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

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

    Lonely Ministers

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

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

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

    What is the strategy?

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

    Led by the science?

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

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

    Test, Trace and Isolate (TTI)

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

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

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

    Auditing misuse of public funds

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

    BAME communities and COVID

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

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

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

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

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

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

    7.6.2020

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

    2 Comments

    Class and race are the biggest factors in determining those that have died or been taken ill by Covid-19, Unite, Britain and Ireland’s largest union, said today (Tuesday 2 June).

    Unite called for a raft of policies to tackle the ‘systemic failures’ that has led to the disproportionate death toll amongst the Black, Asian and minority ethnic (BAME) communities and also the poorest groups in society

    The union was commenting on Public Health England’s report Disparities in the risk and outcomes of Covid-19 which highlighted those groups that had been hardest hit in terms of mortality due to coronavirus.

    Unite assistant general secretary Gail Cartmail said: “This report shines a searing light that reveals the pandemic in the UK is intrinsically linked disproportionately to class and race.

    “These wide disparities are detailed in this data and point to age, race and income and accompanying health inequalities as key determinants as to whom has been the worst affected by Covid-19.

    “This has been amplified among those in undervalued occupations and jobs where zero hours’ contracts and precarious employment are the norm.

    “Working hard to provide for your families is no defence against Covid-19 for these groups – these systemic failures need to be tackled urgently and that work should start now.

    “No one policy size fits all, but such an agenda should include ethnically sensitive risk assessments and income guarantees for workers who through ‘test, track and trace’ would otherwise be reliant on statutory sick pay (SSP), while in isolation.

    “The Real Living Wage should be the basic minimum for those in ‘at risk’ occupations as an interim measure, with a commitment to sectoral bargaining for care workers and the guarantee of the necessary funding.

    “All these measures are achievable with government support. If austerity is over, as ministers claim, the best defence against the inequalities which the report exposes is to narrow the income gap and invest in public services with priority to social care.

    “The pandemic has shown that the crisis in social care can no long be pushed into the political long grass. The lack of testing for residents and staff, and also the shortage of PPE, in care homes has wreaked a terrible toll on the elderly who have died in their thousands due to Covid-19.

    “Social care can no longer be regarded as the poor relation when it comes to funding from the budgets of central and local government – a ministerial blueprint for social care should be a top priority as we emerge from the lockdown.

    “Poverty is the parent of disease and Covid-19 has been a willing accomplice in this respect. Once this pandemic has passed, we need to look as a country anew to how we can recalibrate economic and social policies to create a fairer society.

    “All these issues must be investigated in depth when the post-pandemic public inquiry takes place, which will be needed in the interests of accountability, openness and transparency.”

    The PHE report said that those parts of UK society most affected included the elderly; Black, Asian and minority ethnic (BAME) populations generally and those BAME NHS staff on the frontline in particular; those with underlying conditions, such as diabetes and dementia; those living in care homes; and those from deprived communities.

    Twitter: @unitetheunion

    Facebook: unitetheunion1

    Web: unitetheunion.org

    Unite is Britain and Ireland’s largest union with members working across all sectors of the economy. The general secretary is Len McCluskey.

     

     

    1 Comment

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

    Germany and Greece 

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

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

    Test, trace and isolate

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

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

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

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

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

    Independent SAGE

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

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

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

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

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

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

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

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

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

    When should a School Reopen?

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

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

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

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

     

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

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

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

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

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

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

    31.5.2020

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

    1 Comment

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

    The Westminster Government announced on May 10th that:

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

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

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

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

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

    We believe that the Government should have considered the following:

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

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

    Test one: Making sure the NHS can cope

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

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

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

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

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

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

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

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

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

    Sources

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

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

    NEU five tests for Government before schools can re-open

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

    ONS figures reveal 65 COVID-related deaths in education workforce

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

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

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

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

    Prof John Edmunds

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

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

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

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

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

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

    Comparative school age starts

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

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

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

    Formal learning in early years linked to criminality in teens

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

    Posted by Brian Fisher on behalf of the Policy Team.

    Comments Off on SHA statement on reopening schools in England during the COVID19 pandemic

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

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

    1. Key messages:

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

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

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

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

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

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

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

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

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

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

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

    • Real time analysis and assessment of infection

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

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

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

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

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

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

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

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

    We are concerned that the Government has

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

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

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

    Conclusions

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

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

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

    Sources

    Posted by Brian Fisher on behalf of the Policy Team.

     

    Comments Off on Briefing Topic 3 – Test, Trace, outsourcing

    The Battle of the Surcharge – won

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

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

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

    Who is Dominic Cummings?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    From Vivien Walsh (Greater Manchester)

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

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

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

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

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

    3 Comments

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

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

    Key messages

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

    Source: Douglas et all, BMJ April 2020

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

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

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

    Conclusions:

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

    Actions

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

    Sources

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

    Posted by Brian Fisher on behalf of the Policy Team.

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    Public meeting Wednesday June 3 – Get your ticket!

    We would like to invite you to our first virtual Zoom public meeting

    Internationalism in the Post Covid-19 World

    Wednesday 3rd June, 6pm to 8.30pm

    Speakers are: Harsev Bains, Baroness Christine Blower, Dr Kailash Chand, Jeremy Corbyn MP, Jacqui McKenzie, Murad Qureshi AM.

    Please register for this event at liberation.org.uk/event  And pass it on to friends and colleagues!

    Joint event by The Socialist Health Association and Liberation.

    Please contact Jean Hardiman Smith at admin@sochealth.co.uk for more information.

    Comments Off on Coronavirus: Join us at our first virtual public meeting featuring Jeremy Corbyn

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

    Too slow to act

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

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

    Protect the NHS

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

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

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

    The Privately owned Social Care sector

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

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

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

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

    Follow the money

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

    Test, trace and isolate (TTI)

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

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

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

    Game changers – and what is the game?

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

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

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

    Palantir

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

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

    Conclusion

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

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

    24th May 2020

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

    2 Comments

    Vested interest alert – yes I’m claiming that word back – I come from a family of school staff, teachers, TAs, school governors. The dedication and hard work of all school staff, caretakers, cleaners, cooks, governors have shown for the safety, education, well-being, in many instances feeding, their pupils throughout this crisis has been extraordinary.

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

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

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

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

    Theresa Griffin Labour MEP North West 2014-2020

    Member SHA

    1 Comment

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

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

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

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

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

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

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

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

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

     

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

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

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

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

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

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

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

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    Introduction

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

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

    Game changers

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

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

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

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

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

    Local Authorities and Public Health

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

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

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

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

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

    Social Care

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

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

    Moving out of Lockdown

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

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

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

    Scrutiny of Public Expenditure

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

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

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

    Finally

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

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

    17th May 2020

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

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