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    This is SHA Scotland Secretary Dave Watson’s contribution to a Jimmy Reid Foundation paper; ‘Reconstructing Scotland after COVID-19: learning further lessons from the pandemic.’

    A Scottish Care Service

    Even before the pandemic, it was clear that the social care system in Scotland was in urgent need of reform. The current system is underfunded, lacks capacity, and has major workforce recruitment and retention problems with fragmented delivery through a discredited commissioning process. When former Conservative ministers are openly talking about the nationalisation of care homes, there is widespread recognition that there is a problem (even if not agreement on what should be done to solve the issue). The system is not just failing those who need social care but is also damaging the NHS with over half a million hospital bed days lost every year because of delayed discharges at the cost of £120m. These problems have been magnified during the pandemic. The lack of Personal Protective Equipment (PPE), inadequate testing, minimal sick pay, and use of agency staff, have all contributed to the tragic deaths in care homes and amongst social care staff. Care at home has also been impacted with care packages reduced or abandoned. Informal carers have all too often been left to pick up the pieces.

    The concept of a (national) Scottish Care Service (SCS) as part of the solution is not a new one. It has been Scottish Labour policy for a number of years, most recently as a 2019 General Election manifesto commitment (see p35 here). My own organisation, the Social Health Association, outlined the idea in its recent social care consultation paper. And, UNISON Scotland has recently published what it describes as a ‘road map’ towards the creation of a national care service. But while there is growing support for the principle of a Scottish Care Service, many in the sector have reasonably asked what it means in practice.

    There seems to be a consensus in favour of a national framework rather than a service delivery organisation or making it part of NHS Scotland, not least to recognise the different models of care. But that leaves open what the SCS would undertake directly and what would be the governance arrangements. A national framework approach must end the current marketisation of social care. It could set consistent standards, contracts and charges for services not covered by free personal care. Most importantly, it would include a statutory workforce forum to set minimum terms and conditions, organise effective workforce planning and put a new focus on training and professionalism.

    On governance, the usual approach would be to create a new Non-Departmental Public Body (NDPB). This would leave the SCS with a similar democratic deficit to NHS Scotland and would undoubtedly be populated with the ‘usual suspects’ by the ministers who make the appointments. As the service will be delivered locally, another approach would be to create a joint board from councils across Scotland. This was a solution UNISON Scotland proposed for police and fire, which had the added advantage of keeping the VAT exemptions. The joint board could have places for relevant stakeholders, including users and worker providers.

    A national service would also need to address regulation. The Care Inspectorate’s ‘light touch’ response to rising complaints has highlighted the need for reform. In fairness, it has been constrained by the Scottish Government’s own ‘Better Regulation’ code, together with inadequate powers and resources. There would also need to be a review of workforce regulation currently administered by the Scottish Social Services Council and UK professional regulatory bodies.

    If the service is going to be delivered locally, this leaves open the question of local governance and ownership. As the Accounts Commission noted in its annual overview, the current system of Integrated Joint Boards (IJBs) has struggled to deliver integration or a shift in spending from hospitals to community care. There have been many attempts to improve integration in Scotland since the joint finance arrangements of the 1970s and all have struggled. It may be that this iteration will eventually deliver, but many will argue that it requires stronger democratic accountability to make difficult decisions, and that means a bigger role for councils. This happens in other parts of Europe, but even here, they have not always shifted resources from hospitals to community services.

    Greater integration does not require staffing integration. Professional barriers have been broken down in recent years, and joint teams have shown that they can work effectively together, particularly when physically working together in community hubs. A huge staffing reorganisation would create stasis, just at the time when we need to free up staff to innovate. When IJBs were created, I – as a UNISON Scotland official – wrote a workforce framework, which would have addressed many of the current problems. Sadly, workforce issues were largely ignored at the time.

    The fragmentation in service delivery is a significant problem that does need to be addressed with more than one thousand care at home providers, and the scandal of care home firms registered in tax havens. In the short-term, the pandemic has highlighted the need for greater coordination on issues like procurement. Abolishing the market, standard contracts and common workforce standards will help shift resources to the front-line. In the medium-term, there should be greater common ownership, particularly in residential care.

    Common ownership does not preclude innovative voluntary sector operators who can meet the new standards as the best in the sector already do. The private sector likes to make a false link between personalised care and marketisation. All care should be personalised, and that requires a range of services, not a range of ownership models. Local delivery should also be about greater innovation in service delivery, trying new models of care that integrate people with care needs into communities.

    Finally, there is the tricky issue of funding. In England, the issue has at least been considered in the Dilnott Report, although it was overly focused on protecting assets. In Scotland, we cannot simply hope for the Barnett consequentials of reform in England to plug the current funding gap, let alone future demographic pressures. It requires a mature conversation with citizens about taxation. If we want to go further and fund care on the same basis as the NHS, then the conversation shifts to proposals like the former health minister Andy Burnham’s care levy, which involved a form of inheritance tax. Calling it and similar plans a ‘death tax’ is not a mature conversation.

    The creation of a Scottish Care Service is an idea which has come of age. Turning it from a concept into a practical solution requires more work and some difficult conversations. If we are to ‘Build Back Better’, as the Tories implore, an integrated health and care service, with national standards and local delivery should be the highest priority.

    Dave Watson, Secretary of the Socialist Health Association Scotland
    www.shascotland.org

    sha_social_care_reform

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

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

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

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

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

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

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

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

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

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

     

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

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    The Camden New Journal (CNJ) have published the sixth article about the NHS written by Susanna Mitchell and Roy Trevelion. You can see it on the CNJ website under ‘Forum’ published on 16 July 2020 here. Or you can read it below:

    Neglect and inadequate excuses lie at the heart of the government’s failures, argue Susanna Mitchell & Roy Trevelion

    It is understood that there will be a public inquiry into the UK’s handling of the coronavirus pandemic.

    This should begin now, and not when the current crisis is over. Criticisms will be focused on the government’s disastrous response:

    Its initial adoption of a “herd immunity” strategy.

    Its failure to provide health care workers and others in front-line positions with adequate personal protective equipment (PPE).

    The shambolic state of its belated testing and tracking operations, including the collapse of its much-heralded app.

    Its reliance on private contractors with no relevant experience to supply services and equipment that they were subsequently unable to deliver.

    Critically, it will be claimed that all the measures taken were put in place far too late. With the result that the UK now has the highest death toll in Europe. The proportion of care-home deaths is 13 times greater than that of Germany.

    All these accusations are currently being met with the excuse that the Covid-19 pandemic was unprecedented. The government claims it has worked to its utmost capacity to control and manage the outbreak.

    But this narrow focus on what was done once the virus had established itself in the country is completely inadequate.

    Rather, any inquiry must examine the long-standing reasons why the country was unable to deal with the situation in a more efficient way. Unless this is done, the necessary steps to improve our handling of future pandemics cannot begin.

    For a start, the argument that government was taken by surprise by a global viral attack is false.

    To the contrary, a research project called Exercise Cygnus was set up in 2016 to examine the question of preparedness for exactly this eventuality.

    Its report was delivered in July 2017 to all major government departments, NHS England, and the devolved administrations of Scotland, Wales and Northern Ireland.

    The report concluded that “…the UK’s preparedness and response, in terms of its plans, policies and capability” were insufficient to cope with such a situation.

    It recommended NHS England should conduct further work to prepare “surge capacity” in the health service and that money should be ring-fenced to provide extra capacity and support in the NHS.

    It also stated that the social care system needed to be able to expand if it were to cope with a “worst-case scenario pandemic”.

    These warnings, however, were effectively ignored.

    One government source is reported as saying that the results of the research were “too terrifying” to be revealed.

    And a senior academic directly involved in Cygnus and the current pandemic remarked: “These exercises are supposed to prepare government for something like this – but it appears they were aware of the problem but didn’t do much about it… basically [there is] a lack of attention to what would be needed to prevent a disease like this from overwhelming the system.

    “All the flexibility has been pared away so it’s difficult to react quickly. Nothing is ready to go.”

    But the reason that the system was too inflexible and unprepared lies squarely with the government’s actions during the last decade.

    The Health and Social Care Act of 2012 ruinously fragmented the system.

    The austerity and privatisation of these polices have lethally weakened both the NHS and the social care services.

    As a result, the NHS is under-staffed, under-equipped and critically short of beds, while the social care service is crippled by underfunding almost to the point of collapse. It is therefore vital that we do not allow any inquiry to be limited to an examination of recent mistakes.

    The government’s bungled handling of the present crisis was virtually inevitable within a public health system depleted and rendered inadequate by their long-term policies.

    No post mortem can achieve a productive conclusion unless it is understood that these policies were the root cause of the shambles.

    If we are to avoid another catastrophe, these policies must be radically changed with the minimum of delay, and public health put back into public hands.

    • Susanna Mitchell and Roy Trevelion are members of the Socialist Health Association.

    Other articles written by Susanna Mitchell and Roy Trevelion are:

    Don’t allow the price of drugs to soar: Drug pricing is still a critical issue for the NHS http://camdennewjournal.com/article/dont-allow-the-price-of-drugs-to-soar?sp=1&sq=Susanna%2520Mitchell

    Beware false prophets: Don’t be fooled by the Johnson government’s promise of new money. It masks a move to further privatise the NHS
    http://camdennewjournal.com/article/nhs-beware-false-prophets?sp=1&sq=Susanna%2520Mitchell

    Brexit and the spectre of NHS US sell-off: Americanised healthcare in the UK – after our exit from the EU – would only benefit global corporations
    http://camdennewjournal.com/article/brexit-and-spectre-of-nhs-us-sell-off?sp=1&sq=Susanna%2520Mitchell

    Deep cuts operation threatens the NHS: The sneaking privatisation of the NHS will lead to the closure of hospitals and the loss of jobs
    http://camdennewjournal.com/article/deep-cuts-operation-threatens-nhs-2?sp=1&sq=Susanna%2520Mitchell

    Phone app that could destroy our GP system: A private company being promoted by government to recruit patients to its doctor service spells ruin for the whole-person integrated care we need from our NHS
    http://camdennewjournal.com/article/phone-app-gp?sp=1&sq=Susanna%2520Mitchell

     

    Comments Off on Why the UK failed the pandemic test

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

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

    1. Austerity (2010-2020)

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

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

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

    1. Poor political leadership (PM and SoS Health)

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

    1. Social care

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

    1. Inequalities

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

    1. Privatisation

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

    1. Recovery Planning

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

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

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

    NHS and NIHR

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

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

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

    A wealth tax?

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

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

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

    Populism and COVID

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

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

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

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

    27.7.2020

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

    Comments Off on SHA COVID-19 Blog 20

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

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

    The immediate funding issues

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

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

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

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

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

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

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

    The eligibility needs test

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

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

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

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

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

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

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

    So to the inequity is added injustice.

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

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

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

    Why does the eligibility needs test persist?

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

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

    What will it take to abolish the needs test?

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

    Can the needs test be abolished in a budgeted system?

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

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

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

    Will the needs test be abolished?

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

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

    Conclusion

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

    2 Comments

    Week 18

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

    Facemasks

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

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

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

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

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

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

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

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

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

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

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

    Sharing Test Results

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

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

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

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

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

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

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

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

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

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

    Don’t blame PHE and the NHS.

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

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

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

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

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

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

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

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

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

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

    Clap Clap.

    13.7.2020

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

    2 Comments

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

    Local lockdown

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

    Outbreak plans

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

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

    Public Health England review

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

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

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

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

    Deprivation and health

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

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

    The garment industry

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

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

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

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

    Health and Safety

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

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

    Incompetent government.

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

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

    incompetent people don’t realise their incompetence’.

    5.7.2020

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

    1 Comment

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

    Test and Trace

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

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

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

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

    Workplaces

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

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

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

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

    Contact tracing

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

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

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

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

    Social distancing

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

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

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

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

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

    29.6.2020

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

    Comments Off on SHA COVID-19 Blog 16

     

    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.

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