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    Simon Collins at HIV i-Base reports today that the Conference on Retroviruses and Opportunistic Infections (CROI) has decided to limit access to all conference materials – behind a pay wall –  for up to six months after the conference. As before, copying and distribution of i-Base reports is encouraged and free. But please credit HIV i-Base as source. Here is today’s post about CROI:

    This year, CROI has decided to limit access to all conference materials to delegates or new subscribers for up to six month after the conference. These include abstracts, posters and webcasts.

    Usually, CROI has made all conference material available as an open access resource as soon as the meeting finishes.

    Many people who registered for the virtual conference – and certainly most community delegates – were shocked to learn of this change. A community sign-on letter quickly included more than 200 organisations and individuals calling for the CROI Foundation and the International Antiviral Society–USA (IAS–USA) to reconsider these plans. [1]

    Until 2021, CROI had developed an exemplary model for democratising science and medicine – especially as CROI is the most important of the international conferences.

    Although this might have been suggested as a cautious approach when planning the virtual conference – when there might have been a worry that delegates might not register if the content was available free within a few days?

    Actually, more than 3500 delegates registered for the virtual 2021 conference, only slightly down from last year.

    Also, researchers who present their work at the conference might also want this wider access.

    COMMENT

    Hopefully this retrograde decision to restrict access might be reconsidered by the meeting organisers.

    CROI this year had an extremely dynamic and important programme, also covering COVID-19.

    The quality of the scientific and medical research presented at CROI is actually the reason why broader access is essential. Perhaps sending your own feedback to the organisers could help too.
    https://www.croiconference.org/contact-us

    Reference

    1. Community letter to the Conference on Retroviruses and Opportunistic Infections (CROI) regarding access to presentations and abstracts. (10 March 2021).

    Links to other websites are current at date of posting but not maintained.

    Leave a comment

    MASS TESTING PROGRAMMES FOR COVID 19 USING NOVEL TESTS

    SITUATION

    Last week [November 9th] the government proudly announced a major expansion of the UK s testing programme to provide rapid access testing of asymptomatic people for COVID 19 [1].

    They claimed this programme was : –

    • a“ vital tool to help control this virus and get life back to normal “
    • a partnership between national Test and Trace and local public health directors ‘
    • to develop the evidence base on how testing with rapid reliable COVID-19 tests can be delivered at scale

    Liverpool has nearly completed a two -week “pilot” programme to offer rapid testing to the half a million people who live in the city.

    The stated aim of this pilot is to: –

    “identify many more cases of COVID and break chains of disease transmission” and

    “ to protect those at highest risk from the virus and enable residents to get back to their day to day lives

    Meanwhile the Government has also announced following a report by Public Health England / Porton Down [2] that they are extending this pilot and releasing 600000 lateral flow test kits for local authorities to use on asymptomatic people “ at their discretion “.

    So far, 87 Local Authorities have opted to take part in this new pilot programme. Each will receive weekly batches of 10000 test kits

    ASSESSMENT

    The roll out of mass testing on people without symptoms is happening at an alarming pace

    SAGE s advice [14] on 10 September 2020 was that: –

    “Prioritising rapid testing of symptomatic people is likely to have a greater impact on identifying positive cases and reducing transmission than frequent testing of asymptomatic people in an outbreak area”.

    Some highly respected scientists and public health doctors have criticized the conclusions drawn from the evaluation of these novel tests – namely that they are sensitive and specific enough to use on asymptomatic people.

    Others have described these mass testing programmes [originally part of Operation Moonshot] to be “scientifically unsound unethical, unevaluated and a costly mess “ [3,4]

    What are these concerns?

    [Refs 3,4,5,6 7,8]

    1 Accuracy of the tests

    1. The relationship between these novel tests being positive and clinical infectiousness is unknown. [8]

    Sensitivity

    2 The lateral flow tests chosen for mass testing are not sensitive enough to accurately detect infection when used on asymptomatic people.

    Between 1 in 4 and 1 in 2 infectious cases will be missed, when used in the field. Many people will be given false reassurance that they are not infectious and need to have repeat “gold standard” PCR tests to confirm the results.

    Specificity

    3 When infection rates are low or prevalence is falling as it is in Liverpool , a large number of people will falsely test positive and be told to self isolate. Many will experience the harmful and regressive effects of self-isolation.[ 7 ]

    2 Design and evaluation

    The National Screening Committee and National Institute for Health Research (NIHR) have not been involved or asked about the design of this programme.

    Their design lacks transparency and a clear set of objectives.

    No criteria or protocols for evaluation have ever been made available in the public domain.

    Unlike other screening programmes, there is no systematic call or recall of an identified, registered population and no expectations about population reach or uptake.

    [Initial findings from the Liverpool pilot would appear to indicate that those most at risk of being infected have been the least likely to come forward for testing.

    Positivity rates amongst the 110, 000 people tested so far are low [about half that of the current prevalence [ 2.2%] in the north west region [11]

    3 Follow up of positive cases and their contacts

    More cases will generate many more contacts to follow up

    In Liverpool, follow up of positive cases and their contacts has been entrusted to the national Test and Trace system. Over the last 4 months, this national system has only been reaching around 58% of contacts  [10] i.e. well below that required to stop onward transmission.

    4 Ethical issues

    The ethical basis for expanding mass testing using novel tests is very shaky.

    These pilot programmes have not undergone the normal process required for ethical approval.

    People are invited to have a test which has not yet been properly peer reviewed. The results of these tests if positive could have serious consequences for their personal freedoms, income and well-being. [7]

    There are also concerns about the process and practices for gaining consent to participate.

    4 Sustainability

    The government has, yet again, chosen to use a separate and privately run infrastructure to deliver this mass testing pilot programme.

    If rolled out nationally, the Liverpool population mass testing programme would need the equivalent of 260, 000 army personnel to deliver it. It is hugely expensive and not sustainable.

    Other options, such as using existing well distributed highly accessible primary care services [including local pharmacies] to provide rapid access testing should have been explored.

    5 Overload of local authorities and public health teams

    The burden of organizing new testing programmes for asymptomatic people will place another strain on already overburdened local public health teams.

    Their priorities should be to: –

    • Identify and manage clusters of cases /outbreaks in high risk settings such as schools, care homes, prisons and other geographical hot spot areas [12]

    • Improve adherence to isolation through organizing support and accommodation for people who are finding it difficult to self isolate. [13]

    6 Implementation

    Implementation has so far been rushed –leading to long queues of both symptomatic and non-symptomatic people, wrong invitation letters issued by schools and questionable practice in relation to “ informed consent”.

    The lack of rigour and consistency with respect to research design and implementation across different local authorities means that it will be very difficult understand the impact of these new mass-testing programmes on COVID transmission.

    Conclusion

     The widespread introduction of these mass screening pilot programmes using novel tests can have serious consequences for people’s lives.

    Politicians need to understand that concerns expressed about the choice of tests and the design of these programmes are not just a matter for academic debate or professional discussion.

    Accepted standards for design, ethics and evaluation must be adopted – otherwise they could seriously undermine public trust, confidence and future willingness to engage in helping to control this pandemic.

    RECOMMENDATIONS

    1. The continued roll out of these mass screening pilot programmes should be paused immediately.
    2. 2 The UK National Screening Committee should have oversight of their design and implementation
    3. Mass screening ‘pilot “programmes should be funded as research – and undertaken through the NIHR in order to ensure public and patient benefit
    4. Primary care service [including local pharmacies] should be the preferred route for the future distribution of rapid access tests if these are recommended for use by the general population

    References

    1 https://www.gov.uk/government/news/more-rapid-covid-19-tests-to-be-rolled-out-across-england

    2 https://www.ox.ac.uk/sites/files/oxford/media_wysiwyg/UK%20evaluation_PHE%20Porton%20Down%20%20University%20of%20Oxford_final.pdf

    https://www.bmj.com/content/370/bmj.m3699

    Operation Moonshot proposals are scientifically unsound]

    Jonathan J Deeks, Anthony J Brookes, Allyson M Pollock

    BMJ 2020; 370: m3699  (Published 22 Sep 2020)

     

    4 https://www.bmj.com/content/371/bmj.m4436

    https://www.sochealth.co.uk/2020/11/05/asymptomatic-covid-19-screening-in-liverpool/

    6 https://blogs.bmj.com/bmj/2020/11/09/screening-the-healthy-population-for-covid-19-is-of-unknown-value-but-is-being-introduced-nationwide/

    7 Waugh P. NHS test and trace chief admits workers fear “financial” hit if they self-isolate. Huffington Post 2020 Nov 7.

    8

    https://journals.sagepub.com/doi/full/10.1177/0141076820967906

     

    9 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/926953/S0743_SPI-M-O_Statement_on_population_case_detection.pdf

     

    10 https://www.gov.uk/government/publications/nhs-test-and-trace-england-and-coronavirus-testing-uk-statistics-1-october-to-7-october-2020

     

    11 https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/coronaviruscovid19infectionsurveypilot/6november2020#regional-analysis-of-the-number-of-people-in-england-who-had-covid-19

     

    12 https://www.cdc.gov/coronavirus/2019-ncov/global-covid-19/operational-considerations-contact-tracing.html

     

    13 Covid-19: breaking the chain of household transmission. BMJ2020;370:m3181.doi:10.1136/bmj.m3181 pmid:32816710

    14 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/926953/S0743_SPI-M-O_Statement_on_population_case_detection.pdf

    Comments Off on The Moonshot mistake

    Issue: 111 – 10 November 2020

    Pfizer Covid-19 Vaccine

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

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

    Very Steep Rise in Secondary School Covid-19 Infection Rates

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

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

    https://neu.org.uk

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

    Hospitals are Breeding Grounds for Covid-19 Infections

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

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

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

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

    www.nspcc.org.uk

    www.childline.org.uk

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

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

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

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

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

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

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

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

    More at:

    https://allysonpollock.com

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

    Reduced Support for the Homeless in Lockdown 2

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

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

    One week into Lockdown 2

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

    Southall Park: 265.3 became 244.1

    Ealing Broadway: 247.6 became 281.4

    Acton Central: 147.8 became 113.7

    West Ealing: 132.9 became 122.9

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

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

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

    Town/Hospital Based NHS Activist Groups Slowly Being Marginalised

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

    NHS NWL EPIC

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

    Public Involvement Charter (PIC)

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

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

    Eric Leach

    Comments Off on Our NHS in Crisis

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

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

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

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

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

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

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

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

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

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

    Yours sincerely,

    Allyson Pollock

    Professor of Public Health, Newcastle University

    Anthony J. Brooks

    Professor of Genomics and Bioinformatics, Leicester University

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

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

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

    Comments Off on Asymptomatic Covid-19 screening in Liverpool

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

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

    1. Austerity (2010-2020)

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

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

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

    1. Poor political leadership (PM and SoS Health)

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

    1. Social care

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

    1. Inequalities

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

    1. Privatisation

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

    1. Recovery Planning

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

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

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

    NHS and NIHR

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

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

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

    A wealth tax?

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

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

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

    Populism and COVID

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

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

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

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

    27.7.2020

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

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    The BMA is urging the Government to ensure more people take advantage of routine vaccinations after a concerning fall in coverage rates in recent years.

    In a report published today, the Association says that many immunisation programmes have been disrupted because of the pandemic as the NHS focused on responding to immediate health concerns and now it’s imperative that they are re-started and that people are encouraged to be immunised.

    It also notes that childhood vaccination in particular has plummeted during this time – dropping by around a fifth in total – despite advice that childhood immunisation should continue during Covid-19.

    According to NHS Digital, and highlighted in this report, coverage for the first dose of the MMR vaccine in England was at 94.5% in 2018-19, down from 94.9% in 2017-18 and below the 95% target set by the World Health Organisation (WHO).

    The BMA’s report says that making people aware of the benefits of routine vaccinations, such as the MMR vaccine, is vital. This is not just for their wellbeing, but also when we consider worrying reports about a lack of confidence in a potential Covid-19 vaccine and the implications that could have for general uptake.

    Altogether, the BMA is calling for action to:

    • widen vaccine availability and target specific populations
    • ensure adequate funding to deliver fully resourced immunisation services
    • raise public awareness and understanding of immunisation programmes
    • ensure health service IT supports vaccine uptake
    • increase vaccine uptake among NHS workers

    Dr Peter English, BMA public health medicine committee chair, said: “It’s been incredibly worrying to watch the decline in vaccine rates in the UK over the past few years –  for example, we lost our ‘measles-free’ status in 2019 and the pandemic has of course meant even fewer vaccinations have been carried out as the NHS battled on all fronts to keep the virus at bay.

    “Routine vaccination is so important, and many doctors can remember a time without it. Vaccination against common but often serious ailments has changed the face of public health and are rightly ranked by WHO, alongside clean water, as the public health intervention which has had the greatest impact on the world’s health.

    “That’s why, as we recover from this pandemic, everything must be done to increase vaccine uptake – particularly as we head into flu season and vulnerable people are at greater risk of becoming ill.

    “This means not only making sure the public understands the importance of getting vaccinated, but also resourcing the health service with what it needs to deliver this; adequate funding for immunisation programmes, IT services, and encouraging staff to protect themselves too.

    “Health has never been more at the forefront of people’s minds, and the Government needs to utilise this as a matter of urgency – not just for the sake of the population now, but the generations that follow.”

    Oliver Fry

    The BMA is a trade union and professional association representing and negotiating on behalf of all doctors in the UK. A leading voice advocating for outstanding health care and a healthy population. An association providing members with excellent individual services and support throughout their lives.

    Posted on behalf of the BMA by Jean Hardiman Smith

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

    Blame Game

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

    Local Authorities and their Public Health teams

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

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

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

    Local data

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

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

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

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

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

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

    Workers and Employers

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

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

    Civil servants

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

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

    National Audit Office

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

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

    Vaccines and global health

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

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

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

    Gramsci

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

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

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

    20.7.2020

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

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    Week 18

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

    Facemasks

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

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

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

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

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

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

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

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

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

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

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

    Sharing Test Results

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

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

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

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

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

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

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

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

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

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

    Don’t blame PHE and the NHS.

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

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

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

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

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

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

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

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

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

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

    Clap Clap.

    13.7.2020

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

    2 Comments

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

    Local lockdown

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

    Outbreak plans

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

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

    Public Health England review

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

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

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

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

    Deprivation and health

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

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

    The garment industry

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

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

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

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

    Health and Safety

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

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

    Incompetent government.

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

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

    incompetent people don’t realise their incompetence’.

    5.7.2020

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

    1 Comment

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

    Test and Trace

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

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

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

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

    Workplaces

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

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

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

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

    Contact tracing

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

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

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

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

    Social distancing

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

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

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

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

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

    29.6.2020

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

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    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.

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    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.

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