Blog

  • Categories
  • Category Archives: Public Health

     

    The late 1980s and the early 1990s was a time when the HIV and AIDS pandemic was in the news and high on the political agenda.

    Professor Virginia Berridge, Director of the Centre for History in Public Health and author of AIDS in the UK, gives us this accurate and succinct historical context:

    An expert advisory group on AIDS (EAGA) had been set up in 1985 in the Department of Health with input from clinicians and scientists involved. The Chief Medical Officer, the main public health government official, Sir Donald Acheson, led the group. Despite the level of expertise, the committee faced many problems. They included the attitude of sections of the press, which called for a punitive response to HIV/AIDS. An initial lack of political interest and the danger that, if political interest were awakened, the Conservative government led by Prime Minister Margaret Thatcher might take a punitive stance. Issues such as segregation and quarantine were freely talked about.

    In 1986, a sense of national emergency materialised, and developed high-level political interest on the subject. A Cabinet committee on AIDS was set up, a major health education campaign was initiated, funds were released for research, and the main health education body, the Health Education Council, was reformed as the Health Education Authority. Despite this progress, there were still powerful calls for a punitive approach, such as when the Chief Constable of Greater Manchester, James Anderton, spoke of people ‘swirling in a human cesspit of their own making’. However, the general tenor of the government response was pragmatic – focussing on safe sex rather than no sex, and safer drug use rather than no drug use. This liberal response was influential at the international level too and was promoted through AIDS specific organisations set up as part of the World Health Organisation (WHO) and the United Nations (UN).

    Source https://commons.wikimedia.org/wiki/Category:Epidemiology_of_HIV/AIDS

    In South East London, the local HIV groups were formed in response to the direct experiences of people who faced barriers accessing health and social care. These specialist organisations included the Positive Place in Deptford – which started in an office in Sydenham where Cllr Alan Hall was a volunteer.

    Sydenham is a very interesting area. Geographically it is on a hill which has a ridge with its apex at Crystal Palace. Crystal Palace is the place where five local authorities meet – the boundaries of London Boroughs of Bromley, Croydon, Lambeth, Lewisham and Southwark.

    Locally, social services are provided by Councils and health services were overseen by regional health authorities at this time. The provision of HIV services were very variable and much of the work and support was provided by specialist sexual health clinics at the major London teaching hospitals. Hospital social work could provide some support but the end of life care and care at home fell to the patients’ home local authority.

    By 1991 the Government had put in place a ringfenced Government Grant called the AIDS Support Grant (ASG) – this was to recognise the additional resources needed to provide services for people with AIDS.

    AIMS OF THE GRANT SCHEME

    To enable Social Services Departments to draw up strategic plans, based on local population
    needs assessments, for commissioning social care for people with HIV/AIDS; and to enable Social Services Departments to finance the provision of social care for people with HIV/AIDS, and where appropriate, their partners, carers and families.
    The grant is to assist local authorities with the costs of providing HIV related personal social services.

    At the Positive Place – then in Sydenham – we became aware that people with HIV were having problem accessing social services in Bromley. There were general comments and complaints in the other neighbouring boroughs however, in Bromley people were routinely refused a social service.

    After extensive enquiries and local research, a meeting with Bromley Social Services Committee Councillors was arranged and a briefing document produced. Richard Cowie, the Clinical Nurse Specialist for South East London Health Authority, David Thomas a Trustee of the Postive Place which had established as a centre for people with HIV in SE London based in Deptford – joined Alan Hall who had become a member of the Bromley Community Health Council and set up Bromley Positive Support Group in Beckenham.

    The first section is instructive it is called: NO AIDS HERE

    “The first response to deny HIV services is that there is ‘no demand’ for them. In effect, this means no AIDS in Bromley. In 1992 this was the reason used by the London Borough of Bromley for not applying for AIDS Support Grant. Every District Health Authority must submit returns regarding the number of HIV infections and AIDS related deaths yearly and much more detailed information under the provision of the AIDS (Control) Act 1987.”

    “The figures are collated in a technical manner and require considerable caution interpretating them. However the latest report for Bromley (1993/4) shows that there are ’48 people living with HIV infection and 2 babies of indeterminate status’.

    “It is accepted that this is an underestimate. This includes people who attend Bromley Hospitals or services. It does not include all the people attending specialist centres of excellence, eg Middlesex Hospital, King’s College Hospital, St Thomas’ Hospital, Chelsea & Westminster….of which we know there are several cases. We estimate that there are at least 60 cases – this does not include their families, partners or carers. The no AIDS in Bromley is a myth. Indeed, the Department of Health classifies Bromley as a “moderate” prevelance area.”

    “Frequently, AIDS in Bromley has been dismissed as a small number of cases, insignificant. This is a favourite argument of Cllr Cooke. Clearly, 60 people with HIV plus their families is not a small number. Contrast this with the number of people receiving intensive personal care – this is in the order of 70 people.”

    The conclusion of the document states: “All of the myths, I am sure you will find have their root in prejudice and bigotry.”

    Whilst the Positive Place was in Sydenham the local MP, Jim Dowd agreed to ask a Parliamentary Question. This question revealed that Bromley Council had failed to apply for its indicative allocation of AIDS Support Grant in 1992-3.

    Hansard records the written parliamentary question on 14th January 1993:

    AIDS
    Mr. Dowd : To ask the Secretary of State for Health (Virginia Bottomley)

    (1) on what date the London borough of Bromley applied for AIDS support grant for the current financial year ; and what efforts have been made by her Department to urge Bromley to apply for it ;

    (2) what amount of AIDS support grant was allocated to each local authority in each year since 1990-91 :

    (3) what extra costs she estimates to have been incurred by neighbouring boroughs obliged to deal with HIV/AIDS cases turned away by Bromley social services department ; and what steps she proposes to take to recompense the neighbouring boroughs ;

    (4) by what date London boroughs should apply for the AIDS support grant for 1993-94 ; and what steps she will take to ensure that the London borough of Bromley applies for the grant on time ;

    (5) how many people in each London borough have died from AIDS :

    (6) how many cases of HIV have been reported in the borough of Bromley in each year for which figures are available.

    The Minister for Health, Tom Sackville, MP replied:

    Mr. Sackville : In December 1991 the Department issued a circular (LAC(91)22) inviting all social services departments in England to bid for extra resources for HIV and AIDS services in 1992-93 under the AIDS support grant scheme. Criteria for bids under this scheme are set out in the circular. Copies are available in the Library. The closing date for bids was 7 February 1992. The London borough of Bromley submitted an application in November 1992 although not in the form and detail set out in departmental guidance. By that time AIDS support grant moneys had been fully committed. The Department was, therefore, unable to allow Bromley’s bid to proceed. Although not in receipt of AIDS support grant money in 1992 -93, we understand that the London borough of Bromley plans to spend £15,000 on HIV and AIDS services in the current year. We have no information to suggest that the borough has been compelled to turn away people affected by HIV.

    For 1992-93 local authority social services departments will again be invited to apply for an AIDS support grant allocation. The closing date for applications will be 8 February 1993. It will, of course, be open to the London borough of Bromley to bid for funds under this scheme.

    Information on the number of HIV and AIDS cases reported in individual boroughs and of deaths is not held centrally.

    The table shows the AIDS support grant allocations which have been awarded since 1990-91 for a full list in England see Hansard.

    Allocations for Individual Authorities in London are shown.

     

    London Borough Grant 1990-1 Grant 1991-2 Grant 1992-3
    Camden 471,000 489,840 730,000
    Hammersmith 1,003,359 1,042,000 1,300,000
    Kensington 627,500 652,600 970,000
    Lambeth 551,000 573,040 930,000
    Westminster 625,000 650,000 940,000
    Brent 290,000 290,000 400,000
    Ealing 250,000 260,000 290,000
    Greenwich 136,280 136,280 190,000
    Hackney 322,500 335,400 460,000
    Haringey 357,500 371,800 500,000
    Hounslow 231,250 240,500 320,000
    Islington 235,000 244,400 360,000
    Lewisham 163,750 170,300 240,000
    Richmond 135,000 140,400 200,000
    Southwark 215,000 215,000 300,000
    Tower Hamlets 309,000 321,300 481,000
    Wandsworth 165,122 120,152 188,000
    Barking 14,000 17,173 32,236
    Barnet NIL 26,000 40,000
    Bexley 25,000 26,000 46,000
    Bromley 8,500 9,520 NIL
    City of London 25,000 26,000 47,000
    Croydon 24,500 30,000 49,000
    Enfield 14,938 16,702 50,000
    Harrow 25,000 26,000 42,000
    Havering Nil Nil Nil
    Hillingdon 23,207 35,000 120,000
    Kingston 25,000 26,000 64,000
    Merton 14,000 17,178 66,000
    Newham 72,500 110,000 250,000
    Sutton 22,260 30,000 57,000
    Waltham Forest 70,000 90,000 135,000

    The Boroughs are listed in prevalence order and grant awarded

    Alan Hall followed up the lack of funding and more importantly, the lack of a strategy in 1993. On 11th October he received the following reply from Baroness Cumberlege, Parliamentary Under Secretary of State for Health in the Lords, this said: “The Department is aware that there has been an absence of a clear HIV/AIDS strategy in Bromley and has been monitoring the situation.”

    If the Government were aware, why didn’t they act?

    Perhaps, we will never know the answer to that. But the refusal of Bromley Council’s social services Committee members to allocate funding and support proposals for a change in direction led to protest.

    The community activists in Outrage knew that Bromley Council were resisting change and they decided to mount a protest. Activists enetered the Council Chamber, chanting and holding placards. Labour and Liberal Democrat Councillors stayed in the Chamber whilst shocked tories walked out. The photograph below was taken by the acclaimed photographer, Gordon Rainsford.

     

     

    Outrage in the Bromley Council Chamber

    The Pink Paper carried a report of the protest with the headline: “Tory Mayor flees AIDS protesters in Bromley”.

    Outrage alleged that the Mayor of Bromley, Cllr Edgington attacked one of its members. This is particularly interesting as this is believed to be a counterclaim, when the Mayor of Bromley made a complaint to the Police that one of the protesters drank from his glass thereby assaulting him.

    The fifteen activists held a “die in” where they laid down in the Council Chamber and held tombstone shaped placards with slogans such as killed by Bromley neglect.

    In the press report, the case of a 28 year old man who was refused a home help and told to ‘try a private nursing home’ a day before he died is raised.

    Daniel Winchester a local resident said that Bromley Council had shown ‘contempt’ to the ill and dying over the last ten years of the pandemic.

    The independent voice of social workers – Community Care – carried an article on HIV and AIDS social service provision in March 1993 saying: “Bromley Social Services is behind with its HIV work. It’s bid for 1992-3 was late, so it did not benefit from the 50% increase and that there was great pressure to meet the standards for grant status.” In response a senior Bromley Council social services manager is quoted as saying: “Our services are pretty thin on the ground in this area.”

    Leaders in the social work profession at the time, believed that there were additional benefits with specialised HIV services as they were ground breaking and that they benefit other areas of social work like confidentiality and increasing good practice more generally.

     

    Outrage blow fog horns and whistles to get attention from Bromley Council

    website link:  https://alanhall.org.uk/2020/06/30/bromley-council-and-hiv-the-fight-for-social-services/

     

     

     

    Comments Off on BROMLEY COUNCIL AND HIV – THE FIGHT FOR SOCIAL SERVICES

    On Friday 26 June 2020 HIV i-Base published the fifth COVID-19 supplement to HIV Treatment Bulletin (HTB). Please see this link.

    All i-Base reports are free to copy and i-Base encourages wide distribution. Please credit i-Base when distributing these reports.

     

    HIV and COVID-19: a new supplement to HIV Treatment Bulletin (HTB).

    This publication reviews the latest news on COVID-19, including research that is important for care of people living with HIV.

    All articles are online as html web pages. The PDF files use a single column layout that makes it easy to read each issue on tablets and other hand held devices.

    HIV and COVID-19 no 5 – (26 June 2020)
    HIV and COVID-19 coinfections including data from South Africa, dexamethasone effective in advanced COVID-19, hydroxycholoquine not effective in UK RECOVERY study, plus updates on remdesivir and other treatments…
    Contents online. (html pages)
    HIV and COVID-19 no 5 – 26 June 2020 (PDF)

    HIV and COVID-19 no 4 – (1 June 2020)
    HIV and COVID-19 coinfections, UK access to remdesivir, convalescent plasma, interferon, famotidine, tocilizumab, concern with hydroxychloroquine, UK research plus more…
    Contents online (html pages)
    Download: HIV and COVID-19 issue 4 (PDF)

    HIV and COVID-19 no 3 – (14 May 2020)
    Latest issue includes news on latest treatments, including US approval of remdesivir, plus tentative results with other drugs that reduce immune inflammation (anakinra) – perhaps as essential as antivirals – anticoagulants, ACE inhibitors. Plus latest guidelines and no effect from BCG vaccine.
    Contents online (html pages)
    Download: HIV and COVID-19 issue 3 (PDF)

    HIV and COVID-19: no 2 – (17 April 2020)
    The second supplement of HTB with more than 30 COVID-19 reports: hydroxychloroquine studies, antivirals, transmission and prevention research, online resources.
    Contents online (html pages)
    Download: HIV and COVID-19 issue 2 (PDF)

    HIV and COVID-2019: no 1 – (27 March 2020)
    This 20-page HTB supplement compiles links to articles and resources about COVID-19 including information for managing the care of HIV positive people. It includes short reviews of key studies and early guidelines.
    Contents online. (html pages)
    Download: HIV and COVID-19 issue 1 (PDF)

    Other news and resources on COVID-19 are at: i-base.info/covid-19

    Comments Off on HIV and COVID-19: new publication

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

    Test and Trace

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

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

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

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

    Workplaces

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

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

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

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

    Contact tracing

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

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

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

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

    Social distancing

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

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

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

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

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

    29.6.2020

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

    Comments Off on SHA COVID-19 Blog 16

    We are now into the 15th weekly blog during the pandemic and confidence in the government is plummeting as the weeks roll on. The UK stands out as the sick man of Europe according to the Economist with the highest excess deaths per million population and with the OECD forecasting the UK as having the highest % decrease in GDP for 2020 compared to a year ago

    Channel 4 broadcast a speech by Prince Charles on Monday (June 22nd), saying how grateful the Nation was to the Windrush Generation who came to staff the NHS and other public services after WW2. Viewers have been horrified by the programmes on TV showing how badly they had been treated under the Hostile Environment policy of Theresa May, and how disproportionately they are currently suffering from Covid-19..

    In this week’s blog we will touch on familiar themes such as the slow rebirth of local test and trace/outbreak control plans, the failure of the world beating NHSX app on the Isle of Wight, the scandal of government contracts for PPE purchases and the revelation that there was indeed a Fenton report on BAME deaths that was withheld.

    BAME

    As protests about Black Lives Matter continue across the country and the world, our Ministers are on a learning curve about the historic slavery/civil rights context of ‘taking the knee’, and that Marcus Rashford is a famous black Man U footballer and English international. The PM and his Cabinet Ministers continually display how out of touch they are.

    Having looked at the Fenton Part 2 report “ ‘Beyond the data: Understanding the impact of COVID-19 on BAME groups’ most people will nod quietly at the eminently sensible recommendations he made which were based on a rapid review of the literature, his group engaging with 4,000 people across the country with direct experience of racism and suggestions about what is to be done. These stakeholders expressed deep dismay, anger, loss and fear in their communities about the emerging findings that BAME groups are being harder hit by COVID-19 than others. This exacerbates existing social, economic and health inequalities.

    Professor Fenton’s report recommends that there be improved ethnicity data collection, more participatory community research, improved access to services, culturally competent risk assessments, education and prevention campaigns. He calls for pandemic recovery plans that are designed to reduce health inequalities caused by the wider determinants of health to create long term sustainable change.  The SHA heartily supports these recommendations and, along with David Lammy MP, demand that the government implements findings from previous BAME related reviews that date as far back as the Stephen Lawrence inquiry in 1999.

    We know that inequalities reflect racism and structural factors in society outside health. The Runneymede Trust looked at Pensioners’ Income for the Financial Years 2017-18 and found that Black pensioner families receive almost £200 less a week than white British pensioner families. Black households were the least likely to receive personal pensions. They also found that Black African and Bangladeshi households have approximately 10p for every £1 of white British savings and assets. The figures show that for every £1 a white British family has, Black Caribbean households have about 20p and Black African and Bangladeshi households about 10p. Its not just COVID!

    Test and Trace

    Remember that the Government called a halt to the local test and contact tracing that was happening in early March, claiming that there was too much community transmission for it to have an impact and there were not sufficient local resources to manage the surge? The real reason it has emerged was that there was insufficient test capacity to sustain both NHS hospital testing and testing in care homes and the community. That fateful decision meant that local test and trace schemes were stood down, and did not follow the pandemic by analysing local surveillance and build-local systems. A few weeks ago, quite suddenly, the government recognised the role that such local test and trace schemes might have as the pandemic continued, and demanded that local Directors of Public Health prepare new Local Outbreak Control Plans by the end of June. Thankfully they appointed a CEO from Leeds Council to advise them and quite properly he has been working with the Local Government Association (LGA) and the Association of Directors of Public Health (ADsPH). At long last local plans are emerging and demands increasing for timely access to test results. Some government investment has been extracted from Deloittes and other consultants and safely invested in local government teams.

    As we have touched on before, the government has been too centralised in its approach and the national testing sites have been ‘out sourced’ to firms in the private sector, such as  SERCO, with Deloittes hovering, and also creaming off profit while mismanaging things. This means that there is undue delay in getting test results back to local teams and the initial contact tracing is being handled by inexperienced call handlers at a distance from the person involved. Remember that COVID-19 has shown us that it affects older people, people in care homes, people of BAME heritage and those from the most disadvantaged communities in the UK, disproportionately badly . I wonder what advice scientists might have given about the most effective way of reaching the most at risk people? Surely by now we know that, despite apps and complicated ventilators, health care is still a people business.  Skilled and empathetic care workers matter. Meanwhile GPs and primary care are bystanders to this world beating system and local public health teams are frustrated at step one of outbreak control, namely information about who has relevant symptoms and whether they have tested positive.

    The app!

    The app the app my kingdom for an app!’ It is alleged that people have heard the scream from the SoS who has a boyish interest and naïve faith in apps and other digital technologies. The ‘world beating’ app being developed in the exceptionally clever UK and tested on the Isle of Wight has bitten the dust. Stories are now emerging about the errors and misjudgements that there have been on the way. Developers of successful apps, such as that of Prof Tim Spector of Kings College London which now has 3.5m users, tells us that the NHSX treated his research teams as the enemy. They told him that far from collaborating, their world beating all singing and dancing app would make his redundant. In case we think this is just Tim Spector we hear that Ian Gass of Agitate tried to tell the NHSX in March that its app design, which tried to use Bluetooth signals was flawed. He describes this weird almost paranoid state, where the government says publicly that they’re asking for help, but then rejects it when it is offered.

    PPE contracts

    With the PPE supplies debacle we also heard the refrain that the government was inviting local UK companies to help produce PPE for the NHS and Social Care. Company boss after company boss reported trying and failing to make contact with government commissioners. It seems that it is only the insiders who get the contracts. Some previously small companies like PestFix are under scrutiny having won contracts with a value of £110m. This amount is nearly a third of the £342m public sector contracts signed for COVID-related PPE.

    We are pleased that Meg Hillier MP, Chair of the Public Accounts Committee is taking evidence on these contracts. MPs have said rightly that the pandemic crisis should not be an excuse for failing to achieve value for money.

    And finally

    We started this blog with a reference to a report in the right wing leaning Economist magazine. It is extraordinary that their leader in the June 20th-26th edition under the banner heading ‘Not Britain’s finest hour’ should say:

    The painful conclusion is that Britain has the wrong sort of government for a pandemic – and in Boris Johnson, the wrong sort of prime minister…

    ….beating the coronavirus calls for attention to detail, consistency and implementation…..

    The pandemic has many lessons for the government, which the inevitable public inquiry will surely clarify. Here is one for voters: when choosing a person or party to vote for, do not under-estimate the importance of ordinary, decent competence.”

    Hear hear.

    22.6.2020

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

    Comments Off on SHA COVID-19 Blog 15

    During the COVID19 pandemic, a lot of routine health provision has been suspended or reduced. As we plan to get get these back on track, lets not put prevention at the end of the  list, yet again. The SHA convened a group of its members with relevant expertise , who have developed a briefing on the risks to the public of the temporary reduction of prevention programs.

    Key Messages

    • Childhood vaccination programme: the recent increase in vaccination coverage after a long fall has now been thrown into jeopardy by COVID19, with little resilience in primary care and public health departments to systematically and actively promote catch up programmes.
    • Measles: there would be a significant risk of measles outbreaks because MMR coverage in England among children was well below the threshold required for herd immunity in most areas. Measles is highly infectious with an R0 of 16
    • Influenza vaccination programmes for children and adults will begin in September. It is vital to achieve a much higher uptake, to reduce the risks of having to manage a flu epidemic while COVID19 is still circulating.
    • Screening services should restart as soon as possible, with safety measures in place for patients and staff, and a plan for catching up all who have missed out
    • Sexual health and contraception: there is a serious risk of losing the excellent gains of the last Labour Government’s Sexual Health and Teenage Pregnancy strategies, after major cuts in the public health grant. We need a new sexual health strategy with a return to planning and collaboration rather than tendering of services
    • Prevention spend: The Government should restore public health expenditure in England to at least previous levels

    Prevention is so much better than cure: There are many prevention programmes designed to prevent and detect diseases at an early stage to stop them causing death and illness. These are some of the most highly cost-effective healthcare interventions; a review by NICE found that 85% of 200 case estimates of prevention programmes were cost effective. Vaccination programmes are the most cost-effective healthcare interventions

    Amazing efforts by staff: During the COVID19 pandemic, many services have been impacted through being suspended, or by reducing services. Some may also have been affected by the public reducing their uptake. Staff in public health programmes have been going to heroic lengths to deal with the pandemic while keeping essential preventive services going

    The paltry and reducing investment in prevention and early diagnosis is now under greater threat There is a high risk that prevention programmes will lose out for investment when finances are reduced, as will happen during the coming recession. Many of these programmes have already been deeply affected by austerity, in particular those commissioned by Local Authorities in England.

    Recovery plans: The NHS is attempting to restart, and this must be fully funded and adhere to principles of patient and staff safety and equity.  There has been a lot of great local integration and innovation in the face of a common threat, and this must be nurtured and not used as an excuse for cutting costs. Digital ways of working are not cheaper and not a replacement for face to face in many situations long term

    Emerging public health risks of suspending public health programmes FINAL

    Comments Off on Lets not forget prevention (yet again) or measles and flu may come to bite us

    So we are into our 14th weekly blog tracking our way through the COVID-19 pandemic. There are many issues which we have raised before which remain relevant over the past week. The most notable are the continuing blunders by the Johnson government, intent on appearing to have a strategy and being in control. The podium politics continue with premature announcements blurted out as intent, without having checked out their feasibility with professional advisers. The schools debacle was always couched in terms of recalcitrant Trade Unions rather than the fact that our school buildings have lacked investment over decades, class sizes are high and teacher staffing relatively low. This means that you cannot reduce class sizes to enable social distancing in the buildings you have available! A simple estimate of size of buildings, number of children and staffing levels would have demonstrated that this was always going to be a challenge before taking account of the risks of transmission to teachers and back via children and staff to people’s homes. The embarrassing retreat could have been avoided and the stress on schools reduced by consulting those that know how the system runs. Meanwhile schools are open to vulnerable children and greater efforts can be made to get them back in the school setting.

    A similar fiasco has emerged in health when, suddenly and belatedly worried about outbreaks in hospitals and nursing homes, the government decides to direct all NHS staff in patient/public facing roles to wear surgical facemasks and all visitors to wear facemasks. Imagine the planning this requires and the supplies that will be needed to sustain it! PPE and the scarcity of medical facemasks has been a story throughout the pandemic. But there was no consultation with the NHS before the announcement on a Friday evening.

    As for Test, Trace and Isolate (TTI) this has had a ‘wobbly’ start, as rather than trusting in local Directors of Public Health (DsPH) to build local teams that local laboratories can report to quickly, they have sidestepped the service and asked private contractors, with no prior experience, to set up a telephone answering/contact tracer service. Training has been very basic and it is not delivering the timely communication needed to ensure cases isolate themselves and their contacts traced urgently by local staff. In the ‘post-Cummings stay alert era’ it is already emerging that people may have less commitment to listen to government guidance, and when the lockdown is easing will be reluctant to stay off work and name their contacts who may be in a similar position.

    BAME and Inequalities

    Two issues, which we have raised before, are the need to address racism in our society and its link to general inequalities. The Black Lives Matter movement is trying to ensure that the government does not whitewash this issue and hide behind statistical methods which try to discount the fact that BAME communities are over represented in disadvantaged groups and have additional pressures on them that arise from racism in society, in key organisations and in the individuals they interact with.

    We have seen an extraordinary example of institutional racism over the process of publication of the Public Health England (PHE) report on Disparities in risks and outcomes of COVID-19.

    This report was commissioned by the government, ‘from the podium’ in Downing Street, when confronted by the announcements of deaths related to COVID-19 where BAME people have been heavily over represented. The NHS employs many BAME staff but did not expect to hear that while 44% of NHS doctors are from BAME groups they accounted for 90% of deaths of doctors. BAME nurses are 20% of the workforce but account for 75% of deaths. So Ministers appointed Prof Fenton a senior Public Health Director in PHE to lead the review. This provided some comfort to the BAME communities, as Fenton is an articulate and experienced black health professional able to access the views of BAME communities to deepen our understanding of what was happening to lead to these extraordinary outcomes.

    In the event publication of the report, which had been delivered by Fenton and PHE as promised by the end of May, had been delayed. Professor Fenton had been booked to lead a webinar for the Local Government Association (LGA) on Tuesday 2nd June fully expecting to be able to refer to his report. He seemed unaware that the report would not be published by the Government, without it being clear that this was the Fenton Report, until a couple of hours later, and even then without it being clear that the publication was the Fenton Report. What has subsequently emerged is that the section of his report that starts to address the pathways that lead to these huge differences in health outcome had been taken out of the report without consultation. This was hugely disappointing to the many hundreds of individuals and organisations who had contacted him and the review team during their rapid review process. The LGA webinar had been hosted by colleagues in Birmingham, and both the local Director of Public Health for Birmingham and the Chair of the Health and Wellbeing Board, Cllr Hamilton, were clearly engaged in providing insight and proposals as to how to start to address the challenges.

    Of course we do not yet fully understand the shenanigans that have gone on but suspect that someone else was asked to edit the report and effectively take out all the challenging political bits and resort to a dry re-publication of some of the statistics which we knew about and which had led to the inquiry itself! This new epidemiological input seemed determined to try and account for as much as possible of the higher mortality by apparently neutral factors such as co-morbidities, occupational risk, living in cities and relative deprivation. Such findings had been submitted by a SAGE report at the end of April, which had not been peer reviewed or published. This attempt to explain away the disparities seriously misses the point about racism and how it works through cumulative lifetime risks. Treating Prof Fenton in this way exhibits a form of institutional racism that no doubt the Ministers, and the experts drawn into stripping the report of its insights into how racism works, do not grasp.

    Despite taking account of sex, age, deprivation and region in England people of Bangladeshi ethnicity had twice the risk of death than people of White British ethnicity. People of Chinese, Indian, Pakistani, Other Asian, Caribbean and Other Black ethnicity had between 10 and 50% higher risk of death when compared to White British. By stripping out other factors an attempt has been made to soften the data impact and bin the feedback from local communities based on their life experience and the specific experience with COVID-19.

    Other countries have shown that there is an overrepresentation of black people amongst hospitalised patients. The US Center for Disease Control and Prevention (CDC) report, for example, that: in New York City death rates from COVID-19 among black/African American people was, 92/100,000 and Hispanic/Latino people 74. These rates are substantially higher than the 45/100,000 for the white population and 34 for Asians.

    Back in the UK, if you look outside the health sphere you see similar data in the criminal justice system. The BAME population make up 14% of the population yet 51% of inmates of the youth justice system. Stop and search records show that black people have 38 searches /1000 population compared to 4 for the white population. They are also more likely to be arrested with 35/1000 for the black population compared to 10 for the white population. The black population are five times more likely to be restrained and twice as likely to die in custody. Looking specifically at the black population rather than BAME groups as a whole they account for 3.3% of the population and 12% of the prison population. Black people make up 1.2% of police officers while 93% are of white ethnicity (Sunday Times, 14th June).

    This information has been well known to the black populations of most of our cities since well before the 1981 riots in Brixton, Toxteth, Moss Side, Handsworth and Chapeltown, let alone the Black Lives Matter protests of 2000.

    Inequalities

    The Office of National Statistics (ONS) still manage to produce reports that have not been politically edited in the way that Fenton’s was, and they have published a review on inequalities and COVID-19. This shows that the most deprived areas of England have more than twice the rate of death from COVID-19 than the least deprived. In the period from the 1st March until the 31st May the death rates were 128/100,000 for the most deprived compared to 58.8 for the least deprived. This inequality continues to be proportionately high and is mirrored in Wales too where they measure multiple deprivation differently (WIMD) yet still show a contrast between 109/100,000 for the more deprived populations compared to 57.5 in the least deprived. Both nations show a gradient across the groups, which is the important point that Marmot and others have made that inequality is not just something that influences the socially excluded groups but adversely affects the whole society from top to bottom.

    The SHA has consistently argued that we need to seriously address the social determinants of health and wellbeing. We also recognise the work that Marmot has done globally with the message that where we live, learn, work and play affects our health. The conditions in which people live, learn, work, and play contribute to their health. These conditions over time lead to different levels of health risks, needs and outcomes among people in certain racial and ethnic minority groups.

    The Centers for Disease Control and Prevention (CDC) in America use this approach to set out how these determinants might be tackled despite the fact that the Trump administration is deaf and blind to their advice!

    The international response to the George Floyd murder on the street in Minneapolis must be built on to turn these daily injustices around. The Black Lives Matter campaign needs support.

    As Labour’s David Lammy MP says:

    We can’t just look back in 5 years and remember George Floyd as a hashtag. We have to find a way to transform this righteous anger into meaningful reform’.

    15th June 2020

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

    Comments Off on SHA COVID-19 Blog 14

    ECONOMIC RECOVERY

    But is it also time to share ideas about the contribution the H &SC sector can make to strategies for economic renewal press for some imaginative new ideas for jobs, training and service delivery just as the PM is about to announce how the economy can revive?  Can we not present our future Health and Care Service as a part of the transformation the economy needs as it tries to get people back to work  – greener, fairer and more equal.

    How? New kinds of training and apprenticeships to provide career pathways to and between professions, and between health and social care that will be attractive to the many unemployed and to school leavers? Apprenticeships to help with retrofitting hospitals and health care sites to make them carbon neutral? New forms of procurement in the health sector which create social benefit (see how our failing garment industry has turned to scrubs)? Buying from independent local food producers helping create a more sustainable agriculture? A complete rethink of transport for hospital staff and patients now that we must get more cars off the road? I am sure others can do better at spotting ways in which the sector as well as needing more money  can be a  contributor to the new kind of society in which we want to live.

    TEST, TRACE, ISOLATE

    Test, contact trace and isolate   Our local members, SHA and Defend our NHS Wirral are hopping mad about the way the government has deliberately side-lined local public health, university facilities and even the Crick Institute – all those skilled personnel in favour of the multi million contracts being handed without scrutiny to their cronies like Serco, G4S etal.  And they are making such a complete hash of it too with their apps, call centres and unskilled minimum wage staff   Families are bereaved, valuable lives dust-binned.


    The track and trace system looks to be the next government disaster in their mismanagement of this pandemic.

    Firstly, I was astonished they gave up so early on trace and trace, particularly in areas outside of London and Birmingham that had low prevalence in March and early April. It does seem to have been a mixture of poor coordination, absence of preparation for the testing ( when you dont have a vaccine or a treatment but you have a test….)

    That they have not used the ‘down time’ to establish organised units around PHE and DPH units seems a missed opportunity.

    Contact tracing is specialist sensitive work; TB, food poisoning and sexual health. Trust and local knowledge are vital particularly if the tail end of the epidemic is to prevent break through outbreaks – this is the daily work of a health protection department.

    Setting up an entirely new system at this time seems folly, rather than building and expanding/ scaling up from existing established core services. This is what was done for H1N1 in 2009. From a report in Bloomberg this seems to be what has happened n Germany.

    I suspect there is going to be a delay in transfer of results – which with this disease’s ‘sneaky symptomless infectious period will make the system inefficient in getting on top of local breakthrough outbreaks, that will have a particular situational (going on a BLM demo) or organisational ( in say a post sorting room) context where investigation will be most effectively carried out through a local control centre of a health protection team.

    Information Governance and Track, Trace and Isolate

    The question that the team should pursue is ; what is the arrangements for information governance and has the

    System established by the central scheme been reviewed against Caldicott Guardian principles. (Is the track and trace part of the NHS system of protecting patient confidentiality.)? Dido Harding who leads the English programme has form with poor information governance  – she was CEO with Talk Talk when over 4 million

    Clients got their personal data hacked.

    Dido Harding

    Why Harding was appointed should also be pursued; she is a horse racing enthusiast, like Matt Hancock and is a Jockey Club Board member that will have supported the running of the Cheltenham Festival. A chance to catch the horse that bolted. But best person to lead?


    As a semi-retired GP and having lost access to my normal work following lockdown I decided to join the ranks of the (I understand) 6000 or so professionals signed up for the Test and Trace scheme. I received some welcoming emails from NHS Professionals (NHSP) and also Sitel, the call centre contractor responsible for the system. I was told I could log into NHSP’s training platform but after numerous attempts, my credentials did not work. After an hour on hold to a helpline, I was told that I needed instead to access the training modules on eLFH. I duly did this and completed several mandatory training (safeguarding, information governance, etc.) modules and some online presentations on how the system works. as well as some documents with the script I was supposed to follow in given circumstances.

    I was all ready to start contacting people who had received positive tests and, using the proscribed script, check with them who their recent contacts had been. At 8 o’clock last Monday I duly logged into the four software platforms I needed for this work and was informed I had no contacts to call. I therefore sat and did some emails, looked at some more training material and at the end of the 4 hour shift had still had no- one to call.

    I was disappointed with this experience but decided as this was supposed to be the first day the system went live (before Matt Hancock had decided he could announce it was live the previous Thursday) it was too early to have picked up many positive cases. I had another shift booked on Wednesday and duly logged in again to find there was 1 case to call. I brought up this record and called the number- it went to voicemail. I called again a minute or two later, still voicemail, so I left the message according to the script and scheduled a call back a couple of hours later. The appointed time arrived and the case was no longer on my list…  I hope someone else had picked up the case and called. The rest of the four hour shift turned up no more cases.

    I decided I needed to book some more shifts so looked at the NHSP calendar; there were no shifts available for the next two weeks. I did manage to find a shift to book in a couple of weeks’ time but looking again now, there is nothing available for the whole of the rest of June or July.

    Maybe this system is working so efficiently they’ve got more contact tracers than they need or, more likely, the system just isn’t picking up all the positive tests and feeding them through and it is yet another example of Tory ‘world beating’ hype.

    CONTRACTS WITH PRIVATE COMPANIES

    • What private companies have been awarded contracts to provide goods or services to or on behalf of the NHS between February and the current date?
    • What goods or services have each of these contracts been for?
    • What is the value of each of of these contracts?

    Why are we giving public money to private companies like Serco, which has been fined for defrauding govt, when many scientists argue that university and NHS public labs could as quickly cope with the tests?   Is it because they have contributed to the Tory party?  What about accountability to the British people?

    PEOPLE WITH LEARNING DISABILITIES

    • How many people with learning disabilities living in either i) NHS or ii) private hospitals or iii) care homes have died with covid-19
    • What is the excess death rate for people with learning disabilities in each of the above settings for the period February – End of May 2020?

    RELEASING PROFESSIONAL STAFF AT THE NO 10 MEETING

    Another point I think the team should push is releasing the professional staff from their daily ‘lockdown’ in No 10 at their press conference. Ministers should do this on their own and officials should operate to traditional civil service principles – heard but not seen.  With crumbling trust of the politicians, it is infecting professional staff; CMO etc.

    OPENING SCHOOLS

    How is it possible to open schools and unlock when testing and tracing is not up and running efficiently?

    EXCESS DEATHS

    Can Labour question why excess deaths last week showed that UK has the highest figures for deaths after Peru in the world? Not quite the excellent response the PM is arguing.

    TAKE THE NHS OUT OF ANY TRADE DEALS WITH THE US

    The faith and gratitude expressed to our NHS staff in the present pandemic is beyond belief, and CV19 is the unwelcome political experiment to have tested state versus private efficiency and enterprise in health care. In the light of this will you be insisting that the government withdraw the NHS from any participation in Trade talks with the USA – it is not even Trade, after all. I have suggested to our MP that a legal instrument is needed to protect it.*

    To Craig Mackinlay MP: Public support for our NHS must be near total at the present time as the only way of saving millions of lives from Covid19. By contrast , the USA has effectively no health service. Worse still the USA cut two thirds of its hospital beds in the last 45 years, because they were ‘unprofitable’ . US health costs are soaring by 2,4% cumulatively per year. 28 million USA citizens have no health whatsoever. Last year half of all citizens cancelled or delayed their medical care because of cost. This is third world health in the richest state in the world

    Our government recently published its Trade Bill – the legislation that sets out the basis of future trade negotiations after Brexit. Unfortunately, it currently does not contain any protection whatsoever for our NHS, despite Boris Johnson’s repeated promises.

    I am writing to ask you to table or support any amendments to the trade bill to introduce specific protections for our NHS. Right now, it is automatically “on the table” in trade talks, and this won’t change until it is explicitly taken off in the trade bill. We cannot risk our NHS which is performing so magnificently in this crisis, to be sold off to a US medical insurance company.

    Clapping hands on the street won’t protect it: only our democratic representatives can do that. Please help save our NHS.

    1 Comment

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

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

    Lonely Ministers

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

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

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

    What is the strategy?

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

    Led by the science?

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

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

    Test, Trace and Isolate (TTI)

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

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

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

    Auditing misuse of public funds

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

    BAME communities and COVID

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

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

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

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

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

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

    7.6.2020

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

    2 Comments

    The degree of failure in this study is not an unfortunate scientific event. It is a terrible failure, reports Simon Collins at HIV i-Base

    Simon Collins, HIV i-Base

    On 5 June 2020, the large randomised RECOVERY study announced that hydroxychloroquine (HCQ) will no longer be used to treat COVID-19. [1]

    The results show that hundreds of people died – both taking HCQ and in the comparison group receiving no investigational drugs – and yet the study was only closed because of a safety request by the UK Medicines and Healthcare products Regulatory Agency (MHRA).

    This very large study – with more than 11,000 participants – should have been looking for early signals that experimental treatment might be effective. Instead, the results announced yesterday call for an urgent analysis of other ongoing arms plus immediate use of drugs that are now known to be effective.

    The press release states that people receiving HCQ did no better than people who were given no additional drugs – also called the standard of care. Actually, it is not that HCQ didn’t make enough difference for the results to be significantly better. It looks like people taking HCQ did worse than adding nothing, at least numerically. It is very worrying that this analysis was only carried out because of a request by the MHRA.

    For the main study endpoint – the number of people still alive after 28 days – approximately 25.7% of the 1542 people who received HCQ died compared to 23.5% of the 3132 people who were given no treatment. In a study this large, this signal of no active benefit from an experimental treatment should have been found much earlier. There were also apparently no benefit in other measures, such as length of hospital stay or other clinical factors.

    How many deaths were these researchers going to allow to continue before they would have stopped the study themselves? Almost 400 people in the HCQ arm and more than 700 people in the control arm died and the study still planned to continue?

    Many researchers will not be surprised at the lack of effect with HCQ – but they should be shocked at the time taken to hear this result. Over the last few weeks, other studies have been published showing that HCQ was unlikely to work. [2-6]

    One of these – a very large study published in the Lancet reported that HCQ was not effective, and prompted the RECOVERY study to look at their own results. And they came back saying their study should continue unchanged. [7]

    Anyone reading that letter from the RECOVERY researchers on 22 May 2020, would expect results to perhaps already show a trend towards benefit from HCQ. This would support continuing to allow participants to take a risk until the study reached a conclusion that was statistically significant.

    Instead, nothing close to a benefit could have been happening. It doesn’t even matter that the Lancet study has since been retracted – another complicated story [8, 9] – the important thing is that three weeks ago the RECOVERY study insisted that their data supported continuing to use HCQ.

    Today’s results showing no suggestion of benefit are important for several reasons.

    Firstly, the large RECOVERY study is continuing with other single therapy arms, some of which have even less evidence than HCQ to show they might work. These include monotherapy (single drug) using an old HIV drug called lopinavir/r (LPV/r). Actually, in March 2020, an earlier randomised study was published showing no benefit from lopinavir/r. [10]  For RECOVERY to be continuing with this drug, it needs to already be showing a strong trend towards benefit. Anything less, and LPV/r should also be pulled like HCQ. The RECOVERY study should not be looking for small marginal benefits, but for clear signals that the experimental drugs are considerably better than standard of care.

    RECOVERY is also studying a single antibiotic called azithromycin (AZM). Actually, previous studies claiming a benefit from HCQ used it together with AZM. This does not make it plausible that AZM monotherapy will be a success. Again, anything less than clear benefit compared to standard of care, and this arm should be pulled too. And with a study this large, the results should have been available weeks ago. This shouldn’t need a prompt letter from the MHRA over safety. The DSMB in the RECOVERY study, should be analysing every death, with a low threshold of benefit to continue and a similarly low threshold to stop.

    Secondly, the statistical plans and timeline for analysing early results should be part of the RECOVERY study protocol – as it is for other major studies. The protocol should publish the start/stop criteria and the thresholds that are being used. It is not good enough for the study to say, as it currently does, that it will look at the results every two weeks. If this is the case, why has it taken an MHRA directive to look again now?

    Thirdly, we need to remember the context for COVID-19. Large numbers of participants who are already hospitalised have trusted the researchers to take experimental drugs that have some chance of working (and the chance of no drugs). By joining RECOVERY, people are by default not joining another study – and the UK already has another 20 or so ongoing treatment trials. [11]

    Finally, on 26 May 2020, the new availability of remdesivir, a proven treatment for COVID-19, should have led this to be offered to all participants in RECOVERY. Based on published results from the large randomised ACTT study showing remdesivir to be effective, the MHRA announced a compassionate access programme to enable widespread access. It is also notable that the conclusions of the ACTT paper emphasise the importance of using combination treatment with more than one investigational drug. The RECOVERY has not made any announcement for the use of combination therapy. [12, 13, 14]

    An established principal in ethical research, at least from HIV studies, is that no study participant should use less than current standard of care. When the standard of care changes, research studies need to rapidly change too, to ensure their participants do not use anything less.

    The RECOVERY researchers have publicised how quickly they launched their study. They also claim that early signals will be acted on quickly to stop ineffective drugs and to prioritise newly effective ones. If this was really true, it shouldn’t have taken a request from the MHRA to look again at the HCQ arm. The investigators and the independent data and safety monitoring board (DSMB) for the study should have done this already. The study should also have publicised whether more recent compounds with positive data have been considered – for example using anticoagulants or ACE inhibitors or the anti-rheumatoid anakinra. [15, 16, 17]

    The fact that RECOVERY didn’t stop the HCQ arm based on its own analysis plan, nor announce plans to look at other ongoing arms, are a concern for the study overall, and especially for participants who put their trust in these researchers.

    The press release concludes “These data convincingly rule out any meaningful mortality benefit of hydroxychloroquine in patients hospitalised with COVID-19”. If this is really the case, then slightly less convincing data should have been enough to stop this study arm much earlier and allowed participants the option to use other drugs that stood a better chance of benefit.

    COMMENT

    The degree of failure in this study is not an unfortunate scientific event.

    It is a terrible failure.

    Many of these issues, including on the data plans and timeline, the decision to continue using HCQ and access to remdesivir were raised by email with the RECOVERY coinvestigator Peter W Horby on 24 May 2020. This email has neither been acknowledged nor answered.

    Instead, hundreds of people have died using an intervention that has no signal of benefit, or because they were randomised to standard of care with no potentially active treatment.

    These results should prompt an urgent review of the other study arms in the RECOVERY study and an investigation for why such ineffective treatment continued for so long. Even though the study says the DSMB have been reviewing results every two weeks, the predefined rules to close or continue a study might not be appropriate – but as these have been excluded from the protocol it is difficult to comment. 

    This study – and no doubt others – should be using drugs that have a better indication of efficacy.

    Study participants deserve better.

    References

    1. RECOVERY trial statement. Statement from the Chief Investigators of the Randomised Evaluation of COVid-19 thERapY (RECOVERY) Trial on hydroxychloroquine. (5 June 2020).
      https://www.recoverytrial.net/files/hcq-recovery-statement-050620-final-002.pdf
    2. Molina JM et al. No evidence of rapid antiviral clearance or clinical benefit with the combination of hydroxychloroquine and azithromycin in patients with severe COVID-19 infection. Médecine et Maladies Infectieuses (2020), doi: 10.1016/j.medmal.2020.03.006.
      https://www.sciencedirect.com/science/article/pii/S0399077X20300858
    3. Geleris J et al. Observational study of hydroxychloroquine in hospitalized patients with Covid-19. DOI: 10.1056/NEJMoa2012410. (7 May 2020).
      https://www.nejm.org/doi/full/10.1056/NEJMoa2012410
    4. MagagnoliJ et al. Outcomes of hydroxychloroquine usage in United States veterans hospitalized with Covid-19. DOI: 10.1101/2020.04.16.20065920. (23 April 2020).
      https://www.medrxiv.org/content/10.1101/2020.04.16.20065920v2
    5. Maisonnasse P et al. Hydroxychloroquine in the treatment and prophylaxis of SARS-CoV-2 infection in non- human primates. Nature Research. In Review. (6 May 2020).
      https://www.researchsquare.com/article/rs-27223/v1
    6. Prescrire. Covid-19 and hydroxychloroquine (Plaquenil): new data show no evidence of efficacy.
      https://english.prescrire.org/en/81/168/58639/0/NewsDetails.aspx
    7. RECOVERY trial statement. Recruitment to the RECOVERY trial (including the Hydroxychloroquine arm) REMAINS OPEN. (22 May 2020).
      https://www.recoverytrial.net/files/professional-downloads/recovery_noticetoinvestigators_2020-05-24_1422.pdf(PDF)
    8. Lancet retraction: “Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis” (4 June 2020).
      https://www.thelancet.com/lancet/article/s0140673620313246 (web)
      https://marlin-prod.literatumonline.com/pb-assets/Lancet/pdfs/S0140673620313246.pdf(PDF)
      http://i-base.info/htb/37988 (i-Base report)
    9. Collins S. RETRACTED – Re: No benefit from hydroxychloroquine with or without macrolide antibiotics in analysis of 96000 patients. HTB (1 June 2020).
      http://i-base.info/htb/37988
    10. Cao B et al. A trial of lopinavir–ritonavir in adults hospitalized with severe Covid-19. NEJM. DOI: 10.1056/NEJMoa2001282. (18 March 2020).
      https://www.nejm.org/doi/full/10.1056/NEJMoa2001282 
    11. Collins S. UK guidelines for the treatment of COVID-19: UK prioritises 42 studies. HTB (1 June 2020).
      http://i-base.info/htb/38094
    12. Beigel JH et al. Remdesivir for the treatment of covid-19 – preliminary report. NEJM. DOI: 10.1056/NEJMoa2007764. (22 May 2020).
      https://www.nejm.org/doi/full/10.1056/NEJMoa2007764
    13. MHRA. MHRA issues a scientific opinion for the first medicine to treat COVID-19 in the UK. (26 May 2020).
      https://www.gov.uk/government/news/mhra-supports-the-use-of-remdesivir-as-the-first-medicine-to-treat-covid-19-in-the-uk
    14. MHRA. Early access to medicines scheme (EAMS) scientific opinion: remdesivir in the treatment of patients hospitalised with suspected or laboratory-confirmed SARS-CoV-2 infection who meet the clinical criteria. (26 May 2020).
      https://www.gov.uk/government/publications/early-access-to-medicines-scheme-eams-scientific-opinion-remdesivir-in-the-treatment-of-patients-hospitalised-with-suspected-or-laboratory-confirme
    15. Collins S. Anticoagulants associated with improved survival rates in people hospitalised with COVID-19. HTB (14 May 2020).
      http://i-base.info/htb/37794
    16. Mascolini M. ACE inhibitors and angiotensin receptor blockers for hypertension tied to lower death risk with COVID-19. HTB (14 May 2020).
      http://i-base.info/htb/37884
    17. Rheumatoid arthritis drug anakinra in small study to treat COVID-19. HTB (14 May 2020).
      http://i-base.info/htb/37863
    Comments Off on Disastrous UK RECOVERY study stops hydroxychloroquine (HCQ) for COVID-19: more than 1100 deaths question ethics and safety overall

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

    Germany and Greece 

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

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

    Test, trace and isolate

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

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

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

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

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

    Independent SAGE

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

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

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

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

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

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

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

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

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

    When should a School Reopen?

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

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

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

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

     

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

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

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

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

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

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

    31.5.2020

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

    1 Comment

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

    Too slow to act

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

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

    Protect the NHS

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

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

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

    The Privately owned Social Care sector

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

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

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

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

    Follow the money

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

    Test, trace and isolate (TTI)

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

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

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

    Game changers – and what is the game?

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

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

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

    Palantir

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

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

    Conclusion

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

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

    24th May 2020

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

    2 Comments

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

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

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

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

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

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

    Comments Off on COVID-19 BASHH resources