Blog

  • Categories
  • Category Archives: Professional opinion

    Issue: 111 – 10 November 2020

    Pfizer Covid-19 Vaccine

    This could be the only good Covid-19 news we have had in a very long time. Regulators have still not approved the vaccine though, but allegedly this will happen soon. According to DHSC guidelines issued in September 2020, the top priority list for those being given the vaccine is older adults resident in care homes and care home workers, 80 years of age and over and health and social care workers, 75+, 70+. 65+, and high risk adults under 65.

    The Government has an agreement with Pfizer to buy 30 million doses, with 10 million due by the end of December 2020.

    Very Steep Rise in Secondary School Covid-19 Infection Rates

    The National Education Union (NEU) has analysed Covid-19 infection data published by the Office for National Statistics. The NEU states that Infection rates in Secondary schools in England are an astonishing 50 times higher since September 2020. In Primary schools the rise is nine times. The NEU maintains these figures clearly show that schools are engines for virus transmission.

    The NEU recommends schools staying open only for children of key workers and for vulnerable children during Covid-19 lockdown. The NEU membership is 450,000 teachers, lecturers, educational support staff and leaders. More at:

    https://neu.org.uk

    As a postscript to this, when I researched infection rates across many Ealing neighbourhoods on 9 November 2020 the three highest rates were in neighbourhoods containing secondary schools – Northolt South (349 cases/100,000), Southall Green (310.1) and Cuckoo Park, Hanwell (280.9).

    Hospitals are Breeding Grounds for Covid-19 Infections

    On 9 November 2020, ‘ITV’ reported that of the 12,903 new Covid-19 cases between 18 September and 18 October 2020. 1,772 were acquired in hospital. Of the 700 new hospital cases in south east England, 23% were contracted in hospital.

    It seems for all kinds of reasons hospital staff and patients are not being tested on a regular basis. By 20 November 2020, allegedly, all patient-facing NHS staff will be asked to test themselves at home twice a week with results available before coming to work.

    Covid-19 Lockdowns Impacting the Mental and Emotional Health of Young People

    The NSPCC AND Childline are both reporting increasing telephone and counselling sessions. Young people are increasingly presenting with feelings of isolation, anxiety, insecurity and eating and body image disorders. More at:

    www.nspcc.org.uk

    www.childline.org.uk

    Is Covid-19 Population Testing (Mass-Screening of Asymptomatic People) in Liverpool Simply the Wrong Thing to Do?

    80 test centres and 2,000 troops involved. This sounds expensive. But will it ‘work’? Professor Allyson Pollock, a recognised Public Health expert, has her doubts. On 3 November 2020, as part of the Government’s £100 billion ‘Operation Moonshot’, population-wide Covid-19 testing of asymptomatic people in Liverpool was announced. Eight test centres opened on 6 November 2020.

    Professor Pollock has pointed out that this initiative is at odds with the SAGE advice of 10 September 2020 and with the current World Health Organisation (WHO) guidance. SAGE and WHO favour prioritising the rapid testing of symptomatic people, contact tracing and identification of infection clusters. Her concerns about the Liverpool pilot include:

    • a diversion of public money and resources. The OptiGene tests have cost £323 million.

    • the use of inadequately evaluated Covid-19 tests (direct LAMP test (OptiGene) and a lateral flow assay (Innova)

    • WHO evaluations of similar tests suggest between 1% and 5% of people without infection may get false positive readings. (With 392,000 adults in Liverpool these false positives could number anything between 3,920 to 19,600 adults)

    • there is no evidence demonstrating that Covid-19 mass screening can achieve benefit cost-efficiency

    • smaller pilot studies should have been carried out first before launching a massive pilot study of 498,000 people. (Allegedly a pilot was carried out in Manchester and it was found that half of the infections were missed).

    More at:

    https://allysonpollock.com

    The ‘Sunday Times‘ of 8 November 2020 leaked that three towns would be added to the mass-testing project. One is thought to be in The Midlands and one in the south of England. This would add another 100,000 people to be regularly tested.

    Reduced Support for the Homeless in Lockdown 2

    During Lockdown 1 many homeless people were put up in hotels, hostels and other forms of accommodation. This Government funded ‘Everyone In’ strategy was deemed to be successful in saving lives and reducing Covid-19 infections rates during Lockdown 1.

    Now it appears that money is running out to support the homeless and getting them off the street during Lockdown 2. Almost half of the night sleepers in London are foreign nationals and under the October 2020 post-Brexit legislation they could face deportation if found sleeping in the street.

    One week into Lockdown 2

    On day one of Covid-19 National Lockdown 2 (5 November 2020), I researched the following Ealing Covid-19 infection rates per 100,000 people. A week later I did this again:

    Southall Park: 265.3 became 244.1

    Ealing Broadway: 247.6 became 281.4

    Acton Central: 147.8 became 113.7

    West Ealing: 132.9 became 122.9

    A very small sample I know, but in three out of the four neighbourhoods the rate had fallen.

    Government’s Vaccine Taskforce Chair Spends £670,000 on Public Relations

    Kate Bingham, Chair of the Government’s Vaccine Taskforce, has allegedly hired eight Admiral Associates public relations consultants at £167,000/year each. Ms Bingham, a qualified biochemist and venture capitalist, was hired by the Government in May 2020. She is married to Jesse Norman MP. Bizarrely she reports directly to Prime Minister Johnson.

    Town/Hospital Based NHS Activist Groups Slowly Being Marginalised

    Three main factors at work here. Firstly the demolition of local CCGs. In 2018/19 there were 195 of them. By 1 April 2021 they will all have been closed down and ‘replaced’ be some 42 regional CCGs. Secondly, the Covid-19 response National Lockdown 2 has shifted commissioning from local, through regional, to a national undertaking. Thirdly, Covid-19 has allowed NHS bodies and Local Authorities to remove citizens from any effective, real time involvement in statutory body public meetings. In Ealing, for example, virtual, public Council care meetings employ MS-Teams software in a restricted, unhelpful fashion.

    NHS NWL EPIC

    On 17 December 2019 In NHS North West London (NWL) a public engagement initiative called ‘EPIC’ was launched at a workshop. 80 people attended of whom 34 were ‘patients’. EPIC is being used ‘to gather public opinion about local and NHS activities, involving ‘local residents in shaping and co-producing our services’. NHS NWL EPIC has built a ‘Citizen’s Panel’ of 4,000 north west London residents. The make up of the panel is allegedly representative of the 2.5 million residents in the region. I applied to join this panel but my application was ignored. Another EPIC Citizen’s panel meeting – this time a virtual one – was held 27 October 2020. In this meeting the idea of a ’Patient Forum in each borough’ was floated. The local Healthwatch, the local Council and the local voluntary sector would be invited. No timescale was set and it’s obvious that the forums would have no statutory significance whatsoever.

    Public Involvement Charter (PIC)

    EPIC is also developing its own ‘Public Involvement Charter’ (PIC). The PIC has admirable intentions and ‘core values’ – ‘the right to be involved, influence, improving outcomes, inclusion, engagement as residents want, information and transparency’. And all this as ‘we move more towards the (non-statutory) Integrated Core System (ICS)’.

    With all the generosity I can muster, I find the non-statutory EPIC, Citizen’s Panel and the Public Involvement Charter to be underwhelming, likely to be expensive and probably a complete waste of NHS and citizen’s time.

    Eric Leach

    Leave a comment

    We  are  writing to you in response to the apparently hurried decision to begin population-wide testing in Liverpool, as part of the £100 + billion ‘Operation Moonshot’, in order to “find positive cases and to break chains of transmission” (Government Press Release, 3rd November 2020).

    This announcement is inconsistent with the SAGE advice at its 56th meeting on 10 September 2020 that it had “high confidence” that “Prioritising rapid testing of symptomatic people is likely to have a greater impact on identifying positive cases and reducing transmission than frequent testing of asymptomatic people in an outbreak area”. This chimes with WHO guidance to focus on contact tracing and identification of clusters, and which does not recommend mass screening.  Proposals for mass screening in their current form will undermine this priority.  

    Searching for symptomless yet infectious people is like searching for needles that appear transiently in haystacks. The potential for harmful diversion of resources and public money is vast. Also of concern are the potential vested interests of commercial companies supplying new and as yet inadequately evaluated tests. If the programme is to proceed, then the contracts awarded, or advertised, should be made public, including their cost to the public purse. (The government is already facing a judicial review for failing to publish covid-19 contracts, brought by your fellow MPs Debbie Abrahams, Layla Moran and Caroline Lucas with the Good Law Project.)

     There is currently no evidence demonstrating that SARS-CoV-2 screening can bring benefit cost-efficiently, and experience shows that unless screening is delivered as a systematic programme with quality assurance for every step of the pathway then any theoretical benefit will not be realised in practice, even where a benefit is possible.

    We would like to ask you what has been decided, and how were decisions reached, regarding the types of tests to be used, what exactly are they aiming to detect, and how has their accuracy been evaluated?  We understand that the Liverpool pilot is likely to use a direct LAMP test (Optigene) and a lateral flow assay (Innova). Currently there is little or no evidence of the accuracy of either of these tests from their use in presymptomatic and asymptomatic cases, or in field settings.  There is substantial uncertainty as to whether they can detect the lower viral loads that are likely in symptomless people, which appears to be the aim of this mass pilot.  If the tests fail to detect cases, then the programme will waste resources and time, and give people false reassurance which could increase transmission.   Similarly, the false positive rates of these tests have not been established in community use and neither have the implications for contact tracing services.  Evaluations of other similar tests by the WHO has suggested between 1% and 5% of people without infection may get false positive findings.  This means that if 1 in 100 people tested in the pilot have asymptomatic infections, as few as 1 in 5 of those getting positive results will actually have Covid-19 – and 4 out of 5 would be false positives and they and their contacts would unnecessarily be told to isolate.

    The accuracy of tests for identifying symptomless infection in a healthy population need to be evaluated in a pilot study with proper research design to assess the extent to which asymptomatic people contribute to overall case-loads, whether they play a significant role in transmission, and whether screening can help. We see no evidence that the Liverpool has such a research design.

    It appears unclear what will happen when people test positive, and negative, whether there will be clinical oversight in interpretation of the results and whether the results will be sent to patients’ GPs and integrated with medical records. What will people be offered? What will they be instructed to do? What support structures are in place to achieve this? It is also unclear how this programme will be integrated into, and affect, the track and trace system, which is already performing poorly.

    Are all the above considerations documented in a format suitable for the lay public to understand as part of an opt-in informed consent process? Is there an option to withdraw from the scheme at any stage, including freeing people of any study requirements? Are participants afforded the right to access their information, to know with whom it is being shared, and to request its deletion – in line with GDPR and the Data Protection Act?

    These are just some of the questions and issues that are concerning us and that need to be pursued, along with asking the government to explain why they are acting inconsistently with SAGE’s advice. We urge you to do so as soon as possible.

    If we can be of any assistance, please do not hesitate to contact us.

    Yours sincerely,

    Allyson Pollock

    Professor of Public Health, Newcastle University

    Anthony J. Brooks

    Professor of Genomics and Bioinformatics, Leicester University

    Louisa Harding-Edgar, General Practitioner and Academic Fellow in General Practice. Glasgow University

    Angela E. Raffle, Consultant in Public Health, Honorary Senior Lecturer in Public Health, Bristol Medical School Department of Population Health Sciences, University of Bristol

    Stuart Hogarth, Lecturer, Department of Sociology, University of Cambridge.

    Leave a comment

    ICS have been introduced and developed undemocratically, without consultation and with a lack of transparency.  Their aim is to impose ‘reduced per capita cost‘ control totals to force unproven and unsolicited  innovation, including elements of privatisation and paid for care, in each system’s struggle to meet local population need. This has been NHSE/I’s practice with individual Provider Trusts over recent years. Each ICS will form a new Integrated Care Provider (ICP) organisation. NHS England plans for ICP organisations to be managed through commercial contracts. We therefore call on government to ensure that:

    1. Local Authority Scrutiny Committees across England be allowed to fulfil their legal responsibilities to scrutinise fully the significant changes in NHS services that have been initiated without scrutiny under the COVID-19 emergency measures before they become any permanent part of ICS development. If the Committees decide that the changes require full Public Consultation then this must also happen before the changes are allowed to remain. These actions are well established legal process.
    2. Some democratic representation is created in the Governance structures of ICSs by: i) an increase in Local Authority Councillor representation on the Governing Bodies so as to match in numbers the NHS representation (Partnership) and ii) full public engagement and involvement for all significant changes and developments in the NHS, with full Consultation as well on the more major issues as decided by the Scrutiny Committees which have been set up in our democracy for this purpose.
    3. In the longer term there must be a return to universal risk pooling and funding with renewed efforts for National equity of care and National decisions about affordability. ICS must be replaced by Health Boards with the return to geographically based responsibility for the delivery of health to local populations. The apparatus of the market that divides the NHS must be dismantled. Health Boards as public, accountable bodies would plan and provide the full range of NHS services, with participation from elected councillors, community organisations, Neighbourhood Health Committees as advocated in our paper “Public Health and Primary Care” andtrade unions. The quality of services would then be monitored by locally-based independent bodies involving local patients and community groups, with the powers once enjoyed by Community Health Councils.

    Dr  Jackie Applebee

    Chair Doctors in Unite

     

    4 Comments

    Watching and reading the arguments Tory MPs put forward for voting against an extension of free school meals over the school holidays, there seems to be a common thread. Nearly all of them use the argument of dependency, that is relying on the state to provide for us rather than supporting ourselves through personal responsibility.

    These arguments are not new, “Booth and Rowntree found the greatest cause of poverty was not, as often believed, feckless shirking by the irresponsible lower classes, but low pay for full-time work, or inability to get regular work despite best efforts”. In other words dependency is invalid as an argument for poverty. The causes of poverty are well known. This research was conducted before 1914.

    What the Tories call dependency, Labour calls decency. Whatever defence the Conservative MPs type, say, shout or even belief is at odds with fundamental human rights. The right to water and food is part of our existence. The Tories commodify them through privatisation, e.g. the English water companies. Now, they are re-defining them – again – as dependency.

    The language of dependency is interesting yet alarming. From 1997 onwards, society was not focussed on this language, but on how to design policy around alleviating poverty. These alleviation measures while not focussing on the eradicating poverty, sadly, but they helped reduce child and pensioner poverty.

    Without the state focussing on alleviation and the eradication of poverty, we will go backwards in time rather forwards. I know, as I grew-up in poverty in the 1980s and received free school meals. I am very proud that Lewisham through the leadership of Damien Egan and Cllr Chris Barnham acted quickly in Lewisham to extend the free school meals entitlement over half-term.

    Finally, I suspect the dependency argument will continue to be spoken by Tory minsters and MPs. If they can use that past descriptor for free school meals then it won’t be long before it is extended to universal, free at the point of need, NHS healthcare. I have no doubt that a significant number of Tory MPs want us to follow the US system of healthcare. Such a system is the number one cause for bankruptcy among the American population.

    https://www.paulbell.org/

    Comments Off on Tory dependency argument and free school meals

    Yorkshire Socialist Health Association

    Command and Control Management:

    The Deadly Embodiment of Neo-Liberalism at work in the Public Sector

    John and Joe Carlisle, Mad Management[1]

    Although the Command and Control style of management is a fairly modern phenomenon, like all ideas, its roots go much further back, to a very dominant model of how to discipline and organise institutions. The philosopher Michael Foucault famously uses 18th Century Utilitarian philosopher Jeremy Bentham’s panopticon as a model for how a modern disciplinary society seeks to at all times to survey, or at least give the possibility of surveillance, its populace. The panopticon is a surveillance structure originally designed by Bentham for prisons but reproducible in any environment. The centre is occupied by a watchman who cannot be seen but who is surrounded in the round by the cells or workplaces of those he surveys. Each in their own compartmentalized sections the watchman, or manager, can see everything the prisoners do. As Foucault describes ‘[t]hey are like so many cages, so many small theatres, in which each actor is alone, perfectly individualized and constantly visible.’[2]

    Foucault rightly saw ‘panopticism’ as a paradigm through which individuals could be measured, assessed, marked and surveilled; it was not simply a design for a prison but a “how to” command and control for a whole variety of institutions from schools, hospitals and factories. It is worth quoting Foucault again, this time at length, as he describes the consequences of such a model:

    He is seen, but he does not see; he is the object of information, never a subject in communication… if they are workers, there are no disorders, no theft, no coalitions, none of those distractions that slow down the rate of work, make it less perfect or cause accidents. The crowd, a compact mass, a locus of multiple exchanges, individualities merging together, a collective effect, is abolished and replaced by a collection of separated individualities. From the point of view of the guardian, it is replaced by a multiplicity that can be numbered and supervised. 

    This top down model of designing the workplace was explicitly compatible with industrialization where work was broken down into small repetitive actions that can easily be measured and codified. What is harder to understand is why the model was placed upon all forms of work. Why do so many managers insist upon forcing this model onto industries, such as service, which it does not fit, and more tragically, why use it as the model for management in public services?

    It is now common for most people who work now to have a sense of being monitored. Whether through the ubiquitous CCTV camera, which now often can record audio, to electronic clock ins,’ recordings of all phone calls made in a call centres or on workphones, targets to be hit, milometers which time how long a delivery takes to go from A to B, to IPad’s whose programs must followed to the letter. What this produces is an abundance of data, a mountain of information which can be turned into charts, graphs, and reports. This gives the manager a great sense of control; to him nothing is hidden.

    Except of course a lot is hidden. Data by its very nature hides vast amounts of knowledge. The time it takes to get from A to B does not reveal that the final stage may add 20 mins because there is nowhere to park the lorry. The failure to reach the target may simply reveal the arbitrary nature of the target. In data the whole complexity of the human world is erased, flattened out into a spreadsheet, and the manager ends up mistaking the map for the terrain.

    Not only does it give the illusion of knowledge but command and control management style doesn’t work.  It makes waste rather than reducing it. This article will argue that it is an empirical fact that these modes of supervision fail to achieve what they claim to. Systems thinking is a far more effective way of improving organizations, and ironically, it has the data to back it up.

     Systems Thinking

     In 2003 Professor John Seddon published Freedom from Command and Control. [3] It caused quite a stir, demolishing most of the principles upon which the government had based its efficiency drive – which later morphed into wholly inappropriate and damaging austerity policies. It refuted the top down principle of leadership that is implicit in the New Public Management (NPM), which is a promoter of what Seddon calls ‘the management factory’: ‘The management factory manages inventories, scheduling, planning, reporting and so on. It sets the budgets and targets. It is a place that works with information that is abstracted from work. Because of that it can have a phenomenally negative impact on the sustainability of the enterprise.”

    The case studies gave irrefutable evidence of the damage caused by this neo-liberal mechanism in the public sector. Seddon’s solution was systems thinking as expanded in his next book, Systems Thinking in the Public Sector.[4] Here example after example illustrated the waste caused by NPM, especially as advocated by the likes of Barber (targets etc.) and Varney (shared services – see appendix)

    The research and analysis conducted by Professor John Seddon, which has looked at reasons for diseconomies of scale specifically in service organisations, fundamentally challenges the ‘Command and Control’ logics that underpin much of the public sector. Instead case study after case study confirms that concepts such as ‘designing against demand’, ‘removing failure demand’ deliver outstanding success  , while the typical drive to standardisation and specialisation of function results in inappropriate services being delivered, resulting in turn in escalating monitoring, management and correction costs.

    This, however, requires a change of thinking about how organisations work best in this the 21st century. Over a hundred years ago the workforce was only one generation removed from an industrial culture. Their understanding of industrial production and its organisation was very limited. Consequently even the best designers of organisations, e.g. Henry Ford, the Quakers, Cadburys, Rowntree’s and Clarks, were at best paternal, and at worst, reductionist pragmatists, i.e. treating workers as intelligent tools. However, even the latter did not mean not trusting them or attempting to look after them. After all, Henry Ford doubled the wages of his workforce overnight and refused to allow women to labour after 5pm so they could look after their families. He was also sued by his major shareholder for doubling his workers’ wages at the expense of dividends. The shareholder won.

    Today, we have a workforce that is literate and numerate and is at home with modern organisations, BUT are managed as those of 100 years ago. Why is this? The reason is the Command and Control style is more comfortable for those leaders whose upbringing (conditioning) and training at Business Schools has brainwashed them into feeling that being in charge means taking control. As they cannot be everywhere they therefore use measuring as a proxy for their physical presence. This usually translates into columns of comparative data or run charts, tick boxes compliance, and often targets to be reached as evidence of success of failure.

    So, who is the guardian in the panopticon? It is HR. In many public sector organisations HR has seized this opportunity to become the enforcer of compliance for the board. Rejoicing in their power they have abandoned their traditional role of looking after the workforce and now “guard” it.

    Politicians are entranced by these governance measures. They can conceive of nothing more confidence boosting than setting targets for, e.g. hospital waits, housing allocations, repairs completed. Their mental model is captured in the Table 1, below, in the left hand column. It is informed by their neo-liberal mindset, something they have imbibed from exposure to the right wing press; the fascination with material success, for example Peter Mandelson, playmaker of the Labour party said twenty years ago that he was “intensely relaxed about people getting filthy rich as long as they pay their taxes”; privatisation continues even though it is clearly an utter failure; and cost-cutting  and targets are the first knee jerk reactions to perceived public sector overspend.

    But there is another way. It comes in the form of a System of Profound Knowledge, first propounded by the great management philosopher, Dr W. Edwards Deming, whose principles are best presented in the work of Professor John Seddon, head of Vanguard.

    The Seddon Vanguard model, constructed from his research into effective organisations is the right hand column (Table 1).

    Table 1. The two conflicting models of management

    The question is why, in particular do UK politicians favour the Command and Control model? Our theory is that it is the “control” element that matters most – and, which has caused the most waste, and managers and politicians in particular are comforted by the illusion of control even when it clearly causes so much damage to people and resources as the examples below illustrate. [5]

    • Western Australia’s Department of Treasury and Finance Shared Service Centre promised savings of $56 million, but incurred costs of $401 million.
    • A National Audit Office report said that the UK Research Councils project was due to be completed by

    December 2009 at a cost of £79 million. But, in reality, it was not completed until March 2011, at a cost of £130 million.

    • The Department for Transport’s Shared Services, initially forecast to save £57m, is now estimated to cost the taxpayer £170m, a failure in management that the House of Commons Public Accounts Committee described as a display of ‘stupendous incompetence’

    Covid-19 has made the flaws are even more obvious. That greatest of all control freakery, the centralising state, has been shown for disaster that it is. The Health Secretary has kept control of all the testing and tracing administered from the centre, and it is failing at every level. The report from the Independent SAGE, a group of 12 leading scientists headed by former UK Government chief scientific advisor, David King, said the governments test, track and trace system is not “fit for purpose”.

    The government’s current approach to this system, including the contact-tracing app, is “severely constrained by lack of coordination, lack of trust, lack of evidence of utility and centralisation”, it adds. “The effective operation of this subsystem is also complicated by the apparent failure of the app that was designed to facilitate identification of contacts of those who have Covid-19” (Digital Health, June 16, 2020). We are talking here about thousands of British lives and further damage to a reeling economy.

    Dr W Edwards Deming summed it up perfectly: “Most people imagine that the present style of management has always existed and is a fixture. Actually, it is a modern invention – a prison created by the way in which people interact.”  He then asked the question:

     How do we achieve quality? Which of the following is the answer? Automation, new machinery, more computers, gadgets, hard work, best efforts, merit system with annual appraisal, make everybody accountable, management by objectives, management by results, rank people, rank teams, divisions, etc., reward the top performers, punish low performers, more statistical quality control, more inspection, establish an office of quality, appoint someone to be in charge of quality, incentive pay, work standards, zero defects, meet specifications, and motivate people.”[6]

    Answer: None of the above. (Will someone please tell our politicians.)

    All of the ideas above for achieving quality try to shift the responsibility from management. Quality is the responsibility of management. It cannot be delegated. What is needed is profound knowledge. A transformation of management is required, and to do that a transformation of thinking is required – actually the neo-liberal paradigm is so entrenched that that nothing less than metanoia (a total change of heart and mind) is needed.

    When this transformation happens almost miraculous levels of performance occur. For example, when left to the medical staff only, the level of delayed bed days fell from over 12,000 per month to under 6000 in a year (2017/2018) – an over 50% reduction! Much less command and control leads to much more economic and effective activity. It is time all the politicians learned to trust their public servants much more, and abandon the illusion of control foisted on them by neo-liberal ideologists from Labour and Conservatives. It is a political thing, not a party thing. The whole system of government must be overhauled.


    References

    [1] https://jcashbyblog.wordpress.com

    [2]Michel Foucault, Discipline and Punish, trans. A. Sheridan (Vintage books, New York, 1995) p. 200

    [3] Seddon 2003 ‘Freedom from Command and Control’ Vanguard Education

    [4] Seddon 2008 ‘Systems thinking in the Public Sector’ Triarchy: Axminster

    [5] John Seddon 2012 submission to the Local Government and Regeneration Committee – Public Sector reform and Local Government. 2012

    [6] Deming, W.E. (1993) Out of the Crisis, MIT: Cambridge

     

    4 Comments

    Former Health Secretary, Jeremy Hunt, probably Britain’s worst leader since General Percival surrendered an army of over 80,000 soldiers to 36,000 Japanese soldiers at Singapore in 1942. It was the worst ever British defeat and led directly to the dreadful Japanese concentration camps. Hunt was in charge of over a million highly committed NHS professionals with oversight of Social Care, looking after nearly a million people. He surrendered these to a succession of debilitating neo-liberal reorganisations, privatisations and defunding regimes. Like Percival he could have fought for his people, but chose not to, and England is paying a high price.

    Percival’s reward was the pension of a Major General. Some think Hunt’s reward may be selected as the next Prime Minister. Think again.

    Apart from his duplicity with data, his bullying of Junior Doctors, and his hypocrisy in praising the NHS and shrinking nurse’s pay, there is the question of his ability to manage. Managerial incompetence is a common trait in this Conservative government, as exemplified by Grayling, Hancock, the Prime Minister, Priti Patel and others in the Cabinet.

    Hunt the manager.

    In every good organisation there are key performance indicators whose sole function is to help the executive steer the organisation most effectively. In British Rail one was trains on time. The purpose was to keep the passengers safe and satisfied, as the most important need was reliability, not speed, as the politicians keep getting wrong.

    A key indicator in Social Care was the performance of transferring patients from the hospitals back into their homes and care homes. The indicator was called Delayed Transfer of Care (DToC), which meant that something was preventing the patient from being discharged when they were better. It was measured by the month. It was a very important indicator, for two main reasons:

    • Cost: Each time the transfer from the hospital failed on average it causes up to 31 bed delays, i.e. unavailability. The cost of this is about £400/day, compared with £90/day in a home. So each DToC generates a net loss to the NHS of at least £300×31, i.e. about £9,000. At the time of Hunt’s appointment these Social Care DToCs were averaging 1050/month – a net loss of £9.5 million per month and steady.
    • Care: Patients who are well enough to go back get more ill if they stay in hospital, especially if they are elderly, thus occupying beds for much longer. They also require extra attention from busy nursing staff who are not always used to dealing with the elderly. There is also an increased risk of readmissions.

    The Department of Health details reasons for these delays, 40% of which are generated within Social Care. These are the major reasons, respectively: Awaiting Care Package at Home, Awaiting residential home placement or availability, and Awaiting nursing home placement or availability. As all these delays generate extra bed demands in Acute Care as well as, so to address these immediately would be a win/win, an act of intelligent leadership, especially for an opportunist like Hunt.

    Now, the bad news for Hunt: He has no organisational leadership qualities at all, especially when it comes to doing what is best for the organisation, i.e. the good of the users, the employees and the community. If he had he would have predicted a serious problem emerging in social care, and consequently a rise in the transfer of social care patients into acute care.

    Hunt became Secretary of State for Health in 2012. At that point Care DToCs were running at 1050/month, but trouble was on the horizon. Back in 2011 Nicholson, the CEO, set the NHS and Social Care the challenge of taking out £18 – £20 billion by 2014. Why? It was a classic act of hubris which of, course, the health system paid for. It was to be efficiency savings; but how? The care system was short-staffed, underfunded and, because of the privatisation, in negative productivity. Overworked and underpaid staff, the main source of innovation, were in no position to study ways of improvement. Morale was falling and the staff turnover was 27%.

     

    Hunt should have stopped it, but did not care, or have the nous – or else was confusing fewer staff per user as a sign of efficiency. Either way he should have kept his eye on the statistics. Social Care is a major driver of demand in the NHS. The better the care, the lower the rate of admissions into Acute Care: a very simple equation.

    By 2015 there were ominous signs. The rate of DToCs was beginning to rise in a statistically significant way. The trend was clear. The average was rising to 1250, a 19% increase. Any executive worth their salt would have instituted an instant investigation. Hunt did not. His NHS 10 Point Efficiency Plan mandated the “freeing up about 2000 to 3000 beds by ceasing DTOC delays in social care.” Just like that, like Napoleon instructing his troops to conquer Moscow – winter. There was no strategy, no plan that mapped out the route. Just an edict, and like Napoleon, thing got a lot worse.

    The average for the years 2016 to 2018 rose to 1900 DToCs, 80% greater than in 2012 – so much for “ceasing” DToC delays. It was not a plan but a target, and a silly one. This is worth unpacking. In five years Hunt oversaw an increase of about 900 DToCs from the Care sector alone. This is an increased loss of £8.1 million per month, or close to £100 million a year.

    Just how many staff in Social Care would that have paid for at £25,000 a year? The turnover would have stopped, the facilities enhanced (including private care) and morale and user satisfaction improved.

    These cold statistics disguise the misery of the people involved, nurses, carers, families and, most of all, the users, mainly the elderly. As Neil Kinnock said prophetically of the Tories if they got in:          I warn you not to fall ill, and I warn you not to grow old.”

    In summary, in the first three years of his appointment the total loss due to DToCs was £114 million a year. In 2015 Hunt sat on his hands, no doubt transfixed by Stevens’ unnecessary reorganisation along USA private care lines. Over the next three years the total loss would be £205 million per annum. The damage to the NHS and Social Care is incalculable. And remember we are only looking at 40% of all the DToCs, i.e. half a billion pounds a year. Much of that could have gone into PPE stock replenishment.

    A final irony: In Hunt’s 2016/17 NHS 10 Point Efficiency Plan the target mandated was to “reduce Delayed Days to 4000/day, which translates into 124,000 per month by September 2018”. This equates to 4000 Delayed Transfers of Care per month across the NHS and Social Care – a figure that is actually higher (worse) than they had been achieving regularly in 2010 – 2013! But what makes it even more damning is that it was, statistically, an unachievable demand. The average for 2016/17 was 4560 DToCs and the lower control limit was 4995, which meant that statistically there was less than a 1/1000 chance that it could be achieved. Setting unachievable targets is feature of Hunt’s tenure. Caroline Molloy details these in her withering assessment of Hunt in her article What did Hunt do to the NHS – and how has he got away with it? (Open Democracy, July 13, 2019).

    Matt Hancock now grasps the poisoned chalice Hunt has handed him. Luckily he is an optimist and probably sees it as a great opportunity. One day he may also be rewarded with the Chair of the Health and Social Care Select Committee like Hunt, for the utter failures, especially the disaster of his outsourcing of test and trace to private companies (0ver £10 billion), greatly exacerbating effects of the terrible Covid-19 pandemic in 2020.

    Dr John Carlisle

    Chair, Yorkshire SHA

    Comments Off on Jeremy Hunt, the incompetent ideologue

    The Local Government Association, on behalf the broad leadership of the social care sector including the Association of Directors of Social Services, has published a set of 7 principles to guide the future of adult social care post Covid. But they show the sector’s leadership continuing to be high on rhetoric, but empty on substance. They are bankrupt of ideas to make the rhetoric a reality.

    The 7 principles talk, for the umpteenth time, of social care needing to be based on ‘what works for people, not what works for systems or structures’. They seek to emulate the person centredness that makes the NHS so valued by the public. People trust that when they present symptoms to an NHS clinician the diagnosis and treatment will be based solely on the clinician’s knowledge of what is wrong and what is possible. It would not even occur to the person that the determination of their diagnosis and decisions about the treatment options will be referred upward to a manager, least of all to a manager whose primary task is to manage the budget.

    But, for reasons set out in my recent blog, this is exactly what happens in social care. At the individual level, while need precedes resources in health care, resource precedes need in social care. It’s an arrangement that serves very well the political expedients of keeping spend precisely to budget while denying the existence of any funding gap. The sector’s leadership, sadly and only too willingly, obliges.

    So sector leaders are left yet again repeating mantras with a long record of failure. The history is lamentable.

    Following the failure of the Community Care strategy of the 1990’s to make social care ‘needs led’, the personalisation strategy was launched in 2008 with personal budgets the centre piece. ‘Up-front’ allocations of money would empower service users to purchase their own support package, the ultimate in person centredness. Bu it quickly became apparent that up-front allocations would not happen. Completely impracticable and ignored by the Care Act ‘up-front’ allocations became ‘indicative’ only and thus tokenistic. In 2012, Think Local Act Personal, the organisation charged by Government with leading implementation of the strategy, issued a series on exhortations to practitioners and councils under the banner Making It Real.

    The irony in the implicit message that personal budgets had completely failed to ‘make it real’ was lost on the sector’s leaders. Inevitably, Making It Real had no impact. TLAP duly issued a second iteration of Making It Real in 2018. It too has had no impact. And so to the present and the 7 principles amount to yet a third exhortation to ‘make it real’.

    Exhortations to practitioners and councils to deliver ‘what works for people’ are hopeless in the face of underlying, powerful systemic forces that ensure the system’s priority is to work to sustain itself.

    What of the future for social care – integration with the NHS?

    It’s hard to imagine anyone taking the analysis and remedies of sector leaders seriously. This is not just because of the self harm in exposing the bankruptcy in their own ideas. Covid’s exposure of the impoverishment of social care invites questions of the leadership Councils have provided over the decades. Is it really just about government under-funding? How soon, if not already, before Councils are seen as a busted flush?

    Signs are pointing to integration with the NHS as the political solution. But with social care in its present state, that would be a disaster for both services and the older and disabled people who rely on them. The NHS is at its best delivering clinical care to deliver best possible health. When it moves beyond that into care, its record is even more lamentable than that of local authorities. The bureaucratic opaqueness and gross inequity of Continuing Health Care bears witness to that. A weak and unreformed social care service risks being reduced to little more than a servant to health objectives. This would sound the death knell of the ambition of social care to be the driver of our older and disabled citizens being supported to lead the fulfilling and dignified lives they are capable of.

     

    Colin Slasberg – former Assistant Director of Social Care and Independent Consultant in Social Care.

    Comments Off on THE FAILED LEADERSHIP OF SOCIAL CARE, BANKRUPT OF IDEAS

    This is our twentieth weekly blog the series where we have commented on the course of the pandemic and the political context and implications from its impact on our country. The SHA has submitted our series of blogs to the All Party Parliamentary Group (APPG), Chaired by Layla Moran (LD, Oxford West and Abingdon), who are taking evidence to learn lessons from our handling of COVID-19 in time for the high risk winter ‘flu season’. The Labour MP Clive Lewis is on the group

    This is an edited version of the seven main points we have submitted:

    1. Austerity (2010-2020)

    This pandemic arrived when the public sector – NHS, Social Care, Local Government and the Public Health system had been weakened by disinvestment over 10 years. This was manifest by cuts to the Public Health England budgets, to the Local Authority public health grants and lack of capital and revenue into the NHS. In workforce terms there was staff shortages in Health and Social Care staffing exceeding 100,000.

    1. Emergency Planning but no investment in stocks (Cygnus 2016)

    The publication of the 2016 Operation Cygnus exercise has exposed the lack of follow on investment by the Conservative government which led to problems of PPE supplies, essential equipment such as ventilators and in ITU capacity. The 2016 exercise was a large-scale event with over 900 participants and occurred during Jeremy Hunt’s tenure as Secretary of State. There needed to be better preparation too on issues such as border controls as we note 190,000 people from China travelled through Heathrow between January-March 2020. Pandemics have been at the top of the UK risk register for years and the question is why were preparations not undertaken and stockpiles shown to be insufficient and sometimes time expired.

    1. Poor political leadership (PM and SoS Health)

    During the pandemic there has been a lack of clarity on what the overall strategy is and inconsistency in decision-making. The New Zealand government for example went for elimination, locked down early, controlled their borders and took the public with them successfully. We have had an over centralised approach from the Prime Minister and SoS for Health such as the NHS Test and Trace scheme and creating the Joint Biosecurity Unit. Contact tracing and engaging the Local Directors of Public Health was stopped on the 12th March and only in the past few weeks have their vital role been acknowledged. Ministers have been overpromising such as the digital apps, the antibody tests, the vaccine trials and novel drug treatments. Each time the phrases such as World Beating and Game Changers have been used prematurely. The Ministerial promises on numbers of tests has been shown to have become a target without an accompanying strategy and the statistics open to question from the UKSA.

    1. Social care

    From the early scientific reports from Wuhan it was clear that COVID-19 was particularly dangerous to older people who have a high mortality rate. A public health perspective would raise this risk factor and plan to protect institutions where older people live. Because of the distressing TV footage from Lombardy (Italy) the government’s main aim was to Protect the NHS. This was laudable and indeed the NHS stood up and had no call on the Nightingale Hospitals, which had a huge investment. The negative side of this mantra was that social care was ignored. As we have seen 40% of care homes have had outbreaks and about a third of COVID related mortality is from this sector. There have been serious ethical questions about policies in Care Homes as well as discharge procedures from the NHS that need teasing out. The private social care sector with 5,500 providers and 11,300 homes is in bad need of reform. Some of the financial transactions of the bigger groups such as HC One need investigation, especially the use of off shore investors who charge high interest on their loans. The SHA believes that the time is right to ‘rescue social care’ taking steps such as employing staff and moving towards a National Care Service.

    1. Inequalities

    It was said at the beginning of the pandemic in the UK that the virus did not respect social class as it affected Prince and Pauper. Prince Charles certainly got infected as did the Prime Minister. However we have seen that COVID-19 has exploited the inequalities in our society by differentially killing people who live in our more deprived communities as shown by ONS data. In addition to deprivation we have seen the additional risk in people of BAME background. The combination of deprivation and BAME populations put local authorities such as Newham, Hackney and Brent in London as having been affected badly. The ONS have also shown that BAME has an additional risk to the extent of being double for people of BAME heritage even taking statistical account for deprivation scores. Occupational risk has also been highlighted in the context of BAME status with the NHS having 40% of doctors of BAME heritage who accounted for 90% of NHS medical deaths. The equivalent proportions are 20% NHS nurses and BAME accounting for 75% deaths. The government tried to bury the Fenton Disparities report and we believe that this is further evidence of institutional racism.

    1. Privatisation

    The SHA is strongly committed to a publicly funded and provided NHS and are concerned about the Privatisation that we have witnessed over the last 10 years. We are concerned about the risks in the arrangement with Private Hospitals, the development of the Lighthouse Laboratories running parallel to NHS ones and the use of digital providers. In addition we feel that there needs to be a review of how contracts were given to private providers in the areas of Testing & Tracing, PPE supplies, Vaccine development and the digital applications. There are concerns about fraud and we note that some companies in the recent past have been convicted of fraud, following investigations by the Serious Fraud Office yet still received large contracts during the pandemic.

    1. Recovery Planning

    During the pandemic many of us have noticed the benefit of reduced traffic in terms of noise and air pollution. Different work patterns such as working from home has also had some benefits. The risk of overcrowded and poor housing has been manifest as well as how migrant workers are treated and housed. Green spaces and more active travel has been welcomed and the need for universal access to fast broadband as well as the digital divide between social class families. With the government having run up a £300bn deficit and who continue to mismanage the pandemic we worry about future jobs and economic prosperity. There is an opportunity to build a different society and having a green deal as part of that. The outcome of the APPG review should on the one hand be critical of the political leadership we have endured but also point to a new way forward that has elements of building a fairer society, creating a National Care Service, funding the NHS and Public Health system in the context of the global climate emergency and the opportunities for a green deal.

    Lets hope that the APPG can do a rapid review so we can learn lessons and not have to wait for years. The Grenfell Tower Inquiry remember was launched by Theresa May in June 2017, and we still await its key findings and justice for those whose lives were destroyed by the fire. The Prime Minister has been pointing the fingers of blame on others for our poor performance with COVID-19 but has accepted that mistakes were made and that an inquiry will be held in the future.

    However often these are mechanisms to kick an issue into the long grass (Bloody Sunday Inquiry) and even when completed can be delayed or not published in full such as the inquiry into Russian interference in our democratic processes. So let’s support the APPG inquiry and the Independent SAGE group who provide balance to the discredited way that scientific advice has been presented. As one commentator has pointed out there are similarities to the John Gummer moment when in 1990 he fed his 4yr old daughter a burger on camera during the BSE crisis. The public inquiry into the BSE scandal called for greater transparency in the production and use of scientific advice. During this crisis we have seen confusion whether on herd immunity, timing of lockdown, test and trace, border and travel controls and the use of facemasks.

    NHS and NIHR

    For the SHA we have been pleased with how the NHS has stood up to the challenge and not fallen over despite the huge strain that has been put under. Despite the expenditure on the Nightingale Hospitals and generous contracts with Private Hospitals these have not made a significant difference. These arrangements certainly helped to provide security in case the NHS intensive care facilities became overwhelmed and allowed some elective diagnostics and cancer care to be undertaken in cold hospital sites. However the lesson from this is the superiority of a national health system with mutual aid and a coherent public service approach to the challenge compared to those countries with privatised health care. The social care sector on the other hand, despite some examples of excellence, is a fragmented and broken system. The pandemic has shown the urgent need to ensure staff have adequate training, are paid against nationally agreed terms and conditions and we create an adequately resourced National Care Service as outlined in our policy of ‘Rescuing Social Care.

    Another area where a national approach has paid off is the leadership provided by the National Institute of Health Research (NIHR) which helps to integrate National R&D funding priorities and work alongside the Research Councils (MRC/ESRC) and Charitable Research funding such as from the Wellcome Trust and heart/cancer research funders. These strategic research networks use university researchers and NHS services to enable clinical trials to be undertaken and engage with patients and the public. It is through this mechanism that the UK has been able to contribute disproportionately to our knowledge about treatment for COVID-19 and in developing and testing novel vaccines.

    For example the Recovery trial programme has used these mechanisms to enlist patients across the UK in clinical trials. The dexamethasone (steroid) trial showed a reduction in deaths by a third in severely ill patients and is now used worldwide. On the other hand Donald Trump and Brazil’s Jair Bolsanaro’s hydroxychloroquine has been shown to be ineffective and this evidence will have saved unnecessary treatment and expense across the world.  Such randomised controlled trials are difficult to undertake at scale in fragmented and privatised health systems. The vaccine development and trials have also been built on pre-existing research groups linked to our Universities and Medical Schools. Finally while Hancock’s phone app hit the dust in the Isle of Wight, Professor Tim Spector’s COVID-19 symptom app has managed to enlist 4m users across the country providing useful data about symptoms and incidence of positive tests in real time. This is all from his Kings College London research base reaching out to collaborators in Europe. Ireland has launched the Apple and Google app created with the Irish software company NearForm successfully and it is thought that Northern Ireland is on the way to a similar launch within weeks too!

    A wealth tax?

    In earlier blogs we have drawn attention to the huge debt that the government have run up and we are already seeing the emerging economic damage to the economy and people’s livelihoods when the furloughing scheme is withdrawn in October. Already people are talking about up to 4m unemployed this winter and what this will mean in terms of the economy and funding public services like local government, education and health. The UK’s public finances are on an ‘unsustainable path’ says the Office for Budget Responsibility.

    There is a lot of chatter about the value of a wealth tax and there are some variations to the theme. It is estimated that there is £5.1 trillion of wealth linked to home equity. It is also said that the unearned gains on property are a better target for new taxes than workers earned income. Following this through a think tank has proposed – a property tax paid when a property is sold or an estate if the owner has died. A calculation could be made by taxing at 10% on the difference between the price paid for the property and the price at which it was sold. The % tax could be progressive and increase when the sum exceeds £1m for example. Assuming property rise in value by only 1% per annum this tax would raise £421bn over 25 years. If this sounds like an inheritance tax – that is true but for years now such taxes have become a voluntary tax for those with access to offshore funds and savvy accountants. In the USA, inheritances account for about 40% of household wealth. Fewer than 2 in 1000 estates paid the Federal estate tax even before Trump cut it in 2018. Trusts and other tax havens abound. Apparently Trump’s own Treasury Secretary has placed assets worth $32.9m into his ‘Dynasty Trust 1’

    Inherited wealth has been referred to in earlier blogs in relation to the Duke of Westminster family wealth. Another study which shows how this type of wealth transfer passes down the generations comes from Italy where in 2011 a study of high earners found many of the same families appeared as in the Florence of 1427!

    Populism and COVID

    In our blogs we have pointed to the fact that those countries, in different continents, which have had a bad pandemic experience are ones such as the UK, USA, Brazil, India and Russia. What unites them is a leadership of right wing populists. A recent study has started to analyse why this occurs and what the shared characteristics are:

    1. The leaders blame others – the Chinese virus/immigrants
    2. Deny scientific evidence – use ineffective drugs/resist face masks
    3. Denigrate organisations that promote evidence – CDC/PHE/WHO
    4. Claim to stand for the common people against an out of touch elite.

    What the authors found was that these leaders were successfully undermining an effective response to the pandemic. Sadly there is a risk that populist leaders perversely benefit from suffering and ill health.

    Taking lessons from history and the contemporary global situation we need to continue to speak out against these political forces and advocate for a better fairer recovery.

    27.7.2020

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

    Comments Off on SHA COVID-19 Blog 20

    At a time of heightened public interest in the future of social care, what would be the way forward guided by the principle of social justice? Some of it is in plain view and takes the form of immediate funding shortfalls. The only issue is the political will to find the money. Important as these issues are, their resolution will do nothing to redress what many believe is the most painful injustice of all. The system used to identify ‘need’ and allocate resources – based on the eligibility ‘needs test’ –  is not only inherently inequitable but works in a way that deprives the individual of the control over their lives essential to us all for our dignity, self worth and wellbeing. The system built around the needs test is obscure to the public and has no public appeal. It need be no surprise that social care cannot muster the political will to address the more obvious funding shortfalls.

    For a truly socially just system the ‘needs test’ must be abolished and replaced with a system that manages the tension between needs and resources very differently. This will not require more money. But it will require political will and the intellectual effort for new thinking.

    The immediate funding issues

    Before considering the needs test, it may be worth reflecting on the immediate funding issues.

    The issue presently uppermost in the public mind is the undervaluing of care staff. With something like 1 million care staff, every pound an hour they are paid will cost about £1.8BN

    Not far behind that in the public mind, and with a political head of steam developing to do something about it, is the means test. It results in the unfairness of the ‘dementia tax’, of people having to sell their houses to pay for care, and of as many people funding their own care or going without as receive state support.

    There are two proposals to reform the means test. One is the idea of the ‘care cap’ – a lifetime limit to how much an individual would have to pay in charges. Introduced by the Dilnot Commission in 2011, it is estimated this would cost in the region of £3BN. The other is to make all ‘personal care’ free as in Scotland. The House of Lords Economic Affairs Committee favours this and costed it at £7BN last year.

    A third would be to simply abolish the means test altogether (or charge only the ‘hotel costs’ of a residential care placement which was the very limited intention when the means test was introduced by the Attlee Government in 1948). The cost would likely to be somewhere nearer to £15BN.

    There would be some good news for the Treasury from a system driven by social justice. It would surely bring an end to public companies raking in excess profits. Research by the Centre of Public Health Information established that some £1.5BN is leaked out of the residential care market in this way. That amounts to some 10% of the value of the residential care sector.

    The gross spend on social care is currently £20BN. Addressing the means test and paying a fair price for care to ensure care workers are properly remunerated could potentially double that. But doing all of this would be leave the fundamental nature and character of the service unchanged.

    The eligibility needs test

    A founding principle of the NHS was that need will precede resource and that the resource would be publicly funded.  This has arguably been the principle that, whatever its faults, has made the NHS an enduring beacon of social justice.

    However, when it came to the care of older and disabled people this principle was reversed. The priority of the Attlee government was to end the grave injustice of the institutionalisation of older and disabled people in workhouses. Poor Law Boards would be abolished and responsibility transferred to Local Authorities. But when asked in Parliament what Local Authorities would actually do, the Minister for Health replied ‘as much as our resources will allow’.

    Surely unintended, this had two devastating consequences. It implicitly put care of older and disabled people at the back of the queue for public resources, leading it to its Cinderella status. Secondly, it reversed the polarity of needs and resources. Instead of need determining resource, resource would determine need.

    The modern manifestation of the principle is the concept of ‘eligibility criteria’. The justifying theory is that there is a body of ‘needs’ for care and support that can be applied to any and all. Application by all councils of the same ‘eligibility criteria’ will ensure fairness and equity. It’s a theory that has superficial appeal. It is unchallenged. All councils claim to be delivering the National Eligibility Criteria (currently established under the Care Act of 2014).

    It is, however, a myth without mitigation. In a system where need must be determined by resource, it’s the local resources that must be the driver. The ‘eligibility’ decision must be localised to local budgets. National criteria are irrelevant.  They are, indeed, written in a way that makes the key decisions meaningless. This is necessary for local discretion.

    Not only is this localism logically the case, the empirical evidence leaves little room for doubt. Councils report annually on how many people they support and the amount they spend in doing so. Dividing one by the other – which government reports do not do – gives the average spend per person. Once adjusted for regional price differences, this surely gives the best measure of equity. The highest spending councils in 2018/19 spent an average of £22.7K and the lowest £12.9K – an astonishing 70% difference.

    This is no random unevenness that can be explained away as the uniqueness of communities served. There is a clear pattern. Deprivation of communities served is the key factor. The means test results in the most affluent communities serving 50% fewer people per head of population than councils serving the most deprived communities. Councils spending the most can spread the jam much more thickly. The highest spending councils serve communities significantly more affluent than the lowest.

    So to the inequity is added injustice.

    The damage does not end there. The eligibility process works by standardising ‘need’. Standardisation cannot be made to fit with the highly individual nature of the lived experience of need. Needs arise from the complex interplay of a host of factors each of which are themselves highly variable. It has become a modern cliché that each person is ‘expert in their own needs’. The cliché is reduced to lip service when delivered in a system which allows the person to express only ‘wishes’ while the council determines their ‘needs’. It’s infantilising. It is inaccurate as a way to identify need and therefore inefficient.

    Failure in delivery of the principle must not be allowed to dim the importance of the principle that individuals are indeed the best experts in their own needs. Their view of their needs should prevail subject only to their view making best use of resources to enable them to have their best level of wellbeing.

    There will be a dividend for the Treasury.  The greater accuracy of the assessment will mean much greater for value for money from the resource made available. The sector itself believes, although wrongly ascribing blame on poor social work practice, that the current eligibility driven system wastes significant levels of resource through poor use of resources.

    Why does the eligibility needs test persist?

    The needs test has survived since 1948 and defeated countless attempts at transformative change of social care. These include the Community Care reforms of the 1990’s and the more recent personalisation strategy.

    Why is it so enduring? Again, the answer is plain. It serves two political expedients. Firstly it keeps spending to budget, no matter the real need. Secondly, it ensures there is never any record of unmet need. This is important because, in contrast to the NHS where growing waiting lists in the NHS creates political pressure, there is no equivalent in social care. Sir Chris Wormald, Permanent Secretary to the Department of Health and Social Care told the Public Accounts Committee, who wanted to know how much funding social care needed, told them that councils had all the money they required to meet their responsibilities under the Care Act. What he didn’t say was that would be true no matter the size of the budget or the level of real need.

    What will it take to abolish the needs test?

    One obvious answer is to guarantee funding will meet all needs to ensure all have the quality of life they can reasonably expect. But the uniqueness of individual needs and the huge variability in the cost of meeting them would mean social care could have to be delivered on an ‘open cheque’ basis. No public service, not even the highly valued NHS, enjoys that. Credibility demands that strategies assume social care will continue to be delivered within a budget not likely to meet all needs. Success is to be measured by the smallness of the gap between needs and resources.

    Can the needs test be abolished in a budgeted system?

    The answer is an unequivocal ‘yes’. ‘Need’ must be identified in the context of securing the quality of life reasonable for each older and disabled person to expect through. The resources must make the best use of resources but without regard to what happens to be available. The United Nations definition of Independent Living provides a ready made standard of wellbeing to adopt. This would put the UK in the forefront internationally. From that point, decisions must be made as to how many each of those needs the council can afford to meet. Spending will be controlled to budget. However, it no longer be through eligibility of need but by affordability of need.

    The law, through the Care Act, has already made this possible. It provides for ‘need’ to be assessed against 9 dimensions of wellbeing. These dimensions are synonymous with Independent Living. The Act also creates the legal conditions to enable councils to say if they can or cannot afford to meet need. None of these provisions are currently being used. They are being ignored by councils as, under the influence of the Government’s Statutory Guidance to the Act, they are perpetuating a localised eligibility process.

    In February the Labour opposition in Barnet put forward a 4 point plan to replace eligibility of need with affordability of need as the means to control spending. This was to ensure the assessment process was able always to put the person and their welllbeing at the heart of their assessment process and to ensure the Council would be aware of any gap in funding between needs and resources. The Conservative administration rejected the proposal. They believed the Council was already delivering the Care Act and its wellbeing principle, that resources never interfere with the assessment of need, and that choice always determines what people received. The Labour group is currently testing the veracity of those claims.

    Will the needs test be abolished?

    The key issue is political will. The gap between needs and resources will be publicly exposed. What waiting times do for the NHS in creating political pressure, unmet need will do for social care. Political leaders will have to leave behind the comfort the eligibility system has provided them. The greater the funding gap given authenticity through deriving from the aggregated lived experience of need, the greater the political discomfort. But it can be expected the public narrative will shift from what ‘social care’ requires to what older and disabled people require. Few people understand or care about the former, but many are likely to about the latter. Currently councils are seen as visionless machines, employing what Tracey Lazard of Inclusion London (a network of disabled peoples’ organisations) describes as ‘dark arts’ to ensure the system’s delivery under cover of misleading public messages. Councils will be on the side of the older and disabled people they serve, free to promote public understanding of the real needs within their communities.

    Insofar as public sentiment drives political will, social care will stand a much improved chance of securing the funding it truly requires.

    Conclusion

    The needs test, and all its attendant ills, is the unintended legacy of what was otherwise a great reforming Labour government. Although understandable in the context of the 1940’s, rectification is long overdue. There is a clear moral argument that it falls to Labour to ensure it happens.

    2 Comments

    In this week’s blog we will look again at the emerging Blame Game which is attempting to divert attention away from the PM and Health Secretary, raise again the unbelievable issue of the national Test and Trace scheme not sharing information on test results with local Directors of Public Health, salute the letter to the National Audit Office about PPE procurement and applaud the Vaccine Research group at Imperial College for creating a Social Enterprise company committed to sharing the vaccine globally.

    Blame Game

    The Prime Minister’s innate self-interest is exercising his mind at present and with the support of his political adviser Dominic Cummings is casting around to identify who he can blame for the very poor outcome of the pandemic in the UK, particularly in England. Commentators have pointed out that if a man/woman from Mars dropped in they would struggle to work out whether Cummings or Johnson was the Prime Minister (PM). Dom will do whatever it takes to insulate the PM from criticism says a senior civil servant.

    Local Authorities and their Public Health teams

    Once the PM and Secretary of State, Hancock realised that the COVID-19 first wave ‘sombrero’ had not been flattened, we have not eliminated the virus and the population are likely to continue to suffer from local upsurges of COVID-19 cases. They want to shift the blame onto others. The Local Authority based public health teams had been left out of the loop from the start of the pandemic and their role has been as a local megaphone for central guidance or to help out regional Public Health England with local outbreaks.

    The Department of Health started to get involved in Local Outbreaks and twiddled their thumbs when they noticed increasing positive test results in Leicester. Rather than share the data and engage local leaders they wondered what actions they could take from their Whitehall village and became alarmed and made an emergency announcement in the evening to Parliament declaring a local lockdown. At the same time they passed the buck to the surprise of the local Director of Public Health (DPH) and Local Authority leaders.

    With more test result data ‘passed down’ to the local team things have started to settle and local tracing and community engagement has blossomed. The local DPH and Mayor of Leicester have stood up and accepted the challenge and are dealing with it with the support of Public Health England and local communities.

    Local data

    The whole pandemic response has been top down and now that has been shown to be ineffective and expensive they are shifting the responsibility onto local teams, who welcome the recognition that they should always have been the place for an effective population response. However there remain issues to do with sharing fully and quickly all the necessary information for local teams to plan their prevention campaigns specific to the at risk populations. The national test and trace scheme has been shown to be very expensive and has poor outcomes in terms of speed of test results and their contact tracing efforts. Despite that there seems to be reluctance still in proper sharing of test result details on the basis of information security, which the government in England have failed to comply with.

    Public Health specialists have worked with person identifiable data for decades and the system is compliant with data security. Just get on with it and don’t put the spotlight onto Leicester, Kirklees, Blackburn and Pendle without sharing the data that is available from the testing sites.

    It is estimated that in June a quarter of the 31,000 people who had their case transferred to the Test and Trace scheme were not reached. Almost a third of those who were did not provide any contacts. Compare this to the success rate of local so called Pillar 1 NHS hospital testing system where nearly 100% contacts are traced.  It is time that the Test and Trace budget be devolved and that local DsPH manage the testing arrangements they require and ensure that the most useful information is obtained when samples are taken and ensure that the local public health department gets the results as well as the GPs who need to be drawn into the campaign. In Wales and other devolved nations much better systems are in place.

    Remember the hype about the Isle of Wight phone app? Lord Bethell, the Health Minister responsible for the Google and Apple technology, is now quoted as saying: “We are seeking to get something going for the winter, but it isn’t a priority for us at the moment”.

    If this wasn’t enough the government have had to recall thousands of Randox test kits as a health and safety risk. These were contracted by the Baroness Harding Deloitte’s Test and Trace outfit and used in Care Homes and for home testing. Another embarrassment to add to all the rest!

    Why didn’t they invest in local NHS laboratories linked to local GPs and Public Health teams, who would have got the results back quickly with the information required for effective locally based contact tracing? Centralisation and Privatisation have not worked and have cost the taxpayer billions.

    Workers and Employers

    The Chancellor has been enjoying himself when announcing hand-outs of government resources (in Tory language tax-payers money). Public sector borrowing stands at its highest peacetime level in 300 years. Four million people could be unemployed by next year which according to the Office of Budget Responsibility will be the worst jobs crisis in a generation. The furlough scheme, which is helping pay wages for 9.4m people will end in October. The annual deficit is set to rise to £350bn and economic contraction of 25% in the last 2 months. So it is not surprising that the PM wants to get the economy going again. However his call to open up the offices again and get people spending money in town centre shops by 1st August carries with it huge risk to public health and a burden on employers to make the workplace COVID secure.

    John Phillips of the GMB union has stated: “The PM has once again shown a failure of leadership in the face of this pandemic. Passing the responsibility of keeping people safe to employers and local authorities is confusing and dangerous.” Frances O’Grady of the TUC said that: “The return to work needs to be handled in a phased and safe way. The government is passing the buck on this big decision to employers. Getting back to work safely requires a functioning test and trace system and the government is refusing to support workers who have to self isolate by raising statutory sick pay from £95 per week to a rate people can live on.”

    Civil servants

    The third group of people who have a finger pointing at them are civil servants. The sacking of Mark Sedwill, head of the civil service, is one top of the tree example. His generous departure settlement is the same amount as he would have been entitled to if he had been made compulsorily redundant. In his letter to Mr Sedwill the PM stated that Sedwill was ‘instrumental in drawing up the country’s plan to deal with coronavirus’.

    The PM has reluctantly agreed to have an inquiry into the handling of the pandemic but has lobbed the date into the long grass. He said that: “There are plenty of things that people will say that we got wrong and we owe that discussion and that honesty to the tens of thousands who have died before their time”. We all know that when the blame is distributed it will be civil servants, scientists, public health officials, and some Ministers who will be scapegoated for the outcome that has seen more than 45,000 deaths and left the British economy facing the biggest recession of any European nation. In addition the recent Academy of Medical Sciences report estimates that the risk of a second wave mid winter is of the order of 120,000 excess deaths.

    National Audit Office

    In earlier Blogs we have drawn attention to the potentially fraudulent way that millions of pound contracts have been awarded, sometimes to shell companies or companies that have no history of having undertaken such roles such as PPE suppliers. We are delighted that Rachel Reeves MP and Justin Madders MP of the Labour Shadow team have written to the National Audit Office (NAO) requesting investigation into waste and fraud with especial focus on the PPE procurement, which amounts to £1.5bn. The letter draws attention to many concerns such as awarding the contract to Deloitte without competition. In emergencies governments are entitled to use something called a ‘single bidder emergency procurement process’ to avoid delays that arise with competitive tendering.

    It won’t surprise SHA members to learn that this, EU based measure, has been used by the UK government more than 60 times during the pandemic compared to twice in Spain, 11 times by Italy and 17 times by Germany. The sloppy allocation of contracts to best buddies in the commercial world and Tory Party supporters must be called out and lets hope that the NAO accepts the request and does a speedy audit on some of these contracts.

    Vaccines and global health

    We have already, in previous blogs, pointed out how Trump’s ‘Make America Great Again’ and ‘America First’ is illustrated in examples such as Remdesivir. This antiviral drug, which shortens hospital stays in patients with COVID, was basically bought up by the USA. It was reported at the end of June that the US had bought up virtually all stocks for the next three months leaving none for the UK, Europe or most of the rest of the world. The Trump administration has shown that it is prepared to outbid and outmanoeuvre all other countries to secure the medical supplies it needs. This has implications for the vaccines being actively developed across the world.

    Geopolitics is already at work with reports of Russian cyber crime attacks on the UK based vaccine researchers in Oxford. It was therefore great news to hear that the Imperial College based researchers with Philanthropic and UK government funding have formed a social enterprise. This not for profit arrangement aims to ensure fair distribution by waiving royalties for low income countries so that the poorest get it for free and the richest pay a bit more. Human trials of their vaccine start in October and Imperial are looking for volunteers.

    This group are a reminder that it doesn’t need to be profiteering and greed and stands alongside others who have come through the pandemic with gold stars such as Tim Spector’s C-19 symptoms app group in Kings College London who are using an app that actually works!

    Gramsci

    Finally Michael Gove caused a stir when he recently quoted from Antonio Gramsci, the Italian Marxist intellectual:

    The crisis consists precisely in the fact that the old is dying and the new cannot be born; in this interregnum a great variety of morbid symptoms appear”.

    This quote is from Prison Notebooks, written by Gramsci during his imprisonment in the time of Mussolini. You could look at this quotation in a completely different perspective to those like Michael Gove and Mr Cummings.

    20.7.2020

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

    Comments Off on SHA COVID-19 Blog 19

    Week 18

    In this week’s blog we urge the government to stop dithering and clarify the guidance on face masks; to get on with sharing all test results with local Directors of Public Health; and to stop shifting the blame for our world-beating COVID death rate onto Public Health England (PHE) and the NHS.

    Facemasks

    The important point to note with facemasks, which gets lost in translation, is that face coverings help prevent the wearer from transmitting the virus to others. Remember in the COVID-19 pandemic we have learnt that people without symptoms can pass on the virus to others – by coughing, sneezing, shouting, singing or even talking loudly.  As the prestigious Royal Society report puts it: “My facemask protects you, your facemask protects me”

    The value of the public’s wearing facemasks has been slow to gain scientific support from the World Health Organisation (WHO) as well as within wealthy Western Countries such as the UK and USA. The WHO have, however, changed their tune now and recommend the use of non-medical masks for the public when out and about and where maintaining social distance is difficult. The advice is clear that medical masks are for health care workers as they reduce the risk of the health care worker getting the virus from their patients. It also prevents a healthcare worker who has the virus but doesn’t have symptoms from transmitting the virus.

    For the public there are two groups of people who should wear medical quality masks according to the WHO – people over the age of 60yrs and those with underlying conditions such as diabetes. The point here is that high quality fluid resistant facemasks help protect the wearer from the virus when treating patients and similarly protects older people at risk and those younger people at higher risk due to underlying conditions. This becomes even more important as vulnerable people and those in the shielded groups emerge from their lockdown.

    The rest of the population are advised to wear non medical face coverings that can be homemade and made of cloth. There are plenty of websites (including UK government ones) showing how to make them from old socks, tee shirts, tea towels, coffee strainers and the like. The benefit of this advice is that while there is a worldwide shortage of medical grade masks the use of cloth face coverings does not risk depleting supplies for health care staff.

    Remember: My facemask protects you: Your facemask protects me!

    Mutual benefit is something that socialists have little difficulty understanding and accepting but it does require a high uptake, which is where political leadership comes in. We saw the UK Prime Minister wearing a blue Tory facemask on the 10th July alongside a hint that he is considering making it a requirement to wear them in shops. This has of course already been introduced in Scotland, which is having a comparatively successful campaign to stop the spread of COVID-19 and going for elimination of the virus like New Zealand. Sunday’s BBC News reported that the US President had finally agreed to wear a face mask because someone told him he looked like the Lone Ranger!

    In the middle of June it was made a requirement in England to wear a face covering, if travelling on public transport such as buses and trains, where maintaining a 2m distance was impossible. So the government typically is inching its way towards making a decision – a slow adopter, in the terminology of the Economics of Innovation.

    The UK is starting from a low base with estimates of 25% of the public wearing masks in public places but so too were other countries in Europe like Italy and Spain who now report adherence of up to 80% which is moving them towards the levels achieved in countries which have been successful in containing COVID-19 in East Asia. What it needs is political leadership: for example, politicians like the Chancellor should be wearing a face covering when serving food in Wagamama.

    We know that failed leaders like Trump find it counter to his macho self image to wear a sissy mask but meanwhile thousands of his citizens are going down with the virus. Our PM, who shares many of the Trump traits, has also been slow to show leadership, and he missed the opportunity when they changed the social distancing recommendation from 2m to 1m+. That was the opportunity to require that people going into shops and other enclosed public spaces must wear a face covering.

    As far as the underlying science is concerned there have been research groups in Oxford who have reviewed the literature and state that ‘the evidence is clear that people should wear masks to reduce viral transmission and protect themselves’. On the light blue side of the debate a Cambridge group of disease-modellers have stated that population-wide use of facemasks helps reduce the R rate (the number of people that one infected person can pass the virus on to) to less than 1 and prevents further waves when combined with lockdown. This benefit remained even when wearers ignored best advice, contaminating themselves by touching their faces and adjusting their masks! In answer to critics these researchers have pointed out that there have been no clinical trials of the advice to cough into your elbow, to social distance or to quarantine.

    It comes down to political leadership and we note that Nicola Sturgeon has made the move, successful countries in Europe have too, and London Mayor Sadiq Khan has called on the Government to get on with it. Surely we have learnt enough about COVID-19 being spread before symptoms arise – by the so call silent spreaders?

    Sharing Test Results

    In previous Blogs we have talked about the hugely expensive and unsatisfactory ‘NHS” test and trace initiative. Imagine a Director of Public Health (DPH) within a local patch who has colleagues in Public Health and the local NHS/PH laboratories. Under normal circumstances they have a strong professional relationship and get test results emailed back very fast from the Laboratory with information that is useful for contact tracing – name and address, GP, date of birth and the history leading up to the test being taken. They can act quickly and ensure good liaison with Public Health experts and the local NHS. Logically the government should in England, like they have in Wales, have invested in a greater capacity of local testing. The so-called Pillar 1 tests have been this sort, and results have been supplied to local Directors of Public Health (DsPH) in a timely way.

    Enter stage left Matt Hancock and his buddies. Establish something completely new – the so called NHS Test and Trace initiative– at a great cost and run by an accountancy firm Deloitte and a private contract company SERCO neither with any prior experience. They establish some Lighthouse Laboratories with Big Pharma,  who may be geographically close to the local NHS labs but are contracted privately as a parallel service. They establish contracts with Amazon/Royal Mail/the British Army and others to take the swabs and transport them. Result – a mess where huge numbers of tests are lost, the results delayed and poor quality information is belatedly supplied to bemused DsPH . That is what we have seen in Kirklees, Leicester and now some other districts which have not had the benefit of the so called Pillar 2 tests done by Test and Trace.

    The latest data published by the government shows that there are more than a million tests that were ‘sent out’ but not completed. This all helped Matt Hancock show at the Downing Street press conferences that he had the testing capacity and had posted the swabs out! No wonder that the UK Statistical Authority have been concerned about how the information on testing has been presented!

    One of the excuses offered by the government has been about personal data being shared with DsPH. They forget that this is a PUBLIC HEALTH EMERGENCY and that COVID-19 is a notifiable disease and there is a statutory duty to report on cases.  Again we see dither and delay……

    June 24th PHE starts to share postcode, age and ethnicity with DsPH.

    July 3rd NHS Digital releases Pillar 1 and 2 results.

    July 6th Positive test results reported at below Local Authority level

    July 15th Postcode level dashboard to be supplied including contact tracing at LA level.

    July 16th Test results at smaller population areas (down to a 6000 households level)

    The message here is that the data from NHS Test and Trace is being very slowly shared with local DsPH and their teams who have been charged with managing local outbreaks like the one in Leicester. The key issue is – why did the Government encourage the design of the system from the top down rather than bottom up?

    Don’t blame PHE and the NHS.

    The PM and Matt Hancock have become a bit nervous about the ‘blame game’ as the demand for an urgent and time limited inquiry increases. Their performance has been poor compared to others within the UK like Scotland and across the Irish Sea and the English Channel. So who can they point the finger at?

    The Daily Telegraph is of course the PM’s previous employer and vehicle for his thoughts. It was in this newspaper on the 30th June that we first heard about Public Health England shouldering the blame.  The newspaper headline was ‘Heat on PHE as the Prime Minister admits Coronavirus response was sluggish’.

    The performance of PHE has not been faultless but we know why they were not able to scale up their testing capability when they had the opportunity. During the pandemic they have provided expert public health guidance to the system and supported local Health Protection teams but those teams have been “slimmed down” to anorexic levels during the austerity years, along with Local Authority departments.

    Public Health England was created in 2013 when it replaced the Health Protection Agency. It is an executive agency accountable to Ministers and the Department of Health and Social Care. It has many specialist research laboratories vital to national security – as used when Novichok was used in the attempted assassination of Sergei and Yulia Skripal in Salisbury in 2018. Remember the local DPH leading the local response, and then being supported by Porton Down and Public Health England?

    Public Health England employs 5500 staff with a budget of £287m per annum.

    The infectious diseases element of PHE has a budget of £90m per annum so it surprised everyone to learn that the Government has set aside £10 billion for spending on the NHS Test and Trace system. This money will be going to private firms such as SECO and G4S and dwarfs the entire PHE budget 110 fold because it is paying not just the cost – as it would if it were being done in the public sector – but the cost plus the high profits they demand!

    Remember too that on July10th G4S settled its Serious Fraud Office (SFO) case in which it was accused of overcharging the Ministry of Justice for electronic tagging of offenders. The Serious Fraud Office said that G4S had accepted responsibility for three counts of fraud that were carried out in an effort to ‘dishonestly mislead’ the government, in order to boost its profits.

    As the Guardian reports on the G4S case :“The £44.4m in fines and costs takes the total paid out by outsourcing firms involved in the prisoner tagging scandal to more than £250m. SERCO reached its own £22.9m agreement with the SFO last year, six years after repaying £68m to the Ministry of Justice”.

    So what is our government doing? It is pointing the finger of blame at PHE, which is an executive agency accountable to Ministers, and handing out generous contracts to G4S and SERCO who only recently have been found guilty of fraud.

    The one success in the pandemic has been the way that the NHS coped with the surge of cases – yes: hard to believe, but the PM is also pointing his finger at the NHS, too, and is threatening another round of Tory disorganisation.

    Clap Clap.

    13.7.2020

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

    2 Comments

    In this week’s Blog we will have a look at the lessons learnt so far with the first City lockdown in Leicester and see what this tells us about the UK Government’s handling of the COVID-19 pandemic, raise issues again about their competence, outline why the social determinants of heath matter and assess the risks involved in privatisation of the NHS testing centres and public health functions.

    Local lockdown

    Leicester has been directed by central government (Hancock in the House of Commons on the 30th June) to remain in lockdown this weekend when other parts of England were being urged by the Prime Minister to be brave, to bustle in the High Streets to help ramp up an economy which is waiting to be turbo charged. The government announced in Westminster on June 18th that there was a local outbreak causing concern in Leicester. This news broadcast in the media saw the local Mayor of Leicester and their local Director of Public Health (DPH) in a bemused state. They had been left in the dark because the central government and their privatised drive through/hometesting  service led by Deloittes/SERCO had not shared the so called Pillar 2 data with them. They did not receive Pillar 2 test data for the next 10 days!

    Outbreak plans

    Local Directors of Public Health (DsPH) across England had been required by central government a month earlier to produce Local Outbreak Control Plans by the 30th June. According to the PM they were meant to be in the lead to ‘Whack the Moles’ in his typically colourful and inappropriate language. Whacking moles apparently means manage local outbreaks of COVID-19. Anybody who has actually tried to Whack a Mole on their lawn or at a seaside arcade will know that this is almost impossible and usually the mole hole appears again nearby the following day.

    Local DsPH have been receiving from Public Health England (PHE) regular daily data about local NHS hospital laboratory testing from the Pillar 1 sources. In Leicester this was no cause for concern as there had been a decline since the peak in positive cases in April.  That explains why the Mayor and DPH were bemused. Each week there are now summary bundles of data incorporating both sources sent by PHE but not in a way that local teams can analyse for information of interest such as workplace/occupation/household information. Belatedly, postcode data is now shared which had been hidden before! One of the first requirements in outbreak management is to collect information about possible and confirmed cases with an infection in time, place and person. This information needs to include demographic information such as age and gender, address, GP practice and other data pertinent to the outbreak such as place of work/occupation and travel history. Lack of workplace data has made identifying meat packing plants in outbreaks such as near Kirklees more difficult and another example where the local DPH and the Local Authority were wrong footed by the Minister.

    Public Health England review

    On the 29th June PHE published a review  ‘COVID-19: exceedances in Leicester’. This excellent review showed that the cumulative number of tests in Leicester from Pillar 1 was 1028 tests whereas the number of Pillar 2 was 2188 which is twice as many! The rate per 10,000 people in the Pillar 1 samples was a relatively low rate of 29 while Pillar 2 showed a rate of 62/10,000. The combined positive rate of 90/10,000 is more than twice the rate in the East Midlands and England as a whole. It was on the basis of this Pillar 2 data that the government became alarmed.

    It is just incredible that the government have contracted Deloittes/SERCO to undertake something that they had no prior experience in and to allow a situation to develop when the test results from home testing and drive through centres was not being shared with those charged with controlling local outbreaks.

    The political incompetence was manifest to an extraordinary level when Nadine Dorries, Minister for Mental Health, confirmed to a Parliamentary enquiry that “the contract with Deloittes does not require the company to report positive cases to Public Health England and Local Authorities’.

    It seems as if the point of counting numbers of tests undertaken each day was to simply verify that home tests had been posted and swabs had been taken in the drive-through sites so that Matt Hancock could boast at the Downing Street briefings that the number of tests was increasing.. But we are trying to control COVID-19 and Save Lives. Sharing test results with those charged with controlling local outbreaks must be a fundamental requirement.

    Deprivation and health

    In earlier BLOGs we have highlighted that COVID-19 has disproportionately affected those who live in more deprived areasand additionally has impacted even more on BAME people. Studies have shown that relative poverty, poor and cramped housing, multigenerational households and homes with multi-occupants are all at higher risk of getting the infection and being severely ill. Other factors have been occupation – people on zero hours contracts, low pay and in jobs where you are unable to work from home and indeed need to travel to work on public transport. Many of these essential but low paid jobs are public- or client-facing which confers a higher risk of acquiring the infection.

    All these factors seem to be in play in Leicester. The wards with the highest number of cases have a high % of BAME residents (70% in some wards). One local cultural group are Gujeratis with English as a second language. Another factor that is emerging is the small-scale garment producing factories. It is estimated that up to 80% of the city’s garment output goes to internet suppliers such as Boohoo.

    The garment industry

    Two years ago a Financial Times reporter, Sarah O’Connor, investigated Leicester’s clothing industry. She described a bizarre micro-economy where £4-£4.50 an hour was the going rate for sewing machinists and £3 an hour for packers. These tiny sweatshops are crammed into crumbling old buildings and undercut the legally compliant factories using more expensive machines and paying fairer wages. As she points out (Financial Times 5th July) this Victorian sector is embedded into the 21st century economy and the workforce is largely un-unionised. The big buyers are the online ‘fast fashion’ retailers, which have thrived thanks to the speed and adaptability of their UK suppliers.  Boohoo sources 40% of its clothing in the UK and has prospered during lockdown by switching to leisurewear for the housebound while rivals have shipments left in containers.

    Mahmud Kamani with Kane founded Boohoo in 2006 and it has made him a billionaire. It is said that other competitors such as Missguided and Asos have been put off by concerns about some of Leicester’s factories – including claims over conditions of modern slavery, illegally low wages, VAT fraud and inadequate safety measures. A researcher went into the garment factories earlier this year and is quoted as saying

    I’ve been inside garment factories in Bangladesh, China and Sri Lanka and I can honestly say that what I saw in the middle of the UK was worse than anything I’ve witnessed overseas’.

    Occupational risks, overcrowded housing and poverty have been shown to be risks to contract the virus and become severely ill with it. BAME communities have additional risks over and above these as we have discussed before in relation to the Fenton Disparities report, which was blocked by Ministers who were not keen on the findings of racism in our society and institutions.

    Health and Safety

    In Leicester the Health and Safety Executive has contacted 17 textile businesses, is actively investigating three and taking legal enforcement action against one. In business terms the UK’s low paid sector are an estimated 30% less productive on average than the same sectors in Europe. As unemployment rises in the months ahead it will be vital to focus on jobs as the Labour leadership have stated. However quality should be paramount and the government apparently wants ‘to close the yawning gap between the best and the rest’.

    The Prime Minister has recently promised ‘a government that is powerful and determined and that puts its arms around people’. These arms did not do much for care homes during the first wave of COVID-19 and looking to the future of jobs and economic development the fate of Leicester’s clothing workers will be another test of whether he and his government meant it.

    Incompetent government.

    The pandemic has exposed the UK but particularly people in England to staggering levels of government incompetence. There are other countries too that have this burden and Trump in the USA and Bolsonaro in Brazil spring to mind. They seem confident that the virus won’t hit their citizens and it certainly won’t hit the chosen ones.

    Psychologists say that people like this appear confident because as leaders they know nothing about the complexity of governing. They refer to this as the Dunning-Kruger effect:

    incompetent people don’t realise their incompetence’.

    5.7.2020

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

    1 Comment