors of Public Health (ADsPH), have been involved with the CMO’s office and Public Health England (PHE) they have not been placed at the centre of the Test, Track and Isolate planning. Again the Government’s default position is to ask their consultancy mates to help design a system from scratch which we have seen with the national testing centres and the Lighthouse laboratories by Deloittes. This is a top down approach rather than a collaborative bottom up development.

    Further work now under a Joint Biosecurity Centre (JBC) is again focused on the digital app and how the information provided can be analysed and communicated. This has all the tenor of a security service GCHQ venture rather than a public health pandemic response! If the testing roll out is anything to go by there will be major glitches in communications with organisations at the heart of it not receiving information and the people themselves left waiting.

    It seems to us that local public health teams under the DPH leadership should have been involved from the beginning working with Public Health England/Wales/Scotland,  and Environmental Health departments to help facilitate test, track and isolate policies locally. They have not been closely involved since containment was abandoned prematurely across the UK despite wide variations in the spread of the virus at that time.

    The government announced that 18,000 staff will be taken on to work on the national test, trace and track initiative run by SERCO but Local PH departments were not asked to build local teams as part of the local response but prepare to help implement the national response. Primary care has also not been part of the model which is another wasted opportunity of bottom up work using local knowledge effectively. The GP surveillance system has shown its worth over many years with respiratory viruses like Influenza and patients know their GP practice as a trusted point of contact.

    We have seen that COVID-19 has spread across the UK unevenly and a UK wide response designed in Westminster has not been appropriate elsewhere where case numbers may have been very low with risks quite different from metropolitan London, Birmingham and Manchester. Of course there needs to be national leadership in the design and procurement of such an app and Public Health England with their counterparts in the devolved nations be part of the design team. However for it to be an effective system there needs to be local leadership and engagement which builds links between partners and particularly with local primary care teams to use test results and develop the capability of mapping clusters and initiating further local investigations within national case definitions to ensure testing is done, contacts traced and people are isolated swiftly as there is a risk that the virus will persist for weeks to come. There are signs that devolved governments such as in Wales may be approaching this in a more joined up way.

    Social Care

    In earlier blogs we have talked about the vital role that the social care sector plays, how their staff often work in difficult conditions on low pay. The impact of the pandemic now has shifted to this sector, which has 17,000 homes and look after 400,000 elderly or disabled people in need of care. This sector is where many of the excess deaths have been occurring and thanks to statisticians outside government who have signposted the excess deaths measure we know that they have accounted for 20,000 deaths so far. Weekly deaths in care homes have tripled in the past month. In Scotland recently it is estimated that 57% of deaths from COVID now come from deaths in nursing or residential homes.

    We have heard case after case of social care providers not having the PPE they require, having to accept hospital discharges who may have been infectious, not being supported in the way you might expect from external agencies. They have had to introduce infection control policies, which seem inhumane when considering the resident’s end of life experience and the memories of their survivor families. We should have a quick look at the risk assessments/processes to allow named next of kin to visit their relatives and be there at the end of life. It does feel that this is the time to grasp the nettle and create a new National Care Service which is publicly run and which does not require rental payments to ‘off shore’ bodies, who have invested in the land and properties rather than the commitment to care. Not all care homes are owned and run by business interests of course but all suffer from chronic underfunding, staff shortages and service gaps between the NHS and their own provision. The CQC is unable to bridge the gap.

    Moving out of Lockdown

    We are all getting tired of having our lives constrained by lockdown while at the same time pleased at the social solidarity shown by most of the population. The trade unions are quite right to ensure that the workforce is not endangered by a hasty return to work without rounded risk assessments.

    Take the school debate for example. It is relatively easy to look at children themselves and declare that they as an age group have been relatively spared the harms of COVID-19. However we know that they do seem to get the infection and harbour the virus in their noses and throats too. We don’t know how contagious they are but there is obviously a risk and scientific studies are understandably scarce. European countries such as Norway and Denmark have had far less cases and deaths than the UK and have got down to very low levels. For example Norway has had 8,244 cases with 232 deaths and Denmark 10,927 cases with 547 deaths. Their schools have had to implement big changes in the way they mix outdoors and indoors classes and have had to physically distance children in classrooms and for school meals. Halving class sizes seems the likely way we would need to go in the UK which might mean two day sessions which would have huge implications for schools.

    But its not just children! Teachers and school staff are at risk and there needs to be proper occupational health assessments to assess individual risks in the staff. Then there are parents and grandparents who may be involved in bringing children to school and mingling with others at drop off. Children may in turn bring back the virus to the home where there may be vulnerable others living there. So rather than the hurried declaration made to reopen fully on the 1st June there needs to be proper discussion and agreement with trade unions and parents and staff/school Governors on the risk assessment and plans. Remember too that schools have been open during this time for children of essential workers and vulnerable children many of whom have not attended. Oh, by the way, Eton pupils will return to school in September and they already have small class sizes!

    Scrutiny of Public Expenditure

    It is estimated that the Government has now built up £300 billion national debt through its Pandemic investments. The furloughing scheme has been widely welcomed, as has the cancellation of NHS (England) historic debt. However there have been some decisions made by harried Ministers that have been misplaced (such as the home based antibody test) as well as some of the spend on ventilators and Nightingale hospitals when it was already apparent that the NHS was coping somehow with the huge demand on ITU capacity. The decisions to contract out some of the tasks on testing, track and trace have been questionable and the investments in the pharmaceutical industry for vaccine production/drug development need to be scrutinised. Contracts worth more than £1bn have been awarded to 115 private companies dealing with the pandemic, without allowing others to bid for the contract. This has been under fast track rules which suspend normal procedures and include contracts to provide PPE, food parcels, COVId-19 testing and to run operations rooms with civil servants. This latter group includes Deloitte, PWC and Ernst & Young!

    The last thing we want is to be plunged back into austerity at the end of the pandemic. Already we hear of withdrawal from the rough sleepers investment in accommodation before alternative plans are in place and indeed before realistic resurgence in tourism happens. The new normal needs to preserve the advances that have been made. Similarly simple calls for people to drive to work risks the modal shift that is possible towards walking, cycling to work if public transport is deemed too crowded for social distancing. Electric cycles can be promoted for those with further to travel or in hilly areas. The reduction in air pollution while helping the carbon load is still not at levels this year required if we want to meet the goals of the Paris Accord and keep global temperature rise to 1.5 degrees.

    The Chancellor and his advisers will be wondering how to get more money into the Treasury. Now is the time to look at a proper wealth tax and to deal with off shore tax avoidance. Dyson tops the Sunday Times Wealth list and remember Sir James moved his head office out of the UK to Malaysia during the Brexit debates. He is sitting on £16.2 billion wealth. The Duke of Westminster has had 300 years in the top spot of property wealth  (£10.3 billion) built on their portfolio of 300 acres of Mayfair and Belgravia (remember the Monopoly Board!). Others in the top 10 include the Coates family who have accrued £7.17 billion through gambling business such as Bet365 and we know the damage to public health that gambling does. Finally lets call out Richard Branson who sought a government subsidy of £500m for his furloughed staff in Virgin Atlantic with his £3.63 billion. He has apparently not paid any personal tax in the UK for 14 years. These super rich need to be taxed on their annual earnings as well on inheritance transfers, which by using Family Trusts subvert the process.

    Finally

    As we think of US billionaire David Geffen on his $590m yacht, who posted on Instagram that he was isolated in the Grenadines avoiding the virus – lets consider a better fairer future.

    The pandemic can be an opportunity for progressive change to reduce inequalities but we know that there are entrenched and powerful interests. The rich are often supporters of entrenched interests as they benefit from the status quo. In the light of the pandemic they should reflect on how sustainable the status quo really is. We also need to clear set out a new road map for a fairer future.

    17th May 2020

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

    2 Comments

    FEEDBACK AND TOUGH QUESTIONS 17 5 2020

    TOUGH QUESTIONS

     

    QUESTIONS ON TEST, TRACE AND ISOLATE

    We must continue to press for testing and contact tracing locally and expose contracts going to private sector


    http://edition.pagesuite.com/html5/reader/production/default.aspx?pubname=&edid=a708f69f-8beb-4220-b47c-fb76a4892194

    What stopped the Govt engaging with Local Resilience Forums set up to coordinate local planning in the event of a pandemic?


    The absolutely key issue is testing and contact tracing and why on earth are we easing the lockdown in England when we have not got this system up and running? The R number is far less relevant here. Only 1500 volunteers out of 18000 needed in place? Many volunteers meanwhile twiddling their thumbs (we have a WhatsApp group of former medics many of whom have volunteered but not been called upon.) I am genuinely shocked about the lack of contact tracing still after 4 months


    If the country is now undertaking more than 100,000 tests per day, why is it that the NHS’s own labs are not receiving sufficient reagent supplies? This is resulting in patient samples being transported much longer distances, with longer turnaround times, and increased risks in hospital due to more patients that are pending their test result as a consequence.


    We’ve been working in City and Hackney to persuade Local Government members and officers establish a community based case detection and contact tracing Vanguard demonstrator (proposal attached) – but they are struggling in face of centralised approach. Local politicians have written to Matt Hancock but, I understand, have received no reply.

    There is a news article:

    See https://www.hackneycitizen.co.uk/2020/05/07/coronavirus-local-politicians-challenge-government-trial-contact-tracing-testing-hackney/

    Our approach was informed by the Sheffield Community Tracers project: https://www.communitycontacttracers.com/

    So, my question would be two fold and asking when Secretary of State will:

    1. a) empower local authority staff, under DPH, to establish a local identification and tracing service and
    2. b) ensure data from test centres is fed to local teams to support the process.

     

    DATA SHARING WITH PRIVATE SECTOR

    Has anyone yet asked about the implications of data sharing with the Private Sector?  We had a really big issue in the NW with data being shared with private companies, with disastrous results. Work with the CCG at that time gained some positive changes.


    MENTAL HEALTH

    https://uk.reuters.com/article/us-health-coronavirus-mentalhealth/u-n-warns-of-global-mental-health-crisis-due-to-covid-19-pandemic-idUKKBN22Q0AO

    Has the PM taken notice of this article and will he not only “protect NHS Hospital care” but ensure support and capacity in respect of the emotional/psychological/ psychiatric impact as outlined in this report?


    Where I work, we are heading towards a situation where there are a few remaining COVID-19 wards and many of us back to BAU.

    I think the most important questions to ask now are:

    1. whether the government will renationalise the NHS
    2. will they commit to keep services publicly provided from here onwards, not to give contracts to private providers without full, transparent consultation and justification
    3. will they allow an independent enquiry into the handling of COVID-19 so that we can learn from mistakes and from anything that might have gone well?

    HOSPITALS

    With the NHS recommencing elective surgical activity, including more cancer operations, what assurance can be given on the supply of sterile surgical gowns, which are essential PPE for operating theatre teams?

    Can it be confirmed what equipment (such as ventilators, blood gas analysers and haemofiltration machines) hospitals have requested to support the safe management of Covid-19 patients, and what equipment has been provided to them?

     

    FRONTLINE FEEDBACK

    TESTING

    I was given permission to leave work early, in order to have the test. Although you read stories about the tests being privatised to private companies, this test centre appeared to be run by the army.

    After I had done the test and dropped my sample into the appropriate bag, I was told that I would have to register my card when I got home. I was also told that I should get the result within two days, but not to chase it up unless I did not get it within seven days.

    Later that day, I tried to register my test. The registration card stated that I needed to register my test on https://www.test-for-coronavirus.service.gov.uk. However, this website only took me to the site for booking a test, not for registering a card. I rang the helpline and was directed to a website where I could register my card. When I tried to enter the barcode, I got a message stating that this number was already registered and inviting me to try again. I tried again and got he same result. I rang the helpline again and was eventually told that the site must have registered me anyway.

    Since then, my wife and I have waited, but have not been sent any result for the tests. And we have continued to attend work. This morning (Thursday 14 May 2020), my wife rang the number on the registration card and asked if we could have our results as it had now been 8 days since the test. We both gave our details, including name, barcode number and car registration at the test site. The person who took our details stated that they could not look anything up themselves, but they would pass on our details so that they could be chased up. Since then, we have still heard nothing, either by phone, text or email.

    An eight day (and counting) wait for a test result defeats the object of having a test. My best guess is that the government are more interested in the headline figure of the number of tests carried out, rather than actually getting any useful data from them. I could be wrong. But our tests are entirely separate from each other, but neither of us has had the result.

    DISCHARGE TO CARE HOME

    My friend (female, 50) works at one of the care homes run by a Charitable Trust that were spun off from the Council.

    She says that one of her residents was sent last month to a local hospital for a Covid test, tested positive, then was sent back to the Home.  Whether or not this was the cause, the virus later spread through an entire floor at the Home.

    I find it shocking that this discharge back to the home happened.  Who takes responsibility for this? A consultant, hospital management, or the Government? Or all of them? This is as shocking as the railway worker dying after someone spat in their face!

    SICK PAY

    Secondly, it turns out that if my friend goes off sick with a (non-Covid) sick note, the employer doesn’t pay any sick pay, and she has to apply for sickness benefit through the benefits system, even though she works 5 days a week and was appointed with an interview and references!

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