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    1.   Background

     

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

     

    1. Covid 19 and its legacy

     

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

     

    1. A critique of the Stage 2 document

     

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

     

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

     

    1. Conclusion

     

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

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

    2 Comments

    SHA POLICY ON ADULT SOCIAL CARE AND CARERS

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

    RESCUING SOCIAL CARE

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

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

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

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

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

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

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

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

    FOR INFORMATION

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

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

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

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

    Full document for downloading in both PDF and Doc format.

    Rescuing Social Care SHA policy May 2020

    Rescuing Social Care SHA policy May 2020

    Comments Off on SHA POLICY ON ADULT SOCIAL CARE AND CARERS

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

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

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

    BAME and Inequalities

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

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

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

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

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

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

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

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

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

    Inequalities

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

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

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

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

    As Labour’s David Lammy MP says:

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

    15th June 2020

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

    Comments Off on SHA COVID-19 Blog 14

    ECONOMIC RECOVERY

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

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

    TEST, TRACE, ISOLATE

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


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

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

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

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

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

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

    Information Governance and Track, Trace and Isolate

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

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

    Clients got their personal data hacked.

    Dido Harding

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


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

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

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

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

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

    CONTRACTS WITH PRIVATE COMPANIES

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

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

    PEOPLE WITH LEARNING DISABILITIES

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

    RELEASING PROFESSIONAL STAFF AT THE NO 10 MEETING

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

    OPENING SCHOOLS

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

    EXCESS DEATHS

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

    TAKE THE NHS OUT OF ANY TRADE DEALS WITH THE US

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

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

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

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

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

    1 Comment

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

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

    Lonely Ministers

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

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

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

    What is the strategy?

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

    Led by the science?

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

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

    Test, Trace and Isolate (TTI)

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

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

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

    Auditing misuse of public funds

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

    BAME communities and COVID

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

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

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

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

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

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

    7.6.2020

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

    2 Comments

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

    Germany and Greece 

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

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

    Test, trace and isolate

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

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

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

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

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

    Independent SAGE

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

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

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

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

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

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

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

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

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

    When should a School Reopen?

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

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

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

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

     

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

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

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

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

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

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

    31.5.2020

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

    1 Comment

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

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

    1. Key messages:

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

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

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

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

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

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

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

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

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

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

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

    • Real time analysis and assessment of infection

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

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

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

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

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

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

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

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

    We are concerned that the Government has

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

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

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

    Conclusions

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

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

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

    Sources

    Posted by Brian Fisher on behalf of the Policy Team.

     

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

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

    Key messages

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

    Source: Douglas et all, BMJ April 2020

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

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

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

    Conclusions:

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

    Actions

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

    Sources

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

    Posted by Brian Fisher on behalf of the Policy Team.

    Comments Off on Briefing Topic 2 – Inequalities
    Thousands of social care staff in England could be falling through the net when it comes to the provision of the £60,000 payment in the event of death due to Covid-19.
    Serious concern was expressed today (Friday 22 May) by Unite, Britain and Ireland’s largest union, which has combed through the small print as to who the payment applies to.
    According to the government document, Coronavirus Life Assurance Scheme – Death in Service (England only): ‘Any employee who works for a private social care organisation which receives no public funding’ is not eligible for the payment.
    Unite called on health and social care secretary Matt Hancock to clarify and rectify the situation as a matter of urgency, given that more than 300 NHS and social care workers have now died as a result of Covid-19.
    Unite assistant general secretary Gail Cartmail said: “Matt Hancock needs to clarify what the small print actually means, as it is totally unacceptable that possibly thousands of social care workers are barred from this scheme because their place of work has no public funding.
    “We can’t have this two-tier situation where one care worker’s contribution, fighting coronavirus, is regarded of less value than another in a different setting. If you are risking your life in the battle against Covid-19, your workplace and how it is funded are irrelevant.
    “We don’t know the true scale of the problem across England – it could be that thousands of care workers are being denied this cover – but if it is only one, it is one too many.
    “Unfortunately, the health trade unions have not been consulted in drawing up this eligibility criteria in England – if we had been, we would have objected in the strongest possible terms to what is now in place.
    “The government has shown that it is capable of righting a wrong, as was proved yesterday with the U-turn on the £400 charge for NHS migrant workers. This is another case where a ministerial rethink is in order.”
    Last month, Matt Hancock announced that families of NHS and social care workers, who have died after contracting coronavirus in the course of their duties, will receive a £60,000 payment from the taxpayer.
     
    Twitter: @unitetheunion Facebook: unitetheunion1 Web: unitetheunion.org
    Unite is Britain and Ireland’s largest union with members working across all sectors of the economy. The general secretary is Len McCluskey.

     

    Comments Off on Thousands of care workers could be ineligible for £60,000 Covid-19 payment, warns Unite

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

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

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

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

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

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

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

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

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

     

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

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

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

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

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

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

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

    Comments Off on Covid-19: food and health inequalities and the future of public health nutrition

    Introduction

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

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

    Game changers

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

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

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

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

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

    Local Authorities and Public Health

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

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

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

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

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

    Social Care

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

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

    Moving out of Lockdown

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

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

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

    Scrutiny of Public Expenditure

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

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

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

    Finally

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

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

    17th May 2020

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

    2 Comments

    From Vivien Walsh in Manchester

    Right at the beginning of the lockdown, several of my friends said how concerned they were about the likely impact of enforced social isolation on those who are suffering from domestic abuse. On Monday, the (cross party) Home Affairs Committee of MPs, chaired by Yvette Cooper, reported on this, demanding “that the Government makes domestic violence and abuse a central pillar of the broader strategy to combat the Covid-19 epidemic.”

    Calls to domestic violence helplines, such as Refuge and Women’s Aid, were nearly 50% higher in the week 6-12 April than the average before the pandemic began. Visits to the website of Refuge were three times as high in March 2020 as they were in March 2019. The Home Affairs Committee called for this domestic violence strategy to combine “awareness, prevention, victim support, housing and a criminal justice response, backed by dedicated funding and ministerial leadership”.

    It also made a point of the need for specialist services for different ethnic communities, and for legal aid as an automatic right for women applying for Domestic Violence Protection Orders (DVPOs). An extension of the current time limit for reporting offences is also necessary, since many abused women will be unable to report the abuse they have suffered until after lockdown ends.

    Between March 23 and April 12 there were at least 16 killings of women and children in domestic situations, said the report on Monday. The average number of deaths from domestic violence during lockdown has gone up from 5 per week from a figure of two before. In a year that would be over 250 women killed by the person who is supposed to love them. The Parliamentary Committee had also received evidence that incidents reported were not only more frequent but involved higher levels of violence and coercive control.

    Unless the government takes action to deal effectively with domestic abuse and to properly support the victims of it, we will be facing “devastating consequences for a generation.” Funding is urgently needed to enable a growth in provision of housing for women and children escaping from violence, and to support refuges as temporary accommodation and support. Even before current emergency, England had 30% fewer than the recommended number of beds, and 64% of referrals were turned down in 2018-19.

    There is a National Domestic Violence Helpline (0808 200 247). This is the number to call for  emergency referrals as they are open 24/7. In addition there a variety of services based locally. For example Manchester Women’s Aid (call 0161 660 7999  9:30am-4:30pm Mon-Fri) provides confidential advice and information, safe temporary housing, one to one support for those living in their own homes, access to legal advice and civil orders, specialist workshops for young women 15-25, language workers and access to interpreters, specialist support for women with poor mental health and drug and alcohol misuse. The full list of services in England and Wales is at the end of the article.

    The lockdown is in place to keep people safe from the virus: but it is also providing cover for abusers. Escape from being locked in with an abuser is a matter of life and death. A decade of austerity has not only undermined our NHS, on which we are now so dependent, but has also decimated support for survivors of domestic violence. The Government must increase funding as a matter of urgency – and there will be just as much need for services as abused women and children try to return to “normal” life when the lockdown is over. And Children’s services also need a big increase in funding to make sure children as risk, not only from the mental and physical impact of domestic violence, have access to help and support.

    Amna Abdullatif (whose day job is Women’s Aid lead for Children and Young People, and who is also a Manchester City Councillor) added the following information for the SHA in this blog: “78% of survivors experiencing domestic abuse told us that Covid-19 has made it harder for them to leave their abuser. If you’re feeling trapped, we’re here for you.”

    “Our Live Chat is now open from 10am – 2pm with expert support workers just one click away. You can be reassured that our Live Chat is completely confidential. To access support and advice go to: https://bit.ly/2y7ab0Q

    “If you, or someone you know, is experiencing abuse please read our Covid-19 safety advice for survivors, family, friends and community members https://bit.ly/2yNzqoW

    There are also local services for ethnic groups, such as Saheli Asian Women’s Project in Manchester, which provides advice, information and support services to Asian women and their children fleeing domestic abuse and/or forced marriages.

    The full list of services from the Womens Aid web site is below:

    National Domestic Abuse Helpline

    The National Domestic Abuse Helpline is run by Refuge and offers free, confidential support 24 hours a day to victims and those who are worried about friends and loved ones.

    Telephone and TypeTalk: 0808 2000 247

    Wales Live Fear Free Helpline

    The Wales Live Fear Free Helpline offers help and advice about violence against women, domestic abuse and sexual violence.

    Telephone: 0808 8010 800

    TypeTalk: 18001 080 8801

    Text: 078600 77 333

    The Men’s Advice Line

    The Men’s Advice Line is a confidential helpline for male victims of domestic abuse and those supporting them.

    Telephone: 0808 801 0327

    Email: info@mensadviceline.org.uk

    Galop – for members of the LGBT+ community

    Galop runs the National LGBT+ domestic abuse helpline.

    Telephone: 0800 999 5428

    TypeTalk: 18001 020 7704 2040

    Email: help@galop.org.uk

    Women’s Aid

    Women’s Aid has a live chat service available Mondays to Fridays between 10am and 12pm as well as an online survivor’s forum. You can also find your local domestic abuse service on their website.

    The Survivor’s Handbook, created by Women’s Aid, provides information on housing, money, helping your children and your legal rights.

    Karma Nirvana

    Karma Nirvana runs a national honour-based abuse and forced marriage helpline. If you are unable to call or email, you can send a message securely on the website.

    Telephone: 0800 5999 247

    Email: support@karmanirvana.org.uk

    Hestia

    Hestia provides a free mobile app, Bright Sky, which provides support and information to anyone who may be in an abusive relationship or those concerned about someone they know.

    Chayn

    Chayn provides online help and resources in a number of languages about identifying manipulative situations and how friends can support those being abused.

    Imkaan

    Imkaan are a women’s organisation addressing violence against black and minority women and girls.

    Southall Black Sisters

    Southall Black Sisters offer advocacy and information to Asian and Afro-Caribbean women suffering abuse.

    Stay Safe East

    Stay Safe East provides advocacy and support services to disabled victims and survivors of abuse.

    Telephone: 020 8519 7241

    Text: 07587 134 122

    Email: enquiries@staysafe-east.org.uk

    SignHealth

    SignHealth provides domestic abuse service support for deaf people in British Sign Language (BSL).

    Telephone: 020 3947 2601

    Text/WhatsApp/Facetime: 07970 350366

    Email: da@signhealth.org.uk

    Shelter

    Shelter provide free confidential information, support and legal advice on all housing and homelessness issues including a webchat service.

    Sexual Assault Referral Centres

    Sexual Assault Referral Centres provide advice and support services to victims and survivors of sexual assault or abuse.

    Get help if you think you may be an abuser

    If you are concerned that you or someone you know may be an abuser, there is support available.

    Respect is an anonymous and confidential helpline for men and women who are harming their partners and families. The helpline also takes calls from partners or ex-partners, friends and relatives who are concerned about perpetrators. A webchat service is available Wednesdays, Thursdays and Fridays from 10am to 11am and from 3pm to 4pm.

    Telephone: 0808 802 4040

    Get help for children and young people

    NSPCC

    The NSPCC helpline is available for advice and support for anyone with concerns about a child.

    The NSPCC has issued guidance for spotting and reporting the signs of abuse.

    Telephone: 0808 800 5000

    Email: help@nspcc.org.uk

    If you are deaf or hard of hearing, you can contact the NSPCC via SignVideo using your webcam. SignVideo, using British Sign Language, is available on PC, Mac, iOS (iPhone/iPad) and Android smartphones (4.2 or above). This service is available Monday to Friday from 8am to 8pm and Saturdays from 8am to 1pm.

    Childline

    Childline provides help and support to children and young people.

    Telephone: 0800 1111

    Barnardo’s

    Barnardo’s provide support to families affected by domestic abuse.

    Family Lives

    Family Lives provide support through online forums.

    Support for employers

    Employers’ Initiative on Domestic Abuse

    The Employers’ Initiative on Domestic Abuse website provides resources to support employers including an employers’ toolkit.

    Support for professionals

    SafeLives provides guidance and support to professionals and those working in the domestic abuse sector, as well as additional advice for those at risk.

    Support a friend if they’re being abused

    If you’re worried a friend is being abused, let them know you’ve noticed something is wrong. Neighbours and community members can be a life-line for those living with domestic abuse. Look out for your neighbours, if someone reaches out to you there is advice on this page about how to respond. They might not be ready to talk, but try to find quiet times when they can talk if they choose to. If someone confides in you that they’re suffering domestic abuse:

    • listen, and take care not to blame them
    • acknowledge it takes strength to talk to someone about experiencing abuse
    • give them time to talk, but don’t push them to talk if they don’t want to
    • acknowledge they’re in a frightening and difficult situation
    • tell them nobody deserves to be threatened or beaten, despite what the abuser has said
    • support them as a friend – encourage them to express their feelings, and allow them to make their own decisions
    • don’t tell them to leave the relationship if they’re not ready – that’s their decision
    • ask if they have suffered physical harm – if so, offer to go with them to a hospital or GP
    • help them report the assault to the police if they choose to
    • be ready to provide information on organisations that offer help for people experiencing domestic abuse

    If you are worried that a friend, neighbour or loved one is a victim of domestic abuse then you can call the National Domestic Abuse Helpline for free and confidential advice, 24 hours a day on 0808 2000 247.

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