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

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

    1. Austerity (2010-2020)

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

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

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

    1. Poor political leadership (PM and SoS Health)

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

    1. Social care

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

    1. Inequalities

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

    1. Privatisation

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

    1. Recovery Planning

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

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

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

    NHS and NIHR

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

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

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

    A wealth tax?

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

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

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

    Populism and COVID

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

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

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

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

    27.7.2020

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

    Comments Off on SHA COVID-19 Blog 20

    Week 18

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

    Facemasks

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

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

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

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

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

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

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

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

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

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

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

    Sharing Test Results

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

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

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

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

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

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

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

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

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

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

    Don’t blame PHE and the NHS.

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

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

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

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

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

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

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

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

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

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

    Clap Clap.

    13.7.2020

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

    2 Comments

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

    Local lockdown

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

    Outbreak plans

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

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

    Public Health England review

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

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

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

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

    Deprivation and health

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

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

    The garment industry

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

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

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

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

    Health and Safety

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

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

    Incompetent government.

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

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

    incompetent people don’t realise their incompetence’.

    5.7.2020

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

    1 Comment

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

    Test and Trace

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

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

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

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

    Workplaces

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

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

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

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

    Contact tracing

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

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

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

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

    Social distancing

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

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

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

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

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

    29.6.2020

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

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    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

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

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

    Lonely Ministers

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

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

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

    What is the strategy?

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

    Led by the science?

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

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

    Test, Trace and Isolate (TTI)

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

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

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

    Auditing misuse of public funds

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

    BAME communities and COVID

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

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

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

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

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

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

    7.6.2020

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

    2 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    Twitter: @unitetheunion

    Facebook: unitetheunion1

    Web: unitetheunion.org

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

     

     

    1 Comment

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

    Germany and Greece 

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

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

    Test, trace and isolate

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

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

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

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

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

    Independent SAGE

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

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

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

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

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

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

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

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

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

    When should a School Reopen?

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

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

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

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

     

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

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

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

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

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

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

    31.5.2020

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

    1 Comment

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

    The Westminster Government announced on May 10th that:

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

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

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

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

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

    We believe that the Government should have considered the following:

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

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

    Test one: Making sure the NHS can cope

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

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

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

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

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

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

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

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

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

    Sources

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

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

    NEU five tests for Government before schools can re-open

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

    ONS figures reveal 65 COVID-related deaths in education workforce

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

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

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

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

    Prof John Edmunds

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

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

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

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

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

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

    Comparative school age starts

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

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

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

    Formal learning in early years linked to criminality in teens

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

    Posted by Brian Fisher on behalf of the Policy Team.

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

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

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

    1. Key messages:

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

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

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

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

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

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

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

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

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

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

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

    • Real time analysis and assessment of infection

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

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

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

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

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

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

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

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

    We are concerned that the Government has

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

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

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

    Conclusions

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

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

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

    Sources

    Posted by Brian Fisher on behalf of the Policy Team.

     

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

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

    Too slow to act

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

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

    Protect the NHS

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

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

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

    The Privately owned Social Care sector

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

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

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

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

    Follow the money

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

    Test, trace and isolate (TTI)

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

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

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

    Game changers – and what is the game?

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

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

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

    Palantir

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

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

    Conclusion

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

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

    24th May 2020

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

    2 Comments
    Proposals to create a new super NHS laboratory in the northwest by closing local sites while 200 biomedical scientists are busy testing for Covid-19 will create delays in processing samples, Unite, Britain and Ireland’s largest union, warned today (Thursday 7 May).
    Unite said the plans by Lancashire and South Cumbria Central Laboratories Partnership to merge the labs at Blackburn, Blackpool, Lancaster and Preston into one super lab at a yet–to-be identified site would mean delays in testing samples which would have a detrimental impact on the estimated 500,000 people the super lab would serve.
    Unite, which has 100,000 members in the health service, accused NHS bosses of using the coronavirus emergency to push through this already rejected merger plan ‘under the radar’ when other similar collaborations, such as at Guy’s and St Thomas’ NHS Foundation Trust, have postponed all further plans until the Covid-19 crisis has passed.
    Unite said the plans were ‘a stab in the back’ for the biomedical scientists currently working at full stretch to process lab samples, including those for Covid-19, who have not got the time to examine the plan.
    Merger plans for a super lab at Lancaster, covering the areas of five NHS trusts, were rejected last year as it would make the service too remote from local GPs and hospitals, and increase processing times from the current 24-to-48 hours.
    In a letter to the partnership, Unite regional officer Keith Hutson said: “Unite finds it totally unacceptable that during the Covid 19 crisis you have seized upon this opportunity to force through merger plans and exclude the participation of Unite, the main representative of laboratory workers for this project.
    “Unite calls upon this project to cease until the Covid-19 crisis has ended.  I can say that apart from the despicable manner the trusts have chosen to progress this matter, be aware that when it is appropriate Unite, if necessary, will move to immediately ballot its members for industrial action.”
    Commenting Keith Hutson added: “NHS bosses are using the pandemic to reintroduce this flawed plan under the radar which will increase the times for processing samples. Our members who have given their all during this crisis feel the deliberate lack of consultation is a stab in the back.
    “We are going to involve the region’s MPs in this campaign, including The Speaker Sir Lindsay Hoyle, MP for Chorley, as, in the long-term, we fear that any super lab could be ripe for being sold off to a profit-hungry healthcare company.
    “If one thing has become clear during the last two months, it is that the British public respect and deeply value the NHS and its staff – and don’t want to see it being salami-sliced and privatised.”
    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.

     

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