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

    Blame Game

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

    Local Authorities and their Public Health teams

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

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

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

    Local data

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

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

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

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

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

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

    Workers and Employers

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

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

    Civil servants

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

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

    National Audit Office

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

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

    Vaccines and global health

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

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

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

    Gramsci

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

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

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

    20.7.2020

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

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    On Saturday July 4th, the day before the 72nd anniversary of the founding of the NHS – we demonstrated, jointly with Manchester Trade Union Council, with Unison, Unite and any other unions involved, with Keep Our NHS Public and with Health Campaigns Together (with PPE and social distancing) against the privatisation of the Department of Reproductive Medicine at St Mary’s Hospital Manchester.

    NEXT EVENT

    VIRTUAL PUBLIC MEETING: No privatisation of Manchester’s fertility service!
    Monday, 20 July 2020 from 19:00-20:30

    Details at the end of this article

    Women in the Labour Movement have been campaigning for at least 100 years on issues of maternal health and the right to choose whether and when to have children, and to use any technological advances that might make those choices easier, or even possible. From 1924 onwards the Women’s Labour League annually and unanimously supported birth control. The men in the Labour and Trade Union Movement were not always so unanimous, or so interested in the subject.

    In 1924 the first Labour Government was elected, and the League bombarded John Wheatley – the first Labour Minister of Health – with demands for improved health care in childbirth and after, and for the provision of free, state birth control clinics. They organised meetings and major demonstrations. They kept reminding him that giving birth had four times the death rate of working in the mines, the most dangerous job for men, and twenty times the likelihood of permanent disability.

    However, it was not until 1974 – another 50 years later – that women achieved the right to free contraception on the NHS, irrespective of age or marital status, by which time I had joined the Labour Party and it was one of the issues I was campaigning for myself, first through the Young Socialists and then the Labour Women’s organisation . Nowadays, men can also get free vasectomies  and, whether for contraception or protection against HIV, free condoms on the NHS, also irrespective of age. None of these successes, in areas where some people like to make moral rather than medical judgements, was easy or straightforward.

    For example, even after the beginning of the decriminalisation of homosexuality for men in 1967, homophobia was still rampant for many years. Thus, more than 20 years later in 1988, Thatcher was able to introduce Clause 28. Roy Trevelion (London SHA member) in Age UK’s Opening Doors London, likens the mental health of many HIV positive men – as a consequence of the AIDS epidemic and ongoing homophobia – to Post Traumatic Stress Disorder. Most gay men who obtained free condoms would have been more likely to get them from organisations like the Lesbian and Gay Foundation in Manchester (and similar ones elsewhere), which is registered as a charity and raised money to provide them on that basis. Many gay men would have been more able and less anxious to get their condoms from peer-support charities like this than to risk accidentally outing themselves at the doctor’s or clinic.

    The post World War II economic boom brought rising employment of women and improved living standards, and with increased confidence, women demanded recognition for their contribution to society and the right to control their own lives. These led to the Abortion Act 1967 as well as to Equal Pay (1970) and Sex Discrimination (1975) legislation, and the right to paid maternity leave (1975). The Abortion Act did not give women the right to choose, but made it legal for abortions to be carried out with the approval of two doctors under certain circumstances. In effect it decriminalised what women had been doing for centuries, just as the 1967 Sexual Offences Act (partially) decriminalised homosexual acts between men.

    Making abortion illegal in 1861 had not stopped it, and the 1967 Act did not encourage it: it just made the difference between a woman dying as a consequence, or surviving. (In Romania, abortion was illegal until 1989: but abortions still outnumbered live births – in 1987 by four to one.) I remember providing accommodation to Spanish women coming to the UK for abortions before 1985, when it became legal in Spain, and from the Republic of Ireland before the end of 2018 when it was legalised there.

    However, the 1967 Abortion Act, like the 1967 Sexual Offences Act, was not the end of the matter. There were several attempts to repeal or considerably amend the Abortion Act, such as the White Bill, the Corrie Bill and the Alton Bill, which gave rise in turn to their own protest movements. A very large demonstration against the Corrie Bill was called by the TUC (on the initiative of the Women’s TUC) in 1980, the first time in the world that a major trade union federation had called a demonstration on abortion rights; and another against the Alton Bill in 1988, again with the support of the trade union movement. None of these Private Member’s Bills was successful, but in the end the period during which abortion could be legally carried out was reduced to 24 weeks in 1990, by the Human Fertilisation and Embryology Act.

    The Human Fertilisation and Embryology Act, based on the recommendations of the Committee of the same name, chaired by Mary Warnock, was passed in 1990. When it was originally passed it allowed access to infertility treatment, such as Artificial Insemination or In Vitro Fertilisation, at a cost (in money and patience, especially with IVF) but it also required the women who wanted medical assistance to become mothers, to conform to a very traditional view of motherhood and the family, as reflected in the attitudes of doctors, hospital ethical committees and the Warnock Committee at that time, and laid down in Codes of Practice. These were not medical decisions but social and moral ones.

    For example, to be “suitable” for treatment, a woman had to be living in a stable relationship with a man, and usually had to be able-bodied. Some clinics were reluctant to treat couples where the man was not in work, or the woman not prepared to give up work. Single women and lesbian couples were not usually eligible.  Tory MP David Wilshire made it clear in his speech that he was particularly concerned that “assisted conception” would not produce families dependent on the state, and another amendment was passed to include “the need of a child for a father”.

    Why is Reproductive Technology a Political Issue?

    Thirty years ago I wrote those words in a book called “Whose Choice?”, published at the time of the Human Fertilisation and Embryology Bill which became law in 1990. The question was why the Labour Movement should take up issues such as contraception, abortion and treatment of infertility, which were often seen as purely personal matters.

    My answer, on behalf of the (then) Manchester and Liverpool Labour Women’s Councils, was that it was our belief that decisions about whether or not to have children, how many to have, whether or not to have an abortion or use any of the technologies available to overcome or by-pass infertility, or to avoid having a child with disabilities, or to enable those of us who were lesbians to become parents, were all personal decisions to be taken by the individuals concerned, and not by the Church, the State or the Medical Profession.

    And since it is women who give birth to children and even now usually bear the main responsibility for child rearing, these decisions must primarily be theirs. As socialists we argue for women to have the maximum choice possible in the decisions that shape their lives.

    The campaign then – and still is now – was not just for legal rights, but for the practical means to realise them. In order for a working class woman to have the choices already available to richer women, she must have the economic means (a living wage or income), and necessary social arrangements, such as childcare and decent housing, so that she can choose to have a child. It means expanding the NHS, taking back control of the services that have been contracted out to the private sector, resisting any further attempts to privatise parts of the NHS, and running the NHS democratically so that women can have access to free and safe abortion, contraception, artificial insemination and IVF treatment.

    It means carrying out the research to find contraceptives that meet the needs identified by both women and men; research to enable women to have earlier abortions and make them safer; research into causes of infertility and its prevention; research into chromosomal and genetic disorders and their prevention; and research into products and services that would improve the lives of disabled people.

    All these things are entirely reasonable and technically possible; but they raise, in turn, important – essentially political – questions. Who does the research and in whose interests? The rubber goods manufacturers (for decades before the 1960s, clandestine or even illegal): the vulcanisation of rubber revolutionised birth control as well as road transport; but  nowadays research is dominated by the pharmaceutical industry. And of course the research is done to make a profit.

    The drug industry is one of the most research-intensive sectors: but it spends more on marketing and advertising than on research. That was the case when the last official UK Government report on the industry was published (The Sainsbury Report, HMSO, 1967) and it was even more the case, according to the most recent figures (OECD Main Science and Technology Indicators, annual, covering all OECD member countries in the year of publication.)

    Pressure to be first to market can lead to corner-cutting in testing: the most notorious case where this happened was Thalidomide, a tranquilliser that had been declared safe, and was explicitly prescribed, for pregnant women. But it caused major deformities in their babies who were, most notably, born either without some or all of their limbs or with major deformities in them.

    Although it was known by then that some drugs could cause foetal damage, it was not yet specifically a legal requirement to test for them, and the tests were not done. (Only the USA’s Food and Drug Adminstration refused to grant a licence for thalidomide to be prescribed, because the FDA official responsible insisted on having evidence on the foetal effects of the drug, which were not available.) Criticism of government “interference” in the affairs of business is very common in the United States (often framed as interference in the public’s right to choose – except women’s right to choose abortion). Today the FDA is still the butt of criticism of lack of freedom from government interference.

    The Warnock Report, on which the Human Fertilisation and Embryology Bill was based, commented on the lack of research into causes of infertility. This is still the case to some extent, though knowledge in this area has been increasing since the discussions around the Warnock Report and the debates on the Human Fertilisation and Embryology Bill.

    But we can be sure that thorough studies, once publicised and popularised, will lead to increased demands for improved health and safety at work; and for the replacement of industrial processes, chemicals and other materials causing infertility; and that responding to these demands would threaten profits. A thorough study would also raise questions about the under-funding of the NHS and the number of diseases that are not adequately diagnosed, or possibly not adequately treated, and which lead to infertility.

    The issue of women’s rights in reproduction is therefore a political and class question: not just because it is mainly working class women and men who are affected by lack of choice and unsafe working conditions, but also because the ability of all women to have a real choice will only be possible as a result of the struggle of working class women and men to change society. This means campaigning on reproductive rights as well as on better housing, higher wages and defence of the NHS. It especially means we must control the resources of society and organise them for need rather than profit.

    St Mary’s Department of Reproductive Medicine (DRM) – Summary of Background Briefing

    St Saint Mary’s Hospital, Manchester, was founded in 1790. Today it provides a wide range of medical services, mainly for women, babies and children. It is highly regarded for teaching and research, and has an internationally recognised Genomics Centre and Department of Reproductive Medicine (DRM). The DRM employs 70 staff and delivers clinical, laboratory and counselling services for about 3000 patients a year. Most of St Mary’s services and research activity is carried out in a building dating from the late 1960s. In 2009 paediatric services were transferred to the newly built Royal Manchester Children’s Hospital on the same site.

    The issue at the centre of the protest is that the DRM is housed in the Old St Mary’s Building (also on the same site) which dates from just after the death of Queen Victoria, and is in desperate need of repair. Manchester University NHS Foundation Trust (MFT) believes that relocation of DRM within the Trust could cost up to £10 million just in capital expenditure, and is talking about privatisation.

    DRM offers a fertility assessment and infertility service. Artificial Insemination and IVF are offered to women who may benefit, on referral by a GP. This can be both NHS funded and private – the latter for women for whom it is clinically appropriate but whose CCG would not fund the necessary cycles of treatment. It offers a fertility preservation service for patients who wish to preserve eggs or sperm while having medical treatment – eg for cancer – that might affect future fertility. DRM offers sperm-testing and specialist treatment for patients whose sperm has been identified as presenting fertility issues; and on the other hand post-vasectomy checks.

    An anonymous or by-arrangement sperm-donation service is also offered to lesbians, and to heterosexual women either without a partner or who cannot conceive with their partner’s sperm for any reason. The Department also offers a reproductive endocrinology service which focuses on the way in which hormones affect fertility; and specialist counselling to any of the patients using their services. DRM runs the national proficiency scheme involving distribution to other reproductive medicine labs across the country and checks that the results are consistent. Finally, the Department makes a significant contribution to fertility research in conjunction with the University of Manchester.

    In early March the Trust briefed all service staff that they would undertake a 12 month options appraisal exercise to identify whether the service should remain within the Trust or be re-commissioned elsewhere. (Since the pandemic this has been put back.) The unions argue:

    • that there would be significant capital costs involved in privatising the service, which would have to be borne by the hospital (eg to store embryos – the store would need to remain on the site and continue to be run, inspected and managed by MFT, because the cost of doing otherwise would be prohibitive).
    • that the service is unique in Greater Manchester, and to a large extent in the entire North West Region.
    • It has significant associated capital and operational costs so other NHS trusts are likely to be reluctant to bid to host the service.
    • The private sector may offer an option that appears to be cheaper, but offers a far lower level of service than that currently provided at St Mary’s – but the NHS might be obliged to accept the private bid, because it is lower.

    The unions are also concerned about the impact of any potential future privatisation of the service for many reasons, including:

    • St Mary’s offers specialist care to a number of people with Protected Characteristics under the Equality Act 2010, which might not be available under private sector provision.
    • The services offered by St Mary’s are highly specialised – Trafford CCG ring-fenced them on behalf of all the CCGs in Greater Manchester, not requiring them to participate in an IVF procurement exercise in 2019 for this reason.
    • The andrology service works with eg men with Cystic Fibrosis who are often infertile and need surgery if they wish to have a chance of creating a family, and another specialist service involving the only UK-based partnership with the long established FAIRFAX cryo-spermbank.
    • The National External Quality Assessment Scheme for reproductive medicine is currently based in the DRM laboratories. If DRM was closed or moved, this would need a new home, too.
    • The kind of research investment and relationship with academic institutions that St Mary’s has would not be replicated in private sector provision where profits have to be made.
    • Despite assurances from MFT, the unions believe that the terms and conditions of the staff in the private sector, if they had to move and could do so, would not be as good as those in the NHS under the Agenda for Change national pay system.
    • In other areas where NHS services have been privatised, there has often been an erosion of terms and conditions, and of collective bargaining, either through attrition over time or an aggressive stance by employers. Unions believe that this is a significant risk.
    • The cost to fee-paying patients is less than the alternative provision in the private sector, and for NHS patients, the NHS pays via CCGs around £4000 per IVF cycle at St Mary’s, but significantly more (£5-6,000) to private providers per cycle.
    • The DRM is part of St Mary’s and both are located on the MFT Oxford Road Campus next to the University of Manchester. Patients with co-morbidities and other conditions which may have an impact on their fertility and associated treatments, can benefit from the expertise and clinical care available within MFT close to their fertility treatment. At the same time, staff can benefit from the close proximity of other specialisms which may be relevant to a patient’s ongoing care.

    The Next Stage in the Campaign to Save St Mary’s

    There will be a public meeting (via internet) hosted by Keep Our NHS Public as below. Please join us via Greater Manchester Keep Our NHS Public (GM KONP)’s Facebook page.

    PUBLIC MEETING: No privatisation of Manchester’s fertility service!
    Monday, 20 July 2020 from 19:00-20:30

    https://www.facebook.com/events/280845443022548/

    The fertility service provided by the Department of Reproductive Medicine at St Mary’s hospital, Manchester, faces privatisation. According to reports, Manchester Foundation Trust announced earlier this year that the service would go over to a private company in 2021. This would be a disaster for the service and future patients.

    Now the Trust has begun an “options appraisal” over the future of the service. We insist that the #1 option must be keeping it public and keeping it where it is. We demand a public consultation so the people of Manchester have their say.

    Join our online public meeting to hear about the situation and how we can campaign to win. There will be discussion after the speakers, who are:

    Denise Andrews, Unison union rep, DRM
    Liz Holland, Unite the Union branch secretary, MFT
    James Bull, Unison union regional officer

    Pia Feig, a feminist perspective
    Chaired by Caroline Bedale, Greater Manchester Keep Our NHS Public and Greater Manchester Socialist Health Association.

    This will be a Facebook Live event broadcast through the event page.

    Mailing address for

    Keep Our NHS Public Greater Manchester

    c/o KONP national, Unit 12-13 Springfield House 5 Tyssen Street

    LondonE8 2LY

    United Kingdom

    Vivien Walsh (Greater Manchester SHA)

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    Week 18

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

    Facemasks

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

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

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

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

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

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

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

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

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

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

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

    Sharing Test Results

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

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

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

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

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

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

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

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

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

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

    Don’t blame PHE and the NHS.

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

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

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

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

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

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

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

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

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

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

    Clap Clap.

    13.7.2020

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

    2 Comments

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

    Local lockdown

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

    Outbreak plans

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

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

    Public Health England review

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

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

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

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

    Deprivation and health

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

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

    The garment industry

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

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

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

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

    Health and Safety

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

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

    Incompetent government.

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

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

    incompetent people don’t realise their incompetence’.

    5.7.2020

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

    1 Comment

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

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

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

    BAME

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

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

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

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

    Test and Trace

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

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

    The app!

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

    PPE contracts

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

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

    And finally

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

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

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

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

    Hear hear.

    22.6.2020

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

    Comments Off on SHA COVID-19 Blog 15

    This paper was developed by a group of primary care clinicians for the Labour Shadow Health Team at their request. We hope it helps illuminate the next steps for primary care.

    WHAT ARE THE RISKS, OPPORTUNITIES AND CHALLENGES FACING  PRIMARY CARE PROVISION DURING AND AFTER ITS RETURN  TO A NORMAL STATE OF OPERATION?

     

    “We will be facing some tough challenges over at least the next year: managing more consultations (and clinical risk) remotely by phone or video; catching up with resurgent patient demand, catching up with the care of long-term conditions (whilst trying to protect groups of vulnerable people from a continuing threat of Covid); managing a backlog of people who need to be referred; and coping with any spikes in Covid. This comes on top of the usual (preceding) strains on limited resources and lengthening ‘winter pressures.’ I don’t think that we will be seen as ‘NHS heroes’ in a few months!”

     

    DIGITAL WORKING IS TRANSFORMING CARE

    Opportunities

    • Easier and more flexible for people and practices, so may aid GP recruitment
    • The complex and subtle nature of the consultation seems to be maintained
    • Communication across sectors can be dramatically improved. One GP described helping a patient with lymphoma – in 10mins he was able to include a Ca nurse and consultant in a conversation with the patient.
    • Telephone triage also successful
    • Bricks and mortar general practice may become less necessary
    • Combining online personalised advice with online access to records opens the way to improved self-care

    Challenges:

    • Digital can widen inequalities and disenfranchise. Experience suggests it is the elderly rather than the poor who struggle the most.
    • The best balance between remote and face-to-face is unclear. Video may be best for follow-ups.
    • Video is seldom preferred by people. The telephone or face to face are most popular.

    Actions:

    • Support the elderly to become more digitally able while ensuring that traditional approaches remain available
    • Support digital cross-sector working: GP/hospital/Social Care
    • Encourage digital mentoring to improve self-care for people with LTCs

     

    SHIFTING TO PROACTIVE WORK WITH COMMUNITIES

    Opportunities

    • The spontaneous rise in mutual community organisations has been remarkable, often outwith the traditional voluntary sector, improving safeguarding and perhaps saving lives.
    • Primary care has been able to embrace that.
    • It offers a model for the future
    • There have been many examples of successful cooperation with communities, but they have been dependent on local circumstances and local heroes.
    • The health gain comes when communities can take more control over the area and their lives
    • The NHS and local government need to create the conditions whereby communities can work collaboratively with the statutory sector sharing decisions with their communities. We need a systematic approach for mobilising civil society, working with NHS and LAs.
    • PCNs offer a good base for such cross-sector working

    Challenges:

    • Sharing decisions with communities is a difficult skill the NHS would have to learn, perhaps from LAs and housing associations.
    • Building on existing work and with councillors would be essential. No new unnecessary initiatives.

    Actions:

    • Jointly fund, via NHS and LA, community development workers in each PCN, working with social prescribers. They would support the statutory sector sharing decisions with their communities.
    • Primary Care to be encouraged to support community groups and community development by, for instance, enabling practice space to be used by communities.
    • Asset mapping with LA and PH colleagues would be one early step
    • Encourage and incentivise cross-sector working.

     

    PRIMARY CARE TO ACTIVELY WORK ON THE SOCIAL DETERMINANTS OF HEALTH AND HEALTH INEQUALITIES

    These have been thrown into sharp relief through the pandemic.

    Opportunities

    • Essential to make any progress on health improvement
    • Community development can assist
    • Local work on poverty, race issues, migrant issues, housing
    • Cross-sector working is essential to do this.

    Challenges

    • The independent contractor status of general practice may hinder this process.
    • Cross-sector working is difficult
    • It is political work

    Actions

    • Promote training GPs with a Special Interest in Public Health, sitting astride the PCN and LA
    • Support areas to become Marmot towns.
    • PCNs to link formally with LAs
    • Boost the status and effectiveness of Well-Being Boards
    • Borough-level linking (not merging) of LAs and NHS.

     

    PRIMARY CARE AND LONG-TERM CONDITIONS INC COVID

    Opportunities

    • The importance of community service provision has been made plain by the pandemic
    • Extensive primary care services and rehab re likely to be required for people recovering from Covid

    Challenges

    • Managing more serious illnesses outside hospital may require differently trained primary care staff such as District Nurses

    Actions:

    • Use a range of approaches to contact those who have delayed seeking help for potentially life-threatening illnesses
    • Digital self-care with remote links to home monitoring such as BP, weight, Peak Flows
    • Secondary care doing remote consultations to reduce the backlog
    • Explore a range of differently skilled staff for primary care

     

    RELAXATION OF RULES HAS BEEN HELPFUL

    Opportunities  

    • There has been relaxation of some bureaucracy
    • Flexible approaches have enabled doctors to return to the workforce.
    • These changes have enabled GPs to devote more time to patient care.

    Challenges

    • Some of this bureaucracy is useful. We don’t want wholesale deregulation: that has often been dangerous
    • It is difficult to know which parts need to be kept and which don’t.

    Actions

    • Explore with the profession which regulatory aspects need to be kept and which don’t.

     

    FUNDING, TRAINING AND STAFFING

    Challenges

    • Primary care, GPs, HVs and DNs remain substantially understaffed. This must change.
    • Different training requirements may be needed for a different future.
    • The RCN is calling for wage increases for nurses

    Actions:

    • A system to support on-going review and remodelling of workforce capacity is needed to ensure that the primary care workforce is responsive to emerging need which may increase over time.
    • Clarification of plans for student health visitors and others who have had their training disrupted during the pandemic

     

    STAFF SAFETY IN THE TIME OF COVID

    • Continued need for PPE to protect staff and patients
    • Mental health support for staff

     

    PRIMARY CARE BUILDINGS

    Challenges:

    • Many primary care buildings were inadequate before Covid
    • Many more now need redesign to cope with new patient flows and requirements for cleaning etc

    Actions:

    • Funding must be found where premises need improving
    • Consider links with housing associations

     

    BOOSTING DEMOCRACY IN THE NHS

    Challenges

    • The NHS has used the Coronavirus Act to push through significant changes to the infrastructure of ICSs. This is baking in the risks posed by them: privatisation, fragmentation and cuts.
    • Hosp reconfigurations are happening rapidly without consultation and no equality assessment

    Actions

    • Call out these dangerous changes and use them to explore new approaches to democracy. For instance:
      • PCNs run with a Board with a broad representation of opinion
      • Link PCNs and local government through local forums with budgets – a form of participatory budgeting
      • Community development would assist participatory democracy

     

    ADVANCED CARE PLANNING

    Opportunities

    • Advanced care planning will need to sensitively change for the better.
    • General practice is well- placed to have discussions that allow patients to express their wishes, which will reduce unnecessary and possibly undignified hospital admissions.

    Challenges

    • There seemed to be sporadic inappropriate behaviour from CCGs and practices issuing blanket DNR notices to care homes
    • The pandemic seemed to cast a harsh light on relationships between some practices and care homes

    Actions:

    • Patients suitable for advanced care planning conversations could be identified— perhaps informed by frailty scores — and discussed in multidisciplinary meetings as part of routine care.
    • The public need to be involved, and the sector need to emphasise that these discussions are about providing quality of care.

     

    SOURCES:

    https://www.rcn.org.uk/news-and-events/blogs/covid-19-out-of-this-crisis-we-must-build-a-better-future-for-nursing

     

    https://ihv.org.uk/our-work/publications-reports/health-visiting-during-covid-19-an-ihv-report/

     

    A brave new world: the new normal for general practice after the COVID-19 pandemic.

    https://bjgpopen.org/content/early/2020/06/01/bjgpopen20X101103

     

    https://www.rcgp.org.uk/policy/fit-for-the-future.aspx

     

    CONTRIBUTORS

    Dr Onkar Sahota

    Dr Duncan Parker

    Dr Joe McManners

    Dr Robbie Foy

    Dr Brian Fisher

     

    CONFLICTS OF INTEREST

    Dr Fisher:

    I am Clinical Director of a software company called Evergreen Life www.evergreen-life.co.uk . We are accredited by the NHS to enable people to access for free online their GP records, to book appointments and order repeat prescriptions. We try to help people stay as fit and well as possible.

    Comments Off on SHA Briefing – Primary Care

     

    1.   Background

     

    1. SHA Cymru Wales is pleased to take the opportunity to help shape Welsh Labour’s policies in regard to health and social care in Wales. Our submission is the product of discussions among SHA members in Wales facilitated via several Zoom sessions and exchanges between members of drafts of the emerging response. The contents reflect the views of our membership. Our membership consists of past and current NHS and care staff from a wide variety of health and care backgrounds and also others who have interests as both citizens and users of different parts of the health and care system in Wales, or who are interested in the politics of health and care, and in political discussion.
    2. The Party explained that the consultation document was finalised before Covid-19 arrived. It is clear that the pandemic has altered significantly the context in which Labour’s policy process now sits. Even though Covid-19 is still a major challenge at the time of writing this submission, SHA Cymru Wales believes that many of the issues arising from it are already clear (and are described in the “Independent Sage Report”). These are addressed in section B below which deliberately adopts a broader “emerging futures” perspective.
    3. Not only has the pandemic impacted on the way the care system now works and is likely to work in the future, it has also impacted more widely on society in terms of altered work patterns, the wider use of technology both inside and outside the care system, and of course upon the ability of the economy to resource public services to the level needed.
    4. Adding further to this new uncertainty is a pre-existing one of the consequences of the U.K withdrawal from the E.U. with probable changes to trade terms. Further the extent to which migrant labour will be available to support the health and care sector in Wales is already being adversely affected by the Immigration and Social Security Co-ordination (EU Withdrawal) Bill. The withdrawal – in particular its impact on food security, medicines safety and existing supply chains – must be fully assessed.
    5. Section C deals with the content of the Policy Document itself. Here members sense a persisting lack of momentum and capacity to deliver the key objectives outlined in “A Healthier Wales”. SHA Cymru Wales accept that a decade of austerity has been a major brake on improvements. Some progress has been made in terms of improved co-operation between health and social care at a local level with the establishment of the Transformation and Integrated Care Funds and increased training posts for a number of professions.
    6. Transformational change however is not taking place in terms of promoting public health and rebalancing the care system towards prevention, anticipatory care and a community/primary care based service.
    7. There have been a number of concerns expressed by the public about the quality, resilience, or consistency, of some clinical services in some parts of Wales. For example, hospital emergency services cherished by local populations are under threat and the reasons advanced for changes have not proved persuasive with the public. NHS in-house elective services struggled to treat patients within the target times set by Welsh Government before Covid-19. One Health Board depends heavily on the private hospital sector to undertake its elective work and is responsible for about 70% of all those referred by the Welsh NHS to private hospitals. Response times of emergency ambulances – often for reasons outside the control of the ambulance service itself -are sometimes longer than the service or ill patients would like. More widely there are some concerns about the resilience of the wider primary care services (including dentistry and pharmacy) in some parts of Wales. Finally there have also been a number of concerns about the quality, resilience or consistency of some clinical services in different parts of Wales.
    8. These concerns suggest an enduring problem either with the way that NHS Wales is resourced to meet the requirements laid upon it, or with the managerial linkages between the Senedd and the different care settings in which: i) the maintenance of good health is pursued; ii) early diagnoses of likely ill health are made; iii) treatment is given to restore people to a state of good health and iv) ongoing care and support is provided.
    9. In particular, SHA Cymru Wales feels that the care system in Wales is unbalanced in that anticipatory care and preventive work – in primary care and through public health measures -remains under-resourced despite the recent initiatives cited in the policy document.
    10. Added to public unease about patient services, are worries about financial control in the Welsh NHS. The abolition of the internal market and it’s replacement with a model based on partnership and co-operation ought to provide Wales with a unique advantage compared with an England system driven by competition, outsourcing of work to the private sector, and debts caused by P.F.I. schemes still needing to be serviced. The strengths of the Welsh NHS need to be more effectively exploited. There are worries too about the effectiveness of the special measures regime that is intended to improve both the immediate management of the Welsh NHS, and the way that changes to services that cross Board boundaries are planned and implemented.
    11. Underlying these concerns is an unease that there is no shared and unifying vision of what the Welsh NHS -with its local government and other partners- is being tasked to achieve for the Welsh public. “Healthier Wales” was intended to be the policy statement providing that radical vision. In our view it has been largely ignored and we return to this later in section C where SHA Cymru Wales suggest that NHS Wales builds upon past Welsh achievements in this regard, puts in place the political and managerial mechanisms to agree evidence-driven national policy objectives to be attained locally, and devises the mechanisms by which improved service delivery on the ground is assured.
    12. There is little detail about true co-production of health by both citizens and care professionals and how this can be moved from rhetoric to reality. This too would be a powerful engine for transformation.

     

    1. Covid 19 and its legacy

     

      1. At the time of writing, members believe that Covid-19 will shape the context in which the management and development of the health and care system in Wales sits. The pandemic vindicates many of the policies and approaches of the Welsh Government. The Welsh public service model stands in stark contrast to the fragmented cocktail of private sector provision and procurement which characterises much of the response in England. The time and effort that has been spent over many years in Wales to build better working relationships between the NHS, local government and the third sector has facilitated a more coherent and coordinated response to the pandemic than appears to have been the case in England.
      1. This public service approach allowed for partnerships at a local level which both responded to the leadership provided by the Welsh Government and to the local challenges faced by front line services. These partnerships should be maintained and refined as important community assets to promote local well -being.

    Proposal 1: SHA Cymru Wales propose that Wales considers creating a permanent “Wales Health and Care Reserve” (WHACR) comprising ex-health and social care staff and other volunteers with a wide variety of skills that can be refreshed through updating training on a regular basis, and who can be called upon in an emergency to assist full- time staff. This reserve should be organised on a neighbourhood or Cluster basis to support community clinical and care networks. It should be supported by schemes such as the Duke of Edinburgh award and the Welsh Baccalaureate. Established voluntary bodies with a relevant skill base should be encouraged to become involved.

      1. Welsh Government was correct to seek and encourage a “four nation response” to the pandemic even if it has not always come to the correct conclusion. It is regrettable that this was not always reciprocated by the U.K Government. The devolution settlement came under great strain as the four parts of the U.K. felt it necessary to respond to events as they saw fit. Different approaches to “lock down”, to testing, tracking and protecting across the U.K., and confusion about the purchasing of protective equipment and testing materials, exposed inadequacies in any U.K. wide arrangements meant to deliver a coordinated management to the effects of the virus.

    Proposal 2: SHA Cymru Wales requests that Welsh Labour commit to seek to join with its Scottish and Northern Ireland partners, to pursue revisions to the arrangements that govern these matters with the U.K. Government so that a “four nation” response to any  surge in this pandemic or in future pandemics is maintained. However, we do acknowledge that there will be times when it is necessary for the Welsh Government to take a Wales specific approach and we fully support its right to do so.

      1. SHA Cymru Wales welcomes the Senedd’s early work to review the Welsh experience to date. This is important work in the event of a failure to fully eradicate the Covid-19 virus and if further waves of mass infection have to be faced.

    Proposal 3: SHA Cymru Wales welcomes the First Minister’s support for a public enquiry  to review these events. Its terms of reference should be agreed by all four nations. Further we believe that all advice given to Welsh Government in relation to the options for managing this crisis should be made available to the public.

      1. SHA Cymru Wales recognises the pressure the Welsh Government faced in creating extra health provision as the Covid-19 pandemic began. This meant that the distinction between the health and social care systems became blurred as hospital patients were moved from acute beds to care homes in order to deal with an expected influx of patients with Covid-19. The result was that care homes were put at risk from viral transmission from hospital to care home settings. Further, people receiving domiciliary care services were also exposed to risks from itinerant care staff. Quickly the care system– comprising a range of privately run businesses of different sizes and types– required a degree of state support and guidance to sustain its operations. These took time to put in place. In this context SHA Cymru Wales congratulate the Welsh Government for ensuring a consistent supply of PPE to the care sector, for its extension of the testing regime in line with professional advice, and for the financial support provided to front line social care workers and others.

    Proposal 4: The Covid-19 pandemic highlights the integrated nature of health and social care and the need for quarantine facilities, equity of equipment, training, pay and quality facilities for the social care sector as well as for the NHS.These arrangements should be put in place as soon as possible.

      1. This scale of public service support needed for the social care sector must raise fundamental questions as to the long-term resilience of the current private sector business model.

    Proposal 5: As part of a process of major reform SHA Cymru Wales urge that the social care workforce in Wales is immediately transferred to the public service and that the Welsh Government brings the management of the care sector back under public control and leadership.

      1. Covid-19 has made it clear that the care system is fragmented – relying on multiple contracts with private sector providers especially those driven by commercial aims. Covid-19 exposed the inherent vulnerabilities in the present social care business model.

    Proposal 6: SHA Cymru Wales believes that the time has come for the main components of adult social care in Wales to be brought under public control, stewardship, or ownership and funded broadly on the same basis as the NHS. Domiciliary care services should be brought under the purview of local authorities first.

      1. “Personal care”, whether given at home or in a residential care setting, should be accepted as requiring oversight from the nursing profession and be delivered free under the NHS by staff trained to support individuals needing such care.

    Proposal 7: SHA Cymru Wales recommend that work commences as soon as possible on assessing at what speed, and in what way, the transfer of selected services from the private sector in Wales to the public sector can best be achieved to forge a new and equal partnership of health and social care services in Wales. SHA Cymru Wales asks that work be done to assess the costs, benefits, and problems that would arise from such a change.

      1. Room should be left for selected services to be operated by bona fide charities, co-operatives, and other voluntary groups where they have the skills and / or a reputation that resonates with the public. For example, Marie Curie Cancer Care, services supporting people affected by substance misuse, and charities supporting people through physical disabilities and mental ill health would meet this criteria. Here grants should be considered as an alternative to the formal contracts of a commercial relationship.
      1. While the present pandemic is unprecedented in its extent it does highlight the problems that the NHS and social care face when placed under excess demand, as frequently happens with the regular “winter bed crises”.
      1. The current DGH model combining elective and urgent surgery with emergency medical admissions alongside obstetric and paediatric services may need to be re-thought so that acute hospitals no longer operate consistently at very high levels of bed occupancy providing little head room for seasonal variations in demand. Elective capacity should be maintained in a protected environment by “built in” physical and engineering design and by so managing the protection and deployment of care staff so that transmission of any contagious infection is minimised. Similar considerations need to apply to ambulance services, primary care, community nursing, mental health and other health services, and indeed adult and children’s social care.
      1. 12. In England changes made to the public health function by transferring it to local government and then subjecting it (and other services) to reduced financial allocations have impaired its ability to react quickly and decisively to effect the necessary public health shut down testing and tracking arrangements long associated with controlling such diseases. The use of private sector contractors adds to fragmentation of the service. SHA Cymru Wales supports the current  arrangements in Wales whereby a strong public health tradition set within a public service model has been preserved and is able to serve both Welsh Government, Welsh local government, the Welsh NHS, and the wider public interest. However, SHA Cymru Wales share the concerns of those who feel that the Welsh Public Health function has become too concentrated at its centre and has insufficient presence in or influence within local authorities, health boards, and their partners at a community and neighbourhood level.

    Proposal 8: SHA Cymru Wales propose that Directors of Public Health should simultaneously hold statutory posts both in their local Health Board and in their local authority. This draws on past practice where medical officers of public health had a “proper officer“ function in local government with appropriate links with Environmental Health, Education, Community Development, and social care colleagues. Post holders should provide for both bodies an annual report describing local health status and how challenges of health inequalities should be, or are being met. The report should be taken in the public part of the agenda and drawn to the attention of community councils.This topic must feature highly in the performance regime linking Welsh Government, Local Government, and health Boards.

      1. The pandemic has facilitated, or required, new ways of delivering patient services, managing organisations, and connecting communities. Many people have now experienced remote consultations with their GP or hospital services via video conferencing. Diagnostic results have been shared via the internet between clinicians. Engagement of staff and the wider public in remote discussions have brought into question the traditional ways of linking patients and their relatives. New ways of managing organisations have also emerged as “working from home” has expanded.

    Proposal 9: Welsh Government should ensure that all citizens have reliable access to easy- to- use internet technology so that new forms of “ digital inequality” do not arise. Part of the work of WHACR cited above (Proposal 1) could be to assist people whose abilities or technical skills are not commensurate with relying on complicated technology.    

      1. SHA Cymru Wales believes, along with the Independent Sage Report, that these experiences have increased the desire and ability of communities and people to take an active part in debates about how their care services and indeed other facets of life – need to be re-fashioned “from the bottom up”. This sits alongside the ongoing development of GP clusters with a stronger community or neighbourhood focus.
      1. Covid-19 will leave a harsh legacy and a massive workload in terms of both physical and mental health rehabilitation for patients. This will be in addition to the NHS and social care catching up with deferred elective care delayed due to the pandemic. There is clear evidence that the excess death rate experienced over recent months is not solely due to Covid-19. While it is not fully understood why this is the case, it is probable that a significant proportion is due to the failure to seek, or obtain, health care in a timely way. Also, Welsh Government must prepare for what has been described as a tsunami of rehabilitation care as patients recover from severe episodes of Covid-19 infections and the impact upon their mental health. It must also anticipate – and plan to deal with – a legacy of stress experienced by care staff in Wales.

    Proposal 10: The Welsh Government should establish an urgent working group to plan how health and social care in Wales can recover from the longer-term consequences of Covid-19 on our country to both address the backlog in deferred need and the increased demand for physical and mental health rehabilitation. This should include consideration of making best use of recently commissioned health and care capacity.

     

    1. A critique of the Stage 2 document

     

      1. The Parliamentary Review on Health and Social Care in Wales concluded that there was an urgent need for rapid transformational change in Welsh health and social care services. This has been acknowledged by the Welsh Government. Welsh Labour’s consultation document however neither develops nor furthers this vision, nor does it convey an appropriate sense of urgency about the timing and nature of such change. It is a “steady as she goes” approach with “more of the same”. There is no clear set of priorities, sense of direction, or a picture of what the future of health and social care service in Wales ought to look like for service users, their families and carers.
      1. The stand-still in life expectancy in Wales over the last decade with the persisting health inequalities scarcely merits a mention – again with no policy proposals as to how to respond. The Covid-19 pandemic highlights these inequalities where the most socially disadvantaged communities carried the heaviest illness burden.
      1. Concerns remain about the failure to transform service delivery in line with both the Parliamentary Review and A Healthier Wales. This is exemplified by the tolerance of low levels of investment in primary care and a failure to recruit sufficient clinical staff.

    Proposal 11: GP numbers should be increased to produce an average list size of 1,400 patients per GP. Starting in those clinical network areas with the poorest health profile and least health and social care inputs. Where the traditional GP contractor model is failing to deliver these numbers, health boards need to take the lead in directly employing multi- professional primary care team members, including well supported salaried GPs.

      1. By reducing list sizes, patients will have easier access to, and more time with, their health care professionals so that a long-term caring relationship can be built biased towards prevention and anticipatory care. These communities, and other at-risk groups such as vulnerable children, care home residents, people with chronic illness and multiple morbidity etc. must be clearly identified and the outcomes from the care they receive be continually monitored with a view to continuing improvement. Clinical networks need to become a stronger focus for service innovation through a vision of health and well-being stretching far beyond a narrow medical horizon. The tools of public health and community development need to be harnessed to create stronger, healthier, resilient, and more engaged communities.
      1. These networks must be further enabled to lead the shift away from over-dependence on secondary care and towards localised anticipatory and preventive services aimed at maintaining independence. This shift of resource must enable the GP:patient ratio to improve. It must respond to the challenge of “the inverse care law” and must underpin an increase in primary care resources and effort aimed at reversing the unexpectedly stalled improvements in mortality indicators.
      1. General practice must no longer be viewed as a set of tasks carried out in isolation. It must regain its role as family practice committed to understanding local communities and the families that live in them and supporting them in pursuing their own good health. Practitioners in community development, social prescribing, and advocacy on community issues, must sit alongside continuity of care as part of a team of professionals serving the community.

    Proposal 12: Each neighbourhood should have public health input and advice and should be integrated into the work of primary care clusters. This should be marked with a change of name; clusters should become “neighbourhood networks.”

      1. Public health, primary care (including community pharmacies) and its estate should increasingly combine with other community assets such as post offices, food banks and community volunteers to create hubs which mix primary care provision with schools and community and leisure centres. In this way healthy living can be promoted and communities empowered to change the local culture and environment.
      1. SHA Cymru Wales sees neighbourhoods as the basic democratic unit of the NHS where the local community, comprising both professionals and local people, work to bring about beneficial changes and fashion the NHS as a people’s endeavour. As an example, indicators of any local “food poverty” should be devised as a health measure – for Covid-19 has both highlighted the frailties in how people access food and also brought about beneficial changes locally to support vulnerable people and build new partnerships. Nutrition is recognised as a determinant of health. Food poverty drives health inequalities whether caused by low income levels, unavailability or inadequate skills and accommodation. One suggestion that should be explored is the development of a national food service in Wales tasked with removing food poverty in Wales.
      1. SHA Cymru Wales is pleased to note that part of our submission last year urging the development of housing that supports the independence of older people and others with care needs was welcomed by the Party. SHA Cymru Wales looks forward to further work on developing emerging community models of engagement such as the Local Area Co-ordination arrangements operating in Swansea and similar initiatives elsewhere.

    Proposal 13: SHA Cymru Wales request that the consolidation and expansion of initiatives cited above be included in the manifesto along with a prototype “ Resilient Communities fund” to be deployed in a number of challenged localities to underpin and build on existing volunteer / community efforts such as those operating food box schemes and medicine / prescription deliveries.

      1. Further steps should now be taken to utilise technology so that patient medical and social care records can be “jointly owned” by care practitioners and citizens.

    Proposal 14: SHA Cymru Wales supports pilot projects currently exploring how patients can access and “co-own” their medical records as part of the co-production of good health.

      1. Primary care investment must not be at the expense of clearing the backlog that has built up in the mainstream service provision for cancer, stroke, heart disease and re-ablement surgery (e.g. hip and knee replacement). Nor should a current lack of capacity in services for children and young people with learning needs and mental health issues be allowed to continue.
      1. As noted earlier, for years it has become acceptable to attempt to run the hospital sector on a 90%+ occupancy rate. We have seen the problems this creates with perennial winter bed pressure crises but the onset of Covid-19 has shown the other inherent risks from constantly running the service at maximum capacity most of the time.

    Proposal 15: Staff and patient safety requirements must require the acute hospital system always to run with headroom for the predictable, cyclic variation in annual demand.

      1. Another concern of members was an uncertainty about what the 21st century purpose of the Welsh health and care system ought to be. Twenty years ago Wales had a well-deserved reputation for the quality of its strategic planning processes – aimed at achieving a level of health in Wales on a par with the best in Europe – and its ability to make progress. Evidence was gathered about the best preventive programmes, diagnostic techniques, treatment options, and after-care services across Europe and used to counter the main causes of premature death in Wales and the main causes of significant but avoidable morbidity in Wales. Health Boards (then known as health authorities) – with their partners – used the evidence to craft “local protocols for health” that were resource effective, people-centred, and aimed at increasing the length and quality of life in all parts of Wales. Despite, or perhaps because of, the success of this approach, John Redwood’s arrival in Wales saw the end of this work, no doubt in the belief that market forces would do the planning for Wales. In the view of some, since then NHS Wales has struggled to design a clinical and managerial process that systematically tackles health inequalities and improves health status in Wales.
      1. SHA Cymru Wales believes that Wales should draw heavily on that earlier strategic approach. For while SHA Cymru Wales accepts that Welsh Labour has had a strategic vision since the Wanless report in 2003, and “ A Healthier Wales” that has merit, it has not been accompanied by processes that translate strategy into deliverable Health Board and Trust 3 Year Integrated Medium Term Plans (IMTPs) able to be fully implemented by Health Boards, NHS trusts, and their key partners. The chain of accountability is opaque. Boards are, or appear to be, still dominated by secondary care voices

    Proposal 16: Welsh Labour should provide a clear statement of what the Welsh care system is meant to do (and by derivation what it isn’t) using a National Planning framework within which Health Boards and Trusts have to develop and deliver their plans. SHA Cymru Wales suggest that the Health Boards give a stronger voice for primary and community care and citizens in this process. A clear set of evidence- driven political and managerial processes are needed by which the aims of the Welsh NHS, and the resources needed to achieve those aims, are directly linked. Exhortations to “ do something”, on their own, are unlikely to achieve much.

      1. Setting a national direction and strategic intent must be underpinned by effective local delivery mechanisms to deliver the objectives of A Healthier Wales. The abolition of the internal market in Wales provided a unique opportunity to develop an integrated planning and delivery system at a local level to give effect to the national strategic purpose and direction. However, this has proved more than problematic. Some health boards are subject to Welsh Government intervention of varying extent, and varying success. Repeated reviews have expressed concerns at the capacity and governance of local health and social care planning and delivery. SHA Cymru Wales welcomes the partnership working that is taking place at regional partnership boards, but this process has got to mature, be more transparent and be accountable.
      1. In the light of the foregoing, SHA Cymru Wales welcomes the proposal for a “national executive” as outlined in the Final Report of the Parliamentary Review. The Parliamentary Review recommended that this “national executive” should be about strengthening executive functions to help align national strategic priorities with local service changes and innovations. The present slow pace of change suggests that this is urgently needed. It specifically suggested that the “national executive” should be aligned with national social care policy. SHA Cymru Wales recommends that the “national executive” should be the key national agency for integrating and driving forward both a National Health and a National Care service in Wales.
      1. SHA Cymru Wales is concerned that the consultation document chooses to specifically mention “specialist and hospital-based services” when considering the roles of the “national executive”. This is at odds with the core message of both the Parliamentary Review and A Healthier Wales. Both speak of transforming our care services away from an over-reliance on the hospital sector. We also regret that the policy consultation document makes no reference to the Parliamentary Review’s proposal that the work of the “national executive” should be underpinned by an explicit and transparent performance framework by which progress can be measured with particular reference to measuring progress in improving public health and tackling health inequalities.

    Proposal 17: SHA Cymru Wales believes that a National Health and Social Care Executive, tasked with delivering national health and social care in a clear, evidence based, and coherent way could deliver the transformational change needed. However, it must have clear terms of reference and its performance should be underpinned by a clear and transparent performance framework. The terms of reference, and the performance framework should both be subject to consultation with key stakeholders.

      1. There is also a view that the wider public, and local communities, feel excluded from some of the decision making in the care system. Local Government services in principle have a direct line of accountability to their populations through elected councillors and scrutiny committees. If the proposals in 16 and 17 above are implemented, local government should have an increased oversight of the care system as a whole.

    Proposal 18: SHA Cymru Wales recommends that Welsh Government place a legal requirement on Welsh local authorities to institute rigorous oversight and scrutiny arrangements in regard to the work of both Health Boards and the performance of the local care system as a whole. SHA Cymru Wales suggests that these scrutiny committees should have a minimum of three independent (non councillor) members nominated by local interest groups that can provide an informed view of how local service delivery is experienced by citizens and service users and what changes users desire.

      1. The policy document understandably makes little mention of the resources likely to be available the Welsh NHS and its local government partners over the course of the next four years. The damage done to the U.K. and Welsh economy by the pandemic is still to be assessed, as are the uncertainties of leaving the E.U. However, the NHS and social care in Wales already consumes over half of the block grant. Even with these spending levels, the Welsh NHS is under- powered both in primary care and acute secondary care.
      1. SHA Cymru Wales has long held the view that not only is the Barnett formula in need of refinement, but successive Conservative governments have not operated it fairly across the devolved polities. Further, there is limited scope to deploy the (limited) tax-raising powers now available to Wales in a way that can significantly increase the money available to Welsh Government. It is suggested that Welsh Government should adopt a four pronged strategy to address the issue of spending constraints. The first is to seek to increase – by a fair application of the Barnett formula –the funding available to Welsh Government from U.K. Government. The second is via Welsh taxation and growing the Welsh economy. The third is to examine in an ongoing way the operating costs of the Welsh NHS and social care, applying legitimate cost-saving measures where possible. One example is to examine critically the way in which newly licensed medicines are introduced in Wales. The current system requires only that the new product is not inferior to an existing (often cheaper) product rather than requiring either a superior treatment or lower spending. The fourth is to introduce a long term cost avoidance program that is driven by a primary care and public health preventive and anticipatory care approaches outlined in paragraphs C 14-17.
      1. The Welsh Government seeks to allocate its resources to health boards and local authorities on a needs-based formula. However, a thick fog hangs over how these allocations are used once these local organisations receive them. The First Minister correctly said that there are more inequalities within the populations served by health boards and local authorities than there are between the individual organisations Currently there is no obvious way to assess and compare how these inequalities within health boards and local authorities are addressed.

    Proposal 19: Public Health Wales and Stats Wales should develop a methodology by which it will be possible to measure inputs and outcomes in terms of resource allocation to the most vulnerable communities and groups within health boards and local authorities.

     

      1. Finally, it is suggested that the efforts of the NHS (and its local government partners) to contribute to the “green agenda” be welcomed. This aspect of its work should be highlighted and reported publicly as part of the overall performance regime.

     

    1. Conclusion

     

    1. The unexpected arrival of the pandemic, and the havoc and loss of life it has wrought has altered the perspective from which future health and care policy can be assessed. It threw into sharp relief those individuals and communities that are our most vulnerable.
    2. For this reason our response has been crafted in two parts – one to anticipate needed changes in order to make the Welsh care system more resilient to any future virus, and another to address challenges that were obvious prior to the arrival of Covid-19, but have proved resistant to change. SHA Cymru Wales believes that the 19 proposals described above will make a positive contribution to the health status of the people of Wales and it commends these to the Party.

    Labour Stage 2 SHA Cymru Wales final response Health and Social Care

    2 Comments

    SHA POLICY ON ADULT SOCIAL CARE AND CARERS

    This policy document is our first significant step towards a more complete statement on social care. It will require further work over time with our members and others. It fleshes out the motion that we carried about a year ago which reads as follows:

    RESCUING SOCIAL CARE

    England’s Social Care system is broken. Local Authorities faced £700m cuts in 2018-9 with £7 billion slashed since 2010. 26% fewer elderly receive support, demand grows.

    People face isolation, indignity, maltreatment, neglect, barriers to inclusion and independent living.

    Most care is privatised, not reflecting user needs/wishes. Public money goes to shareholders and hedge funds as profits.  Service users and families face instability as companies go bust.

    Staff wages, training and conditions are slashed.  Staff turnover is 30+%.

    8 million unpaid, overworked family carers, including children and the elderly, provide vital support.

    Conference demands Labour legislates a duty on the SoS to provide a universal system of social care and support acknowledging a right to independent living wherever possible:

    • Based on need and offering choice.
    • Meeting the needs of all disabled, frail and sick throughout life with robust safeguarding procedures.
    • Free at the point of use, universally provided, fully funded through progressive taxation
    • Subject to national standards based on Human Rights, choice, dignity and respect for all, complying with the UN Rights of persons with disabilities, including Articles on Independent Living (19) Highest Attainable Health (25) and Education (24).
    • Democratically run services, delivered through local public bodies working co-productively together with users and carers.
    • Training to nationally agreed qualifications, career structure, pay and conditions.
    • Gives informal carers strong rights and support, including finances and mental health.

    Labour to establish a taskforce involving users and carers/Trade Unions/relevant organisations to deliver the above, including an independent advocate system, and national independent living support service.

    FOR INFORMATION

    National independent living service – from the ROFA document https://www.rofa.org.uk/independent-living-for-the-future/

    The social care element of Disabled people’s right to independent living will be administered through a new national independent living service managed by central government, but delivered locally in co-production with Disabled people. It will be provided on the basis of need, not profit, and will not be means tested. It will be independent of, but sit alongside, the NHS and will be funded from direct taxation.

    The national independent living service will be responsible for supporting disabled people through the self-assessment/assessment process, reviews and administering payments to individual Disabled people. Individuals will not be obliged to manage their support payments themselves if they choose not to.

    Authored by Brian Fisher and a group of SHA experts and those with lived experience?

    Full document for downloading in both PDF and Doc format.

    Rescuing Social Care SHA policy May 2020

    Rescuing Social Care SHA policy May 2020

    Comments Off on SHA POLICY ON ADULT SOCIAL CARE AND CARERS

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

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

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

    BAME and Inequalities

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

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

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

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

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

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

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

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

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

    Inequalities

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

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

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

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

    As Labour’s David Lammy MP says:

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

    15th June 2020

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

    Comments Off on SHA COVID-19 Blog 14

    ECONOMIC RECOVERY

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

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

    TEST, TRACE, ISOLATE

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


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

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

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

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

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

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

    Information Governance and Track, Trace and Isolate

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

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

    Clients got their personal data hacked.

    Dido Harding

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


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

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

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

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

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

    CONTRACTS WITH PRIVATE COMPANIES

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

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

    PEOPLE WITH LEARNING DISABILITIES

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

    RELEASING PROFESSIONAL STAFF AT THE NO 10 MEETING

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

    OPENING SCHOOLS

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

    EXCESS DEATHS

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

    TAKE THE NHS OUT OF ANY TRADE DEALS WITH THE US

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

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

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

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

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

    1 Comment

    There will be nationwide celebrations on July 4th and 5th to mark the 72nd year of the NHS. Keep Our NHS Public and Health Campaigns Together are rallying round the occasion.

    Please follow this link for the first of a series of campaign materials and plans:

    OUR NHS DESERVES BETTER: 72nd anniversary coming soon

    SHA is disseminating these in support and solidarity. Please campaign locally and with SHA branches.

    Watch here for more soon!

    Comments Off on CELEBRATION OF THE NHS AT 72 – 4th AND 5th JULY

    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