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    From Ekua Bayunu, Member of Greater Manchester Socialist Health Association, and selected candidate for Hulme in the next Manchester City Council elections.

    When I joined SHA a couple of years ago I wanted to focus my energies on action against inequalities in the health systems around race, particularly in mental health. We now have evidence of the toxins that were seeping into us from the right, distracting us from actually building effective socialist action on health issues here in Greater Manchester.

    Skip forward and we are slap bang in the eye of the storm of the Covid 19 pandemic and still searching for some strength in our unity to make a difference to our communities. Many of our members are fully immersed in either working on the frontline, in providing care in our institutions, or in volunteering in mutual aid groups, many doing both and I send love and admiration out to us all.

    We lost my neighbour, an elderly Somalian man, to the virus on the last weekend in March. It felt like the storm that was brewing had just swept in and taken one of ours before we barely knew it was coming. Then the statistics started coming in. We are dying in inexplicably large numbers. We? I’m a woman of African heritage, my community is African, South Asian, Working class.

    My close friend, a street away, is a nurse working at MRI, already stressed by the lack of PPE, worrying about her family, the risk she posed to her 3 daughters and husband at home, when she got ill two weeks ago, together with two colleagues from her ward. They got tested. She doesn’t have access to a car, and the only testing is drive-through. No you can’t walk in. No you can’t get in a taxi! She started talking to us about wills and supporting her daughters and all the worries she has for them. Her eldest also works as a nurse, the youngest is only 10. Her cultural background is Turkish, and she knew she might die.

    She is in recovery, but the statistics get worse and worse. The demand for action grows as do the questions and desire for investigation. I read articles in the silo of my social media accounts and watched as it began to break slowly into mainstream media. At first I thought: they are holding back on the narrative, because it doesn’t suit their agenda to highlight how many were dying in service to us all who were from Diasporan African, Asian and other minority communities. We entered this year with forced deportations built on a narrative that these were the communities of criminals and spongers on the state. Suddenly the NHS workforce were our heroes, they put out ads supporting these workers and most of the workers were white. Did you all notice?

    Then as the statistics leaked into a wider societal consciousness, I became openly worried. Information being fed via the television is so absent of any real analysis that it actually begins to shape a eugenicist narrative, which the Prime Minister does little to distance himself from. Our deaths are not real sacrifices based on years of inequalities in education, health care, housing and employment, but gives out a message of our inherent weakness and inferiority! And whilst we all are shut in, angry, confused, needing to have something or someone to blame, in the place of blaming this government for its lack of care in putting profit over people, it is easy to discern they are creating a diversionary agenda.

    It is becoming increasingly clear BAME people are dying disproportionally, on the wards, driving our buses, cleaning our streets, in our care homes. They are presented as the problem, when they are the heroes and victims of the pandemic. Last week the government finally pulled together a commission with PHE to investigate the causes of BAME people dying disproportionally. Do we all assume that the why will lead to how to stop this? To a solution to help us? I can’t.

    Posted by Jean Hardiman Smith on behalf of Ekua Bayunu, Member of Greater Manchester Socialist Health Association

    1 Comment

    BUYING BEDS FROM PRIVATE HEALTHCARE PROVIDERS

    Can the minister explain why the Government has chosen to buy beds from private healthcare providers rather than requisitioning private hospitals and staff as the Spanish Government has done?

    The Centre for Health and Public Information (CHPI) has demonstrated that the government’s deal to purchase their entire capacity in return for covering their “operating costs, overheads, use of assets, rent and interest” is in effect a bailout for private hospitals. https://chpi.org.uk/blog/who-benefits-from-the-nhss-bailout-of-private-hospitals/

    Based on the accounts (2017 or 2018) of their operating companies, four of the largest private hospital providers (Spire, BMI, Nuffield, Ramsay) have an average gearing (total debt / equity) of over 300%. This means that they are heavily reliant on debt to finance their businesses, and are therefore potentially vulnerable to a prolonged period of low or non-existent demand.

    Without the deal, private healthcare providers would face the same fate as other industries who are experiencing a significant drop off in demand due to the virus. Crucially it also represents a bailout for the landlords and lenders of the private hospitals whose investments would also be at risk if the hospitals were unable to honour their payments.

    Why is the Government acting to protect private healthcare providers, and the profits of their investors, rather than taking the alternative approach of requisitioning private hospitals and their staff to support the NHS?


    What payments will the government have to make for requisitioned private health care capacity?


    Can the government provide assurances that the contracts signed for ventilators from known Tory backers like Dysons and JHB are of the required standard to enable gradual re-establishment of breathing?

    CARE AND NURSING HOME RESIDENTS

    Are you confident that all care and nursing home residents who are symptomatic are being tested for COVID-19?


    Why there is a difference in priority for the NHS and Care sector?

    Please supply any figures of death rates and infection rates as incidence and prevalence.  It should surely be easy for every care home retirement village and other institutions to collect daily stats and report regionally.

    How can you ensure that Trusts, NHS charities and local authorities work together to provide a system coordinated response?


    PUBLIC HEALTH ADVICE

    Why does the Government advise 7 days isolation for those who are symptomatic for COVID-19 while the WHO advice, followed in most of Europe is to isolate for 14 days?

    CONTACT TESTING, TRACING AND NUMBERS

    • What is the best estimate of the proportion of the population who have had Covid-19?
    • What is this estimate based on?
    • Is there any community surveillance for Covid-19 taking place? If so what are the details? What are the results?
    • How much contact tracing is done for patients who have been diagnosed as having Covid-19?
    • What role will contact tracing play in managing the easing of the current public health measures?
    •  What steps is the government taking to have a robust tracing capacity in place as we emerge from the current public health measures?
    • What criteria will be government use in terms of R0, new cases, patient deaths, herd immunity, contact tracing capacity etc to inform any decision to ease current public health measures?
    • How many of the NHS and care staff who have died in this epidemic are from overseas?

    The figures now emerging for the deaths of those working in the NHS cover the very substantial numbers of outsourced workers, a cohort that the public just don’t know about. Aside from being cheaper and allowing corporates to cream off a profit, these workers are treated as second class employees, with worse conditions, oppressive supervision, abysmal support and non-existent occupational health. Aside from low pay and the insecurity of zero hours contracts there are countless ways in which they are coerced to “just get on with it”, risking serious harm.

    The DHSC is undercounting numbers of health workers infected, can the government give assurances that they will provide accurate figures and include out sourced agency and locum staff?

    Hospitals have been asset-stripped for years by outsourcers, PFI partners and management and IT consultants, and Lansley’s Health and Social Care Act has undermined the structural coherence of the NHS. The malign results of this we now see with hospitals struggling against collapse with the untold sacrifices of heroic staff. And even here, the government (Matt Hancock) has consistently under stated the numbers of deaths of NHS staff: on Friday he said the number was 19 when it was 31 and he repeated the 19 figure on Saturday when it was in the 40s and in the public domain. Can we be assured that Mr Hancock will provide accurate figures and strive to remain on top of his brief?

    We know the numbers of front line workers losing their lives to Covid is now in excess of 40  – why has the government not acknowledged this nor yet apologised for their gross mishandling of PPE supplies.


    The finger-prick antibody tests that Hancock has ordered are widely regarded as unreliable with low sensitivity and specificity. Can we be assured that this is not the case?


    With respect to testing – why has the government wasted millions on a test which quickly proved not to be reliable. Who sanctioned this?


    What are the step changes to increase current testing capacity to 100,000 by the end of the month?  When will each new site come on stream and how much capacity will be added – and then say what actually happened – on a weekly basis?

    What really is the approach to testing front line staff? Pretending to test all front line staff is pointless as someone who is negative today could be positive tomorrow – so this would mean testing everyone everyday which would need significantly more capacity than planned. Are they testing staff who are currently self isolating and not at work and those who become symptomatic?

    What is their approach to testing care home residences and staff? Initially this should focus on those home with assumed cases and needs to be done in a consistent way

    FUTURE FUNDING

    We are pleased to hear of the Prime Minister’s recovery, and noting his praise for the dedication and commitment of NHS staff, will he now reinstate the NHS as the preferred provider when work is commissioned?

    Given the inability of local Public Health teams to provide an adequate local response to the epidemic given recent cuts and reorganisation, will be now ensure the reinstatement of Public Health powers and budgets?


    Public support for the NHS has never been higher, arguably because the population understands better than this and the previous Tory government how vital it is to national life. Will the government undertake to reinstate the NHS on its former footing as a National health service, and undertake to spend the same proportion of GDP on it as comparable countries?

    COMMUNITY SERVICES

    There is likely to be a wave of people being discharged from hospitals who remain very ill. Given the shortfall in GP and District Nurse numbers, how does the SoS expect that these patients will be adequately supported?

    Is now the time to commit to a significant increase in District Nurse numbers with upskilling to enable more people to remain at home post-Covid with GP support?

    PPE

    PHE has continually prevaricated about the spec – and in comparison to other countries still falls short, yet even that is still proving impossible to obtain for too main frontline workers, both in hospitals and in the community. We know the supply chain in England in particular is flawed because the Cabinet Office brought in an a ‘middle man’ without any experience of handling PPE or the manufacturing industry. Cabinet Office must be told they should be stood down with immediate effect from their role in England and allow industry to liaise directly with hospital Trusts, primary care bodies and care organisations for fast track targeted purchasing to unblock this ASAP.

    Why has the government persisted in shipping PPE/ventilators equipment from abroad  –  some of it substandard or out of date  – when we have received skilled offers from such as GTech in Worcester offering 30k ventilators ( not CPAPs) and the British textiles manufacturing industry being continually blocked from their significant capacity to provide PPE  – some of which is now going abroad in frustration?

    Tough Questions

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    Jeremy Corbyn wrote a long letter to Boris Johnson on 31st March.
    As well as wishing him a speedy recovery, Jeremy made some strong points about aspects of the current crisis, and asked for immediate action on:

    • Full PPE now for Health and social Care workers
    • Test Test Test
    • Expand Social Care
    • Enforce Social-distancing and Protection
    • Bolster Support for Workers
    • Lead a Global Reponse

    (the 4  pages of the letter are attached)

    Posted by Jean Smith on behalf of SHA member Diane Jones.

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    The Socialist Health Association (SHA) published its first Blog on the COVID-19 pandemic last week (Blog 1 – 17th March 2020). A lot has happened over the past week and we will address some of these developments using the lens of socialism and health.

    1. Global crisis

    This is a pandemic, which first showed its potential in Wuhan in China in early December 2019. The Chinese government were reluctant to disclose the SARS- like virus to the WHO and wider world to start with and we heard about the courageous whistle blower Dr Li Wenliang, an ophthalmologist in Wuhan, who was denounced and subsequently died from the virus. The Chinese government recognised the risk of a new SARS like virus and called in the WHO and announced the situation to the wider world on the 31st December 2019.

    The starter pistols went off in China and their neighbouring countries and the risk of a global pandemic was communicated worldwide. The WHO embedded expert staff in China to train staff, guide the control measures and validate findings. Dr Li Wenliang who had contracted the virus, sadly died in early February and has now been exonerated by the State. Thanks to the Chinese authorities and their clinical and public health staff we have been able to learn about their control measures and the clinical findings and outcomes in scientific publications. This is a major achievement for science and evidence for public health control measures but….

    Countries in the Far East had been sensitised by the original SARS-CoV outbreak, which originated in China in November 2002. The Chinese government at that time had been defensive and had not involved the WHO early enough or with sufficient openness. The virus spread to Hong Kong and then to many countries showing the ease of transmission particularly via air travel. The SARS pandemic was thankfully relatively limited leading to global spread but ‘only’ 8,000 confirmed cases and 774 deaths. This new Coronavirus COVID-19 has been met by robust public health control measures in South Korea, Taiwan, Hong Kong, Japan and Singapore. They have all shown that with early and extensive controls on travel, testing, isolating and quarantining that you can limit the spread and the subsequent toll on health services and fatalities. You will notice the widespread use of checkpoints where people are asked about contact with cases, any symptoms eg dry cough and then testing their temperature at arms length. All this is undertaken by non healthcare staff. Likely cases are referred on to diagnostic pods. In the West we do not seem to have put much focus on this at a population level – identifying possible cases, testing them and isolating positives.

    To look at the global data the WHO and the John Hopkins University websites are good. For a coherent analysis globally the Tomas Peoyu’s review  ‘Coronavirus: The Hammer and the dance’ is a good independent source as is the game changing Imperial College groups review paper for the UK Scientific Advisory Group for Emergencies (SAGE). This was published in full by the Observer newspaper on the 23rd March. That China, with a population of 1.4bn people, have controlled the epidemic with 81,000 cases and 3,260 deaths is an extraordinary achievement. Deaths from COVID-19 in Italy now exceed this total.

    The take away message is that we should have acted sooner following the New Year’s Eve news from Wuhan and learned and acted on the lessons of the successful public health control measures undertaken in China and the Far East countries, who are not all authoritarian Communist countries! Public Health is global and instead of Trump referring to the ‘Chinese’ virus he and our government should have acted earlier and more systematically than we have seen.

    Europe is the new epicentre of the spread and Italy, Spain and France particularly badly affected at this point in time. The health services in Italy have been better staffed than the NHS in terms of doctors/1000 population (Italy 4 v UK 2.8) as well as ITU hospital beds/100,000 (Italy 12.5 v UK 6.6). As we said in Blog 1 governments cannot conjure up medical specialists and nurses at whim so we will suffer from historically low medical staffing. The limited investment in ITU capacity, despite the 2009 H1N1 pandemic which showed the weakness in our system, is going to harm us. It was great to see NHS Wales stopping elective surgical admissions early on and getting on with training staff and creating new high dependency beds in their hospitals. In England elective surgery is due to cease in mid April! We need to ramp up our surge capacity as we have maybe 2 weeks at best before the big wave hits us. The UK government must lift their heads from the computer model and take note of best practice from other countries and implement lockdown and ramp up HDU/ITU capacity.

    In Blog 1 we mentioned that global health inequalities will continue to manifest themselves as the pandemic plays out and spare a thought for the Syrian refugee camps, people in Gaza, war torn Yemen and Sub Saharan Africa as the virus spreads down the African continent. Use gloves, wash your hands and self isolate in a shanty town? So let us not forget the Low Middle Income Countries (LMICs) with their weak health systems, low economic level, weak infrastructure and poor governance. International banking organisations, UNHCR, UNICEF, WHO and national government aid organisations such as DFID need to be resourced and activated to reach out to these countries and their people.

    1. The public health system

    We are lucky to have an established public health system in the UK and it is responding well to this crisis. However we can detect the impact of the last 10 years of Tory Party austerity which has underfunded the public health specialist services such as Public Health England (PHE) and the equivalents in the devolved nations, public health in local government and public health embedded in laboratories and the NHS. PHE has been a world leader in developing the PCR test on nasal and throat samples as well as developing/testing the novel antibody blood test to demonstrate an immune response to the virus. The jury is out as to what has led to the lack of capacity for testing for C-19 as the UK, while undertaking a moderate number of tests, has not been able to sustain community based testing to help guide decisions about quarantining key workers and get intelligence about the level of community spread. Compare our rates of testing with South Korea!

    We are lucky to have an infectious disease public health trained CMO leading the UK wide response who has had experience working in Africa. Decisions made at COBRA and announced by the Prime Minister are not simply based ‘on the science’ and no doubt there have been arguments on both sides. The CSO reports that SAGE has been subject to heated debate as you would expect but the message about herd immunity and stating to the Select Committee that 20,000 excess deaths was at this stage thought to be a good result was misjudged. The hand of Dominic Cummings is also emerging as an influencer on how Downing Street responds. Remember at present China with its 1.4bn population has reported 3,260 deaths. They used classic public health methods of identifying cases and isolating them and stopping community transmission as much as possible. Herd immunity and precision timing of control measures has not been used.

    The public must remain focused on basic hygiene measures – self isolating, washing of hands, social distancing and not be misled about how fast a vaccine can be developed, clinically tested and manufactured at scale. Similarly hopes/expectations should not be placed on novel treatments although research and trials do need supporting. The CSO, who comes from a background in Big Pharma research, must be seen to reflect the advice of SAGE in an objective way and resist the many difficult political and business pressures that surround the process. His experience with GSK should mean that he knows about the timescales for bringing a novel vaccine or new drugs safely to market.

    1. Local government and social care

    Local government (LAs) has been subject to year on year cuts and cost constraints since 2010, which have undermined their capability for the role now expected of them. The budget did not address this fundamental issue and we fully expect that in the crisis, central government will pass on the majority of local actions agreed at COBRA to them. During the national and international crisis LAs must be provided with the financial resources they need to build community hubs to support care in the community during this difficult time. The government need to support social care.

    COVID-19 is particularly dangerous to our older population and those with underlying health conditions. This means that the government needs to work energetically with the social care sector to ensure that the public health control measures are applied effectively but sensitively to this vulnerable population. The health protection measures which have been announced is an understandable attempt to protect vulnerable people but it will require community mobilisation to support these folk.

    Contingency plans need to be in place to support care and nursing homes when cases are identified and to ensure that they can call on medical and specialist nursing advice to manage cases who are judged not to require hospitalisation. They will also need to be prepared to take back people able to be discharged from acute hospital care to maintain capacity in the acute sector.

    Apart from older people in need there are also many people with long term conditions needing home based support services, which will become stressed during this crisis. There will be nursing and care staff sickness and already fragile support systems are at risk. As the retail sector starts to shut down and there is competition for scarce resources we need to be building in supply pathways for community based people with health and social care needs. Primary health care will need to find smart ways of providing medical and nursing support.

    1. The NHS

    In January and February when the gravity of the COVID pandemic was manifesting itself many of us were struck by the confident assertion that the NHS was well prepared. We know that the emergency plans will have been dusted down and the stockpile warehouses checked out. However, it now seems that there have not been the stress tests that you might have expected such as the supply and distribution of PPE equipment to both hospitals and community settings. The planning for COVID-19 testing also seems to have badly underestimated the need and we have been denied more accurate measures of community spread as well as the confirmation or otherwise of a definite case of COVID-19. This deficiency risks scarce NHS staff being quarantined at home for non COVID-19 symptoms.

    The 2009 H1N1 flu pandemic highlighted the need for critical care networks and more capacity in ITU provision with clear plans for surge capacity creating High Dependency Units (HDUs) including ability to use ventilators. The step-up and step-down facilities need bed capacity and adequate staffing. In addition, there is a need for clarity on referral pathways and ambulance transfer capability for those requiring even more specialised care such as Extracorporeal Membrane Oxygenation (ECMO). The short window we now have needs to be used to sort some of these systems out and sadly the supply of critical equipment such as ventilators has not been addressed over the past 2 months. The Prime Minister at this point calls on F1 manufacturers to step in – we wasted 2 months.

    News of the private sector being drawn into the whole system is obviously good for adding beds, staff and equipment. The contracts need to be scrutinised in a more competent way than the Brexit cross channel ferries due diligence was, to ensure that the State and financially starved NHS is not disadvantaged. We prefer to see these changes as requisitioning private hospitals and contractors into the NHS. 

    1. Maintaining people’s standard of living

    We consider that the Chancellor has made some major steps toward ensuring that workers have some guarantees of sufficient income to maintain their health and wellbeing during this crisis. Clearly more work needs to be done to demonstrate that the self-employed and those on zero hours contracts are not more disadvantaged. The spotlight has shown that the levels of universal credit are quite inadequate to meet needs so now is the time to either introduce universal basic income or beef up the social security packages to provide a living wage. We also need to ensure that the homeless and rootless, those on the streets with chronic mental illness or substance misuse are catered for and we welcome the news that Sadiq Khan has requisitioned some hotels to provide hostel space. It has been good to see that the Trade Unions and TUC have been drawn into negotiations rather than ignored.

    In political terms we saw in 2008 that the State could nationalise high street banks. Now we see that the State can go much further and take over the commanding heights of the economy! Imagine if these announcements had been made, not by Rishi Sunak, but by John McDonnell! The media would have been in meltdown about the socialist take over!

    1. Conclusion

    At this stage of the pandemic we note with regret that the UK government did not act sooner to prepare for what is coming both in terms of public health measures as well as preparing the NHS and Local Government. It seems to the SHA that the government is playing catch up rather than being on the front foot. Many of the decisions have been rather late but we welcome the commitment to support the public health system, listen to independent voices in the scientific world through SAGE and to invest in the NHS. The country as a whole recognises the serious danger we are in and will help orchestrate the support and solidarity in the NHS and wider community. Perhaps a government of national unity should be created as we hear much of the WW2 experience. We need to have trust in the government to ensure that the people themselves benefit from these huge investment decisions.

    24th March 2020

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    COVID-19 Pandemic

    The SHA wants to contribute to the tremendous national and international debate about controlling and mitigating the worst effects of the COVID-19 pandemic. We will base these thoughts through the lens of a socialist society, which advocated politically in the 1930s to create the NHS in the UK and for other socialist policies, which see the social determinants of health being as important as the provision of health and social care services as we strive for a healthier and fairer society.

    This blog will be the first of a series and will cover

     

    1. A global crisis
    2. The Public Health system
    3. The NHS, Local Government and Social Care
    4. Funding for staff and facilities
    5. Staff training, welfare and support
    6. Vulnerable populations
    7. Assuring Universal Basic Income

     

    1. A global crisis

    This COVID-19 pandemic has already been cited as the greatest public health crisis for at least a generation. The HIV/AIDS pandemic starting in the 1980s had a much slower spread between countries and is estimated to have caused an estimated 25-30m excess deaths so far.  The potential scale of this type of respiratory viral infection pandemic with a faster spread means we should probably look back to the 1957 Asian flu pandemic and indeed the 1918 post war ‘Spanish flu’. The 1918 pandemic led to an estimated 40-50m global deaths and was when there was also no effective vaccine or treatment for the new variant of flu. So basic public health hygiene (hand washing), identifying cases and quarantining (self isolation) are still important. We recognise this as a global challenge, which requires global solidarity and the sharing of knowledge/expertise and advice.

    The WHO, which is part of the United Nations, needs our support and is performing a very beneficial role.  This will be especially important for those Low Middle Income Countries (LMICs) who often have unstable political environments and weak public health and health systems. Remember the Democratic Republic of the Congo who have only just seen off their Ebola epidemic, war torn Syria and the Yemen.

    The USA and other high-income countries should be unambiguous about recognising this as a fundamental global pandemic requiring collaboration between countries along the principles of mutual aid. The UN and WHO need our support and funding and we look to international financial organisations such as the IMF/World Bank to rally around in the way that the world banking system showed they could in their own self inflicted 2008 financial crash. The WHO has recently referred to Europe as the epicentre of the pandemic and we urge the Government to put aside their ideological objections and co-operate fully with the EU and our European partners.

     

    1. The public health system

    The UK itself is in a relatively strong position with a national public health service, which has focus at a UK level (CMO/PHE), scientific advisory structures (SAGE), devolved governments, municipalities and local government. The NHS too still has national lines of control from NHSE to the NHS in England and the equivalents in devolved countries. The Tory ‘Lansley’ reforms in England destroyed the health authority structure below national levels (remember the former Strategic and District Health Authorities) but at least PHE has a regional organisation and Local Government have Directors of Public Health. We regret the fact that the 10 years of Tory austerity has depleted the resources in PHE and Local Government through not funding the PHE budget adequately and not honouring the public health grant for local authorities. We hope that the recent budget will mean that the public health service and local government does receive the financial and other resources required to help lead the pandemic response. Pandemics have always been high up in the UK risk register.

     

    1. The NHS, Local Government and Social Care

    We are grateful that despite the privatisation of many parts of the NHS in England we still have a recognisable system and a culture of service rather than profit within our one million or so staff and their NHS organisations. We were pleased to hear the open ended funding commitment from the Chancellor at the last budget and urge that leaders within the NHS in England and the devolved countries use this opportunity to try to mitigate the underfunding over the last 10 years and implement the emergency plans that exist and calibrate them to deal most effectively with this particular viral threat. Any debates about further privatisation of the NHS needs to be taken off the agenda and let’s not use the budget money to prop up the private sector but requisition capacity if that is what is needed and compensate usage on an NHS cost basis. We want to protect the NHS from the risk that the NHS Long Term Plan proposals for 44 Integrated Care Schemes opens up the risk of US styled private insurance schemes.

     

    1. Funding for staff and facilities.

    It will of course be difficult as a result of the staffing crisis that has been allowed to drift over the past 10 years with shortages of NHS workforce of 100,000 of which 40,000 are nurse vacancies but also includes doctors and other key staff. We and our Labour Party colleagues have been reminding Tory Ministers  that it takes 10 years to train a medical specialist so you cannot whistle them up or poach them from other poorer countries. The government needs to abolish their proposed points based immigration regime and indeed the compulsory NHS insurance of £650 per adult which is a huge disincentive to come here and work in the health and social care system.

    Hospitals and other health facilities in the UK take time to plan, build and commission. We can of course learn from Wuhan in China where they built a 1000 bedded hospital in weeks! Our own war preparation in the late 1930s when industry shifted production rapidly from civilian to military supplies is another exemplar. Despite the negative impact of 10 years of Tory austerity we urge the NHS to embrace this opportunity to invest in staff, supplies and facilities needed to manage the effects of the pandemic. Creating strategic regional NHS bodies will ensure that capital and revenue resources committed from the centre are used optimally and equitable to meet population needs in collaboration with local authorities.

     

    1. Staff training, welfare and support

    Front line NHS and social care staff will need our support over this time. We must ensure that working practices protect staff as much as possible from the risks in the workplace. Training and provision of Personal Protective Equipment (PPE) is vital and employment practices will need to adapt to the changing situation. Lets not forget social care workers, dentists, optometrists and district nurses who are part of our front line. Staff will need retraining if doctors and nurses are to be diverted to unfamiliar roles as we will need A&E, pandemic pods and intensive care unit capacity to be enhanced. Sadly, we now have a significant workforce who work for private contractors as part of the Tory privatisation of the NHS. We need to ensure that they have the same employment safeguards, minimum pay levels, sick pay and the health and safety entitlements as NHS staff. This is the time to renationalise such services back into the fold.

     Patients with existing long-term conditions remain in need of continuing care as will patients presenting with new life-threatening conditions such as cancers, diabetes and circulatory diseases. NHS managers will need support to organise these different services and decisions to postpone non-urgent elective surgery to free up resources. What also makes sense is testing novel ways of supporting people digitally and by teleconferencing to reduce attendance at NHS premises. This can be rolled out for Out Patient provision as well as GP surgeries. The NHS 111 service, and other online services  and the equivalents in the devolved nations can easily be overwhelmed so pushing out good health information and advice is being done and needs to continue. The public and patient engagement has always been at the heart of our policies and can be rolled out in this emergency utilising the third sector more imaginatively.

     

    1. Vulnerable populations.

    In our assessment of what needs to be done we must not bypass the urgent needs of some of our most vulnerable populations. The homeless and rootless populations, many of whom have longstanding mental health conditions and/or substance dependency, are particularly at risk. They need urgent attention working closely with the extensive voluntary sector. Also those populations with long term conditions who will feel at risk if services are withdrawn due to staff redeployment or staff sickness need planning for. Primary care needs to be the service we support to flag up those in need and ensure that their medications and personal care needs continue to be met even if we need to involve volunteers and good neighbours to help out with daily needs such as shopping/providing meals and other tasks.

    Undocumented workers such as migrants and refugees are often frightened to use health services for fear of police intrusion. The government needs to make it clear that there will be no barriers to care for this population during this crisis and beyond.

    Social care is in need of particular attention. It was virtually ignored in the budget. This sector is at risk in terms of problems with recruiting and retaining staff as well as the needs of the recipients of care and support.. While business continuity plans may be in place there is no question that this sector needs investment and generous support at the time of such an emergency. They will be a vital cog in the wheel alongside home-based carers in supporting the NHS and wider social care system. Those most at risk seem to be the most neglected. Disabled people with care needs have received little advice and no support. Already carers are going off sick and can be replaced only with great difficulty. Those paying for their own care with Direct Payments seem to get no support at all.

    With the COVID-19 virus we are seeing that the older population and those with so called ‘underlying conditions’ are at particular risk. We must ensure that this large population do not feel stigmatised and become isolated. Rapid assembly of local support groups should be encouraged which has been referred to as ‘local COBRA groups’. Local government can play a key role in establishing local neighbourhood centres for information and advice on accessing support as we move toward increasing quarantining and isolated households. Again wherever possible the use of IT and telephone connectivity to share information and provide remote support will make this more manageable.

     

    1. Assuring universal basic income.

    Finally the SHA recognises that the economy will be damaged by the pandemic, organisations will go to the wall and staff will lose their jobs and income stream. We have always recognised that the fundamental inequalities arise from the lack of income, adequate housing and the means to provide for everyday life. This pandemic will last for months and we think that the Government needs to ensure that we have systems in place to ensure that every citizen has access to an adequate income through this crisis. We pay particular attention to the 2m part time workers and those on zero hours contracts as well as the 5m self-employed. There have been welcome changes in the timely access to the insufficient Statutory Sick Pay but this is not going to be the answer. People will be losing their jobs as different parts of the economy go under as we are already seeing with aviation, the retail sector and café/restaurants. The government needs to reassure those fearful of losing their jobs that they will stand by them during the pandemic. It may be the time to test the Universal Basic Income concept to give all citizens a guarantee that they will have enough income for healthy living. We already have unacceptable health inequalities so we must not allow this to get worse.

     

    1. Conclusion

    The SHA stands ready to support the national and international efforts to tackle this pandemic. We assert our belief that a socialist approach sees universal health and social care as an essential part of society. That these systems should be funded by all according to a progressive taxation system and meet peoples needs being free at the point of use.  We believe that a thriving state owned and operated NHS and a complimentary not for profit care sector is essential to achieve a situation where rich and poor, young and old and citizens in towns, cities and in rural areas have equal access to the best care.

    We recognise that the social determinants of health underpin our health. We agree with Marmot who reminds us that health and wellbeing is reflected by ‘the conditions that people are born, grow, live, work and age and by the inequities in power, money and resources that influence these conditions’.

    The pandemic is global and is a major threat to people’s health and wellbeing. Universal health and public health services offer the best means of meeting this challenge nationally and globally. Populism and inward looking nationalism needs to be challenged as we work to reduce the human suffering that is unfolding and direct resources to meet the needs of the people at this time.

    On behalf of officers and vice chairs

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    One on International Trade dispute settlements and the other on Social Care.

    These are not official SHA policy.

    Issues for the NHS during UK Trade deal Negotiations

    As socialists we have an almost irreconcilable set of principles

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    Advanced paramedics in England will be able to prescribe medicines to people who do not need hospital treatment, under new laws starting on Sunday.

     Who will be able to prescribe?

    Advanced Paramedics  – those undertaking or having completed a Master’s-level (Level 7) qualification – will be allowed to complete a prescribing module, if their employed role has a need for it (i.e. you must be employed in a prescribing role, e.g. in a GP surgery. An AP cannot complete it if employed in a standard frontline paramedic role where prescribing is not a required qualification).

    How does this fit with other professions?

    Many other health professions can already prescribe. Nurses led the way, followed by various others including radiographers and chiropodists.

    Will this mean frontline paramedics will prescribe?

    No. To register, frontline paramedics have only completed a Bachelor’s-level qualification (Level 6) (from 2021), a Foundation level qualification (currently) or an in-work IHCD qualification (in the past), and therefore will not be able to apply for the prescribing module.

    Why are paramedics being given the ability to prescribe?

    Paramedics don’t just work in ambulances. We also work in GP surgeries, A&Es, walk-in centres, and Intensive Care Units across the country. Many of these roles are limited because the Advanced Paramedic, often employed alongside Advanced Nurses or other Advanded Allied Health Professionals, cannot prescribe, unlike their nurse & AHP counterparts. The change to the law will allow these to work equally to other professions, and will expand the number of range of jobs Paramedics can do (e.g. why employ an Advanced Paramedic who can’t prescribe, when you can employ an Advanced Nurse who can?).

    Will there be any prescribing in the Ambulance setting?

    Paramedic Prescribing is up to each Ambulance Service Trust to implement. There is certainly scope for benefiting the patient & the system if Advanced Paramedics are able to support frontline crews with prescribing skills. There are many cases where patients are taken to hospital or referred to the out-of-hours GP for a simple prescription that could, now, be handled by the ambulance service.

    Is prescribing just for non-emergency cases?

    No. Paramedic Prescribing will also widen the range of drugs paramedics are able to administer in an emergency when supported by an Advanced Paramedic. This too will be up to each Ambulance Service Trust to implement.

    Won’t people just call for an ambulance for a prescription because its quicker than waiting to see a GP?

    This question assumes that ambulances currently only go to emergency cases. This isn’t true, and we already attend many non-emergency cases that could/should be dealt with outside of the ambulance service. This has become the case through a combination of factors discussed in another article. Many of these patients, now they have entered an ambulance system ill-equipped and ill-trained to deal with their non-emergency health condition, are fed into the out of hours GP or hospital system.

    Giving the ambulance service the ability to prescribe will not reduce the amount of non-emergency cases we attend, but it will reduce the onward burden of these cases to other health systems.

    Furthermore, sometimes patients have multiple needs, some of which are urgent and some non-urgent, which may all contribute to an ambulance call-out. For example, a patient may have fallen and is unable to get up – a paramedic’s bread & butter – but the patient may also have an underlying chest infection or unmanaged chronic pain, which could have caused the fall.

    Say you’re wrong. What happens if calls for non-urgent cases do increase?

    The underlying issue here is that the Ambulance Services are already stretched between trying to provide quality care to both emergency and non-emergency groups. The concern highlighted in this question is that this tension may increase further if the patients begin to use the ambulance service in order to obtain a prescription quicker.

    The solution is not to stop ambulance services from prescribing in order to manage the tension, but to look at the systems that bring about the tension in the first place.

    Here I wrote how current ambulance services might overhaul the system by providing only emergency care, while another group of paramedics, either still employed by the ambulance service but with exclusive resources, or employed by new non-emergency ambulance services or by GP surgeries themselves, could handle non-emergency care.

    Paramedic Prescribing increases the ambulance services ability to provide 24 hour care in the community, independent of other services, across a whole range of acuities.

    This provides a potential solution to the increasing difficulty found by General Practitioners to be able to afford to conduct home visits and to provide out of hours care. Ambulance Services have held GP visits & OOH GP contracts in the past, and have delivered well. As long as we ensure that this doesn’t impact the emergency care delivery, ambulance services could reshape the landscape of care in the community.

    Where can I find out more?

    The College of Paramedics has led the campaign for paramedic prescribing, and has a lot of good information and documents on their website.

     

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    The National Audit Office documents only failure in its ‘Reducing Emergency Admissions’ report

    On 1 March 2018, the National Audit Office published a damning report on successive failed initiatives to reduce emergency admissions at NHS hospitals in England. The National Audit Office scrutinises public spending and holds Parliament to account and improve public services. Apparently the Department of Health  wants elective and emergency admissions to be reduced to 1.5% (whatever that means). The NHS England mandate is however extremely weak in the admissions arena. – ‘…to achieve a measurable reduction in emergency admissions by 2020’.

    Cost is a big issue here and reducing mortality and patient pain and suffering makes no appearance in the 54 page report. The current annual cost of emergency hospital admissions is £13.7 billion. This cost has remained static over recent years. Between 2015/16 and 2016/17 emergency admissions increased by 2.1 %. So all attempts over recent years to reduce emergency admissions have failed.

    The elephant in the room here is the oft quoted 2009 McKinsey & Co theory that 40% of patients admitted to hospital should not be there. The theory continues with the notion that Out of Hospital/community care/intermediate services could ‘replace’ these hospital admissions. NHS England states that currently 24% of emergency admissions could be avoided.

    79% of the growth in emergency admissions from 2013/14 to 2016/17 was by people who did not stay overnight in hospital. Reducing beds (bed use) is clearly a key factor as staying overnight in hospital is expensive. The emergency admissions’ increase is mostly of older people.

    It’s pretty clear that attempts to reduce the impact of emergency admissions have failed. These reduction programmes include the urgent and emergency care programme, the new care models, the Better Care Fund, RightCare and Getting It Right First Time.  Re-admittance rates rose by 22.8% between 2012/13 and 2016/17.

    In October 2017 the Department of Health admitted that £10 billion spent on community care ‘could have been better used’ and that ‘programmes to focus on community care had stalled’.

    The Department of Health, NHS England and NHS Improvement all admit that they have no idea why there are local variations in hospital emergency admissions. NHS England is not happy with emergency admission data, and the lack of linked data across healthcare and social care.

    On page 10 of the report we find ‘…the challenge of managing emergency admissions is far from being under control’.

    There are enormous amounts of data analysis on performance, beds and intermediate care.

    The number of days that beds are used by people admitted as emergency admissions has increased from 32.4 million in 2013/14 to 33.59 million in 2016/17 – an increase of 3.6%. The majority of bed days (96% in 2016/17) are used by people who stay for two days or more after being admitted as an emergency admission.

    The recommendations in the report are stunning and include:

    • Establish an evidence base
    • Disseminate learning on new care models effectively
    • Link primary, community health and social care data
    • Figure out why there are local variations in emergency admissions
    • Figure out how community services will support reductions in emergency admissions
    • Introduce an Emergency Data Care Set to improve data on daycase emergency care
    • Publish data on re-admissions.

    View the NAO report 

     

    1 Comment

    A socialist analysis of any health programme requires recognition of the competing tensions of resource, patient care and working conditions, and the necessity of balance to prevent a crisis. Therefore, the following analysis will reflect these tensions. Finally, I will analyse the crisis points which caused this to be necessary. During this analysis, I will exclude increased funding as a consideration, due to the low liklihood under the current government, and because increased funding would ameliorate, but not solve, some of the underlying problems.

    The Ambulance Response Programme

    The Ambulance Response Programme was the largest overhaul of the way the ambulance services deals with calls for 20 years, and was trialled in the West Midlands, South West and Yorkshire Ambulance Services from 2015, before now being rolled out to other services.

    The major changes that the ARP brought about were:

    1. Increased time to assess call requirement before resource allocation (through new ‘Nature of Call’ and ‘Dispatch on Disposition’ processes)
    2. Increased number of categories with longer response times

    Prior to the ARP, calls were broadly coded as follows:

    Category Call examples Response Time Target
    Red 1 Cardiac Arrest, choking 8 minutes
    Red 2 Chest Pain, Shortness of Breath, Heavy Bleeding 8 minutes
    Green (1-4, local variation) Everything else 19 minutes

    After a series of trial and error, the latest iteration of the ARP codes calls as follows:

    Category Call examples Response Time Target
    1 Cardiac Arrest, actively fitting, <5 year old with priority symptoms 8 minutes
    2 Chest Pain, Shortness of Breath, Heavy Bleeding 19 minutes
    3 Nosebleeds, headaches, other urgent health complaints, concern for welfare 60 minutes
    4 Fall without injury 90 minutes

    Analysis: Old vs New

    Resource efficiency

    Efficiency is important, no matter your political position. However, the motive for efficiency is key. Clearly, it was inefficient for 50% of ambulance calls to be responded to within 8 minutes, especially considering the 90%+ rate of false positives (University of Sheffield, 2017). This was both detrimental to patients who couldn’t get an ambulance, and workers who dealt with the stress of demand. Therefore, better ways of matching clinical need to resources were required.

    There is detailed evidence-based analysis provided by the University of Sheffield (2017) (Presentation, Final Report) regarding the effect of the ARP on resource efficiency. As they make a much better argument than I can, I will only summarise their main findings:

    • Increased time to correctly assess calls before resource allocation has resulted in increased operational efficiency on all measures, and subsequently better response times for seriously ill patients.
    • The change in call categorisation is a large overhaul and still in its infancy, and many adjustments are yet to be made, however, the initial results reveal that resource allocation more closely matches clinical need, and reports from staff in EOC appear positive.

    While it has clearly been driven in response to decreased funding to meet rising demand, the important question to be made is whether this efficiency has been beneficial to patients and workers, or whether it has been solely to meet a wider agenda.

    Effect on patient care

     It is easy to take away headlines such as “Patients will wait 20 minutes instead of 8 minutes when having a heart attack”, but it is obviously more complex mechanism than that. Of course, ideal conditions and unlimited funding would lead to an ambulance on every street, but reality imposes constraints, even in a well-funded health system such as one under a Labour government.

    It is important to recognise what the numbers mean. The numbers are arbitrary and represent a target (i.e. 75% of Category 1 calls responded to within 8 minutes) by which to measure performance and evaluate the effectiveness of changes. So the changes that have been made to call categorisation are only to increase the number of categories and to what delay is deemed acceptable for each category. The number of minutes can be changed at any time. That being said, studies have shown that there is no clinical benefit for response in less than 8 minutes for any condition other than out-of-hospital cardiac arrest (University of Sheffield, 2017).

    Where efficiency has been gained is because of the greater time allowed to ambulance controllers to send an appropriate resource (e.g. one that may be about to come clear close to the incident), rather than forcing controllers to dispatch resources immediately, only to stand them down once half way across the city. This is especially evident when one considers the maximum response time for an emergency call was previously 19 minutes, even for very low-urgency calls (e.g. minor ailments such as a cold) – it is now 90 minutes, allowing controllers plenty of time to allocate a resource while ensuring emergency needs are met.

    One unintended side-effect that has had a detrimental impact on patients arises due to the change in the ability of Rapid Response Vehicles (RRV) to ‘stop the clock’. RRVs were located in many rural towns, where being highly localised enabled them to have a good relationship with other health care providers (impossible in the urban environment), were manned by experienced paramedics who were highly skilled in the use of alternative pathways. Not only this, they were able to provide rapid response in time-critical conditions. In summary, RRVs were good for patient care.

    From a performance target perspective, they were able to ‘stop the clock’, which financially justified the lack of ambulance provision to these rural areas and their presence masked the long (several hour at times) waits for a conveying ambulance to arrive (which wasn’t a performance target). This tragedy led to the removal of ability of RRVs to ‘stop the clock’ when it was apparent a conveying ambulance was required (e.g. elderly fall with hip pain). In practice, what has happened is, in organisations forced by policy makers to place meeting budget requirements above patient care, that the financial justification for RRVs disappeared and the RRVs were quickly replaced by ambulances, which spend a long time away from their locality conveying to city A&Es leaving those rural areas with little or no cover. The towns involved have rightly been incredibly angry at this change.

    Clearly, a middle way is required in this circumstance, and it is imperative that NHS policy makers recognise the unintended side effect of their decision and adjust accordingly.

    It is a complex picture to say whether this change has benefited patient care overall. While I would like no-one to wait a long time for an ambulance, a utilitarian approach must be taken – the greatest amount of good for the greatest amount of patients. Patients who are uncomfortable but stable, (e.g. elderly fall with no injury) might now be waiting longer for ambulances, but that means resources are available to reach seriously ill patients quicker.

    The major confounding factor in the analysis of the ARP is the inability of current triage systems to differentiate between emergency and urgent conditions in some circumstances, leading to symptoms becoming groups to be dealt with together. A triage system that could sort heart attacks from other non-emergency causes of chest pain would enable, for example only, a 8 minute response to one, and a 40 minute response to the other. However, the computer triage system treats all chest pains as one common group. As a result of this, the previous categorisation system took the lowest common denominator and required an 8 minute response to all chest pains – which, along with other similar processes, proved unsustainable without massive increases in funding that’d be eye watering even under socialist governments. The current categorisation system, therefore, has had to compromise, allowing Ambulance Services a faster response than necessary to some chest pains, but a slower response than necessary for others. The weakness of computer triage systems will be examined briefly later in this analysis.

    Effect on workers

     The effect of ARP on ambulance clinicians has been positive on the whole. The major concerns of Ambulance Clinicians are finishing on time, getting a break, and fatigue, including blue light driving fatigue.

    Prior to the ARP, it was common to respond to a call for a low urgency condition only minutes before you were relieved by an oncoming crew.

    The increased number of categories, and the increase in time allowed to respond to urgent and non-urgent calls has allowed unions to push for improved end-of-shift policies and break policies, for example, not responding to calls with a 60 or 90 minute response time within the last hour of your shift, and getting a break halfway through the shift unless there is an outstanding emergency call. Both of these policies represent major steps forward in ambulance working conditions only made possible through the ARP. No figures have been released around whether these policies have decreased late finishes and late breaks (and of course, there are many confounding factors), but I believe the positive conclusion follows logically.

    The inefficiency of the previous system led quickly to crew fatigue. While, of course, fatigue is still a major issue for ambulance crews, a small amount of the burden has been improved.

    Many outsiders find it hard to believe that blue lights & sirens are used to go to every call, from stubbed toes to shaving cuts and to mothers struggling to get their baby to sleep (I’ve been to all 3!).  This policy, suited to an era gone by where few calls were not life threatening emergencies, is still enforced by Trusts in the name of benefit to the patient, but it is widely believed on the frontline that the motive is purely financial (less time driving between jobs means more jobs achieved during the shift). Driving on blue lights is fatiguing, especially in rural environments where you may be driving for an hour routinely. One major shift represented within the ARP is the recognition that some responses (Category 4) don’t require a blue light response – again, reducing the burden of fatigue. In reality, few conditions benefit from blue light responses, and the correct solution would be a flexible approach: allowing the clinician to make the decision according to weather & traffic conditions and clinical need, rather than rigid blanket rules.

    Fundamental tensions: is there a better way than ARP?

    Now, one must ask, why was such an overhaul of response times necessary? It is only by addressing the fundamental tensions that led to such a change occurring that it would be possible to improve on ARP.

    While it was certainly correct to move away from old systems of working, the driving factors arise from two points – the tension between emergency and urgent care within the Ambulance Service and the high rate of false positives as a result of computer triage systems – both of which are subjects for in-depth analysis themselves, but about which I will make only a brief assessment.

    Demand for emergency pre-hospital care is what the Ambulance Service evolved to supply, and almost everything within the Ambulance Service is oriented to this demand, including previous systems of call categorisation, the medication & equipment we carry and our training. It also evolved in an evironment where 999 was infrequently used by patients for urgent healthcare. However, due to austerity in other areas, especially General Practice, Mental Health and Social Services, patients have turned to 999 (and now, 111) to meet their urgent needs. In simplest terms, the Ambulance Service is overwhelmed by urgent and primary care requests, such that when a time-critical emergency occurs, there are few or no resources to respond. The ARP is a clear shift in ambulance service policy to attempt to more efficiently bridge this tension between emergency and urgent care.

    This tension is fundamental within the Ambulance Service, yet is little debated in absolute terms in the public realm. While reversing austerity in GP, MH and local authorities would reduce ambulance urgent care demand, the tension remains beneath the surface. Not only that, ambulance clinicians have shown that they have a place in supporting medicine in the community.

    The reality is that no single pool of resources can meet demand for both urgent care and emergency care without one or both suffering, and therefore exclusive resources must be allocated for each purpose, probably through split emergency and non-emergency organisations (potentially into 999 & 111, Fire Service & Ambulance Service, or new organisations entirely). Implicit in this is the recognition that emergency care requires resources in reserve.

    The system that made ambulance services vulnerable to the increase in urgent care calls is the use of a computer triage system which will always be designed to be near risk-free. While it brings benefits such as standardisation and ability to audit, its weakness is the removal of the human subjective element from it. The easiest example to illustrate is that of Chest Pains: A risk-free computer system will be designed to miss no heart attacks, and therefore every chest, back or jaw pain is treated as a heart attack, despite that call being for 10 year old back pain, or for dental problems. The system churns out a high number of false positives of many conditions, stretching resources such that they are unable to attend the true positives. It is due to this that over 50% of ambulance calls required 8 minute responses under the old categorisation system.

    Regarding solutions, due to the non-standard presentation of medical conditions, it would near-impossible to improve the false positive rate through question refinement (e.g. at what duration of chest pain do you not treat it as a heart attack? Do they have to say “crushing chest pain”?). The job of clinicians, however, is to consider many subjective factors simultaneously and come to a conclusion as to the likelihood of a condition being present. The weakness of clinicians, on the other hand, is that they make mistakes, and their telephone clinical assessment could delay response. The return of clinicians to call-taking is expensive and introduces some risk, but would produce system wide benefits in reducing ambulance responses, and therefore improving response times to seriously ill patients.

    One further question on which there has been no debate is: if it has been deemed safe for a patient to wait 60 minutes for an ambulance, but ultimately will require admission, and they live only 10 minutes from the hospital, should they receive an ambulance or be told to make their own way to A&E? In many cases, asking them to wait for an ambulance, when they could make their own way only serves to delay treatment, which is unethical.

    The question that must ultimately be asked is whether they should receive an emergency ambulance at all, if their condition is so stable. I do not propose leaving such people without care at all, but I return to my previous point on the tension between emergency and urgent care. I merely propose that other forms of urgent care services could meet this demand better, and from a resource perspective, patients with urgent care conditions who can make their own way to A&E or other services should be encouraged to.

    Only a brief assessment of these factors has been made here, as a true assessment must be far more in-depth than this analysis allows, and I hope to elaborate on these issues more in future.

    Conclusion

    The ARP, though still early on, has appeared to have improved resource efficiency, have had a broadly positive effect on patient care for the most seriously ill patients, and allowed unions greater scope to develop better working conditions. I can find no reason for socialists to oppose this change.  However, socialists must look beyond surface symptoms for deeper tensions, and by understanding and attempting to resolve these tensions, alongside others, it is possible to improve patient care, working conditions, and resource efficiency at a magnitude far greater than current attempts.

    Further reading would be the in-depth report by the University of Sheffield, which provides a detailed background and evidence based analysis on its effect on resource efficiency.

    James Angove is a pseudonym. The author is a socialist and a paramedic in the UK, whose identity must be hidden due to the treatment of health care professionals and other whistleblowers who talk about issues within the health service.

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    Demand has grown for the Ambulance Services by 35% since 2010. While the government announce that the budget has seen a 16% increase in budget since 2010 (National Audit Office, 2017), in reality matching inflation counts for 12% of this increase. This demand is not predominantly the ‘living longer effect’: while that of course does play a part, aging is largely a predictable variable and with effective planning could have been corrected for many years ago. The increase in demand comes largely from four areas: undifferentiated urgent care complaints; failed secondary care; mental health problems; and social care problems. All the above have occurred as a response to the cuts seen in Primary Care, Hospital, Mental Health and Local Council budgets. In this first of a series of articles, we will focus on the effect of cuts to primary care and the shift from GP provision to Ambulance provision as a result.

    Ambulance services

    Ambulances outside the Accident and Emergency Dept

    During this article, I will refer to urgent and primary care interchangeably. This is because the classification for ambulance is ‘urgent’, where many of these patients should be managed in primary care. Many of the concepts of which I speak here are not the subject of research. I have linked to evidence where possible, but much of what I say comes from personal experience, and from talking to other ambulance clinicians around the country.

    The Ambulance Services used to deal with, largely, emergency care. The perception of this remains, but it masks the true nature of today’s Ambulance Service. A mobile GP surgery, with none of the equipment, training or support. Older paramedics reminisce of days gone by where they only went to “genuine calls” – heart attacks, respiratory problems, road traffic collisions and cardiac arrests. Today, these make up only a small percentage of call outs. Today, we go to a variety of calls from mild belly ache, urine and chest infections to “baby won’t settle”, months-old complaints of back pain and other primary care conditions.

    While this may appear on the surface as misuse, and therefore an issue of public ignorance towards the severity threshold for a 999 call, as many clinicians and social media users alike will propose, there are underlying processes at work that socialists must examine.

    Many patients will talk on crew arrival of the immense difficulties they have undergone to try to get an appointment with a GP, only to either be instructed to call 999 as the surgery, under immense pressure themselves, are unable to assess the patient within a safe timeframe, or to be told the nearest appointment is in 3 weeks, to which many concerned relatives will see no choice but to seek a quicker assessment – and none are quicker than the ambulance service, despite increased waiting times. Others have been referred by the 111 service which has a notorious infamy amongst ambulance clinicians for referring a large number of false positives – and missing false negatives.

    Some may reply that if Ambulances are sat around waiting for emergency calls, and GPs are overstretched, then we should be available to help. While I shall deal with the issue of the need for a ‘reserve’ within the ambulance capabilities later on in this series, it is also important to examine how we deal with these primary care cases.

    At no point do Emergency Care Assistants, Emergency Medical Technicians, Associate Ambulance Practitioners or even Paramedics receive training in the management of urgent or primary care cases. Our guidelines make no provision for it either. Our assessment training only covers so far as to identify conditions that fall under the Emergency remit (Strokes, heart attacks, pulmonary embolisms etc.). Due to the lack of training, many do not have the confidence to make decisions on primary and urgent care cases, fearful of missing an atypical heart attack or other hidden emergency condition and such like. Alongside the perception of lack of support from employers and regulatory bodies (which does not always align with the evidence), this leads to an inordinate number of conveyances to A&E “just in case” – and not always in the patient’s best interest.

    Our assessment equipment, again, is tailored to emergency situations – electrocardiograms, blood sugar tests (in case of an unconscious diabetic), oxygen saturation probes – and we lack the necessary equipment to make primary care decisions. For example, “Dipping” urine is a very simple skill, no more difficult than a litmus test or an old pregnancy test, such that relatives and patients are sometimes taught to use it. However, paramedics are unable to “dip” urine, with no explanation given (one can only assume a cost factor), needing for us to rely on District Nurses, GPs and A&E to conduct the urinanalysis, delaying diagnosis and treatment for a common elderly condition, which can progress to life-threatening sepsis if left untreated.

    Not only this, but we carry only enough medication to prolong or save life in emergency situations – adrenaline, salbutamol, and morphine among others. Even if we correctly assess the primary or urgent care complaint, we have no management tools. We carry no long-term antibiotics (and maybe for good reason with a view to antibiotic resistance, but it has implications if we are to respond to these jobs). We can offer nothing for long-term pain management (only enough to move an in-pain individual to hospital). Again, with GPs unable to fit in appointments, this leads to a large number of conveyances to A&E as ambulance clinicians (rightly) view it as unethical to delay treatment, even if A&E are over-stretched.

    The biggest problem caused by ambulance response to primary care is the lack of emergency reserve. I personally have heard so many calls from the Control Room pleading over the radio for someone to make themselves available to respond to hyper-time critical emergency events like choking, fitting or cardiac arrest, because the closest crew is 20 minutes away being drafted in from another city. Amongst other causes of increased demand (mental health and social care), this is because closer ambulances are dealing with primary care conditions. A major source of stress for ambulance clinicians is knowing you’re only a few minutes away from a time-critical emergency, but being unable to leave the primary care patient you’re currently dealing with.

    However, there are advantages that are appearing as the ambulance profession absorbs primary care into its remit. An obvious example is care for patients who are unable to leave their home due to current or past medical conditions or their age. Traditionally dealt with by visits by their GP, these patients are left without care out of hours (except by out-of-hours GP visits) and struggle to ever be seen by health care professionals due to cuts to both in-hour and out-of-hour GP provision. A more detailed argument would be required by someone with experience in GP Primary Care provision dealing with whether home visits are an efficient and appropriate use of a GP’s time (as opposed to other HCPs). Ambulance clinicians are traditionally mobile and used to working in people’s homes, and are now used to dealing with some primary care complaints, could be one alternative. Before the Ambulance Service merger, Staffordshire Ambulance Service conducted GP Home visits on behalf of many surgeries, and provided the out-of-hours provision. This was backed up by training, good local working relationships, equipment and a more advanced management portfolio than the one provided to clinicians in the same region now.

    Another advantage is that paramedics are more regularly exposed to emergency patients than GPs, which gives them skills and experience that would assist GP assessment and to start the pre-hospital management of emergency care. One example of such a skill is that paramedics are fast becoming experts in 12 Lead ECG interpretation, and with this skill being almost routine, paramedics would be well placed in GP surgeries to provide an additional experienced opinion. Cardiac arrests are an uncommon occurrence within a GP surgery, and no matter how well a clinician knows the theory and has memorized the protocols, the management of this condition is difficult out of hospital, especially for clinicians who don’t have regular exposure to it. This is another example where ambulance clinicians who have a lot of real life, hands on experience with out of hospital cardiac arrest, would help primary care providers deliver effective care.

    The two competing processes of dealing with urgent care and emergency care represent a tension that at times, such as winter, represents a crisis. In simpler terms, Ambulance Services struggle to provide a timely response to emergency care by being tied up in urgent care, and, as society’s last line, leave urgent patients without access to care due to dealing with higher priority requests (e.g. reports of elderly ladies left on the floor for hours).

    So, what is the solution?

    First and foremost, GP surgeries require sufficient funding to make sure no-one waits an unethical amount of time for an appointment. If Ambulance clinicians are to respond to primary care calls, clinicians should receive the correct training, equipment, management tools and support from GPs to provide the right care to the patient.

    However, no amount of amelioration will resolve the contradiction. One set of resources balancing the two types of care will always be only one disturbance from crisis, no matter how well balanced it may appear.  What is appearing as the most fundamental requirement of any solution is that exclusive pools of resources to deal with each category of demand is required.

    To achieve this, Emergency Ambulance Services should not take responsibility for responding to these primary care/urgent calls, and responsibility should pass to another group of resources. Possible splits could be for emergency care to pass to the fire service, or for urgent care to be taken up by the 111 service. It would also be possible for a split to occur within the ambulance service, much how the Patient Transport Service or the High Dependency service operates separately from Emergency care.

    However, my suggestion is instead for non-emergency ambulances staffed by specialised urgent/primary care paramedics with the necessary equipment to be attached to individual GP surgeries, with a good working relationship with the surgery staff, that can carry out home and urgent visits at all hours. For clinical governance purposes, they could be managed by a national non-emergency ambulance organisation, while being paid and employed by the GP surgery.

    The reasons I believe this to be the correct solution are:

    • Continuity of care for patients with acute exacerbations of chronic conditions, which is good for both the patient and helps clinicians make good decisions
    • Ambulance Crews are able to access a patient’s medical records to make informed decisions
    • A good working relationship between ambulance clinicians and GPs is difficult to achieve in many urban areas, due to the large number of regionally employed ambulance crews and the multitude of localised GP surgeries, however, one must only look to community paramedics based in rural villages and their relationship with the local GPs to see the increased benefit for the patient and the wider NHS.
    • A clear delineation between Primary/Urgent GP care, Emergency Ambulance Care and Secondary Care, where currently the lines are currently very blurred, allowing for correct training and equipment.
    • An embracing of the advantages of ambulance clinician primary care

    The Socialist Health Association should oppose any attempt to load further primary or urgent care on to Emergency Ambulance Services – either directly, or indirectly through further GP cuts. The SHA should recognise the internal contradiction and its effect on patient care, and to call for primary care provision to return to GP services, allowing emergency ambulance services to have crews available to respond to true emergencies. However, the SHA should embrace the positives of mobile primary care response units and the unique experience of ambulance clinicians and call for ambulance clinicians to become more involved in primary care provision in GP surgeries through a number of possible mechanisms.

    James Angove is a pseudonym. The author is a socialist and a paramedic in the UK, whose identity must be hidden due to the treatment of health care professionals and other whistleblowers who talk about issues within the health service.

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    I am just writing this as me. It isn’t going to be the most perfect piece of prose, partly because the information has come from my husband/carer and because I still feel the fear whenever I think about it. My brush with co-payments was traumatising for me, my husband and could have had very serious consequences – including death.

    I live with a rare, and potentially fatal condition. It has been what they call “brittle” from the beginning. Nevertheless, I am well insured and of course carry all necessary documents for health treatment in an EU country. What could possibly go wrong??

    Early one morning while on holiday in an EU country I started to feel nauseous. This is a warning sign of a crisis. The nausea progressed to projectile vomiting, then voiding, as my temperature plummeted and I began to lose consciousness. My husband phoned the local health centre. They spoke English and he fully explained the danger – left too long my organs will shut down, and the end game is potentially death.

    The first words spoken were – “that will cost you 180 euros. “OK” said husband, but he was not at all confident in any system that could put the money first.

    “Bring her down to the centre” were the next words down the phone.

    “But she is unconscious and covered in sick” said hubby, “I can’t just put her in a taxi”.

    “We don’t do home visits” was the response.

    “I don’t know the system”, said my husband, “I can’t bring her anywhere, what do I do?”

    Well it might seem obvious, but my husband was panicking

    “Phone an ambulance”.

    Hubby did, and the ambulance came, but the co-payment fiasco didn’t end there.

    The ambulance people were caring and somehow got me downstairs and into the ambulance.

    We then proceeded to go past at least one gleaming private hospital, slowly down some narrow country roads, and well out of town to the nearest public hospital.

    I was off loaded.

    Alone with me in a room, hubby was then asked for another co-payment. “just go to the desk”. Imagine if it was your loved one, and you were asked to leave them in a crisis, and alone.

    The doctor came and told him to hurry, go to the front of the queue as an emergency, as she wanted to start treatment urgently. Hubby ran.

    Once back he could talk about my medical history, allergies and so on. The doctor was knowledgeable, efficient and kind. It doesn’t take long to bring me round from a dangerous situation, and I can usually get home in the NHS in around 6 to 8 hours, but even so, I was told to get a taxi probably a bit earlier than I would have needed/wanted in the UK.

    Going home the taxi driver treated us to a very informed chat on how this was a trojan horse and the end of their public healthcare system. A few days before we had a taxi driver talk on TTIP and chlorinated chicken.

    If anyone is tempted to think we would do it differently under the current model of defunding the NHS, just think of the brilliant success of the co-payment systems we have already.

    The Care System has always been co-payments for the less poor. I will not say the rich, as demands for some contribution are made to many we would not consider that well off. The situation is dire: abuses of human rights, starvation diets, neglect; the list goes on. There are repeats of the TV programme “Waiting for God”. Not even the wealthy can ensure they are not being herded and milked for the benefit of the shareholders. It is the law.

    Then there is dentistry. I was warned years ago that dentistry was the pilot for the NHS direction of travel by a totally distraught dentist, who felt his patients no longer came first, and the less well-off would be excluded. Hubby has paid £600.00 for dentures (just a couple) under the NHS system. They are not fit for purpose. Treatment is basic now, and in my town people are often seen with big gaps and rotten teeth. The old pull it out by using the door trick has even re-appeared. It is tempting to go private if you have the money, and friends have paid thousands to private dentists, though they are against the concept.

    Co-payments will have the most terrible impact on the sick, disabled and poor. They will be excluded, frankly, so the worried well can have blue fitted carpets and no queuing. It will fix the NHS in the same way as taking those truly needy cohorts out and shooting them would also fix it – just it’s more acceptable/less obvious.

    I have not heard a single person as a patient under the co-payment scheme who isn’t well off express that they liked it. Quite the opposite, and I work with healthcare staff and academics in the US and Australia. They know it puts their lives on the line.

    Like dentistry a “reasonable” co-payment will soon start to look like quite a chunk of your money – loads more than we all first thought. And for what? This was posted on our SHA Website and I’ll repeat it here:

    NHS Dental Care Faces a Severe Collapse

    One of the health concerns neglected by the NHS is dentistry regardless of the fact that teeth matters as much as any other part of our body. As revealed by the British Dental Association in September 2016, the NHS had to bear a cost of £26m when around 600,000 people in a year made nugatory appointments with GPs over dental issues. Though this statistic has resulted in ridicule, yet in all honesty, it is the government, not its citizens, who should be embarrassed.

    It is the NHS bills that are drawing patients away from the official government system and driving them toward GPs for their dental problems. As indicated by the BDA’s new analysis, this practice might soon outclass government financing as the main revenue source for NHS dentistry.

    The NHS charges for dental services were first instituted in 1951 to bring down the demand. The BDA has named these charges as “health tax”, which veil actual trims in the service and debilitate the patients most needing care. Due to the incurred charges, about 1 of every 5 patients has deferred treatment as per the official findings.

    The government funding for the NHS has been cut down by £170m since the Tories first made it to No 10, and it is hoping that patients should constitute the shortage. In 2016, dental charges were climbed by 5%, and they are anticipated to take the same hike even this year too. Considering the 16 years of time, it is assumed that majority of the NHS budget for dentistry will be financed by patients instead of the central government. But what is the use of the NHS if it is not a free service at the required time, and treatment isn’t according to one’s need but ability to pay?

    Children are entitled to avail free NHS dentistry – but even they are being pulled down by the government as it is unable to meet the demand and offer enough dentists. Earlier in 2016, a letter was signed by more than 400 dentists exhorting that dental care in Britain is falling to the levels of “third world”. According to them, the NHS dental system in England is ill-equipped for the purpose. These crises are of grave nature; about 62,000 people mostly including children turn out to be at the hospital each year due to tooth decay; half of the adults haven’t been to a dentist for the past two years; and one of every seven kids hasn’t gone to a dentist since the age of eight.

    People in Britain are already paying higher bills for fundamental care, and add a bigger sum of a dental budget by submitting these charges than their correlates in the devolved countries – systems of which have become less dependent on charge income throughout the recent decade. To deal with this gap, the BDA is sending information posters to more than 8,000 NHS dentists all through England to help picture patients’ feedback on the eventual fate of the charge.

    When dental charges were made a part of the NHS in 1951, Nye Bevan who was the formulator of the NHS resigned from the service in protest. Today, after sixty-five years, the service is damaged by inadequate investment, exaggerated charges, and a shortage of dentists. There is a genuine need to form a government-funded NHS dentistry which wouldn’t rip off the patients. However, as of yet, we are going in the other direction of which the consequences will be borne by lower-income Britons.

    Co-payments in health to me sound very much like the position refugees are suffering under this government according to the latest briefing by Asylum Matters. I have approached them to ask to reproduce the paper and recommendations, and been given the go ahead. This will follow shortly.

    Finally: Imagine:

    You have a heart attack in a local park. You and your partner set off in the ambulance only to discover that you must pay, and your wallets and cards are locked up at home. Precious time is lost chasing the money. Your partner is scared you will die when they are away getting the plastic.

    You just gave every bit of spare funding you had for the youngest child/grandchild to access university for 3 years, and then you get cancer (or another serious and maybe longer-term condition). It is might be difficult to fund all these co-payments to your GP and specialists. It is not worth a blue carpeted half empty waiting room. Under the current defunding you won’t get that anyway. I have loads of co funding horror stories from the USA.

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    Traumatic brain injuries, as the name clearly points out, are caused by a trauma to the brain. This often presents itself in the form of an external force, applied with violence at the level of the brain. Despite being protected by the sturdy cranial cavity, the brain can be easily damaged in such cases, its overall functioning being affected. Depending on the type of trauma, the injury can be closed or it can penetrate the cranial cavity. The symptoms of such traumatic injuries depend on the area of the brain that has been affected; the type of injury will also dictate the chosen course of treatment.

    Brain injuries

    Symptoms

    The symptoms of traumatic brain injuries, as it has already been mentioned above, depend on the actual type of injury and the damaged area of the brain. Many people deal with brain injury and memory loss, especially after violent accidents. However, it is important to understand that the cognitive functioning can be affected as well; one can exhibit a wide range of other symptoms, related to the emotional, social and behavioral functions of the brain. The more severe the injury to the brain was the more diverse and intense the consequent symptoms are going to be.

    Right after the actual trauma, one can lose consciousness or experience life-threatening symptoms, such as lethargy, inability to move or speak. One can experience moderate to intense headaches, blurred vision and inadequate coordination. Nausea and vomiting are frequent, as well as loss of balance, dizziness and tinnitus. If the cognitive functioning has been affected, one will have difficulties responding, speaking or concentrating.

    The speech can be affected as well, with patients exhibiting slurred speech, aphasia or dysarthria. They may lose their ability to move and coordinate, especially when balance problems are associated (damage to the cerebellum). Patients who have suffered from traumatic brain injuries may exhibit personality changes, not to mention experience confusion, social behavioral problems and constant agitation.

    If the intracranial pressure reaches high levels, life-threatening symptoms can appear. The patient can lose consciousness, experience an abnormally low heart rate or enter in a state of respiratory depression. In such situations, emergency intervention is necessary, in order to prevent sudden death.

    Causes

    The brain is protected by the tough cranial cavity and it does not become easily damaged. However, in case of trauma, things change. A violent force can cause a lot of damage to the brain, especially in case of vehicle accidents. Traumatic brain injuries are also common in those who engage in contact sports or those who have been involved in work-related accidents (constructions in particular).

    Regular sports can lead to traumatic brain injuries as well, especially when violent force is involved. Other recreational activities are responsible for such health problems, especially in children. They are more fragile, as their bones are still developing and, thus, more vulnerable to such injuries. Traffic accidents, involving any kind of motor vehicle, are often responsible for traumatic brain injuries, including in the pediatric population.

    Physical violence is one of the most common causes of traumatic brain injuries, not only in children but also in adults. Child abuse and domestic violence are two main causes of such injuries, leading to life-threatening complications and even death. Industrial accidents, such as the ones that occur on oil platforms, as a result of explosions or due to chemical products, are responsible for traumatic brain injuries (more commonly in men). Traumatic brain injuries are often encountered in war zones, being often caused by explosive projectiles, gun attacks and open-fire combat.

    Treatment

    In all traumatic brain injuries, emergency treatment is essential, in order to prevent life-threatening complications and death. Depending on the severity of the injury, the patient might need intubation (respiratory support). Emergency surgical interventions are performed, in order to reduce the intracranial pressure and avoid the excess swelling of the brain. Surgery is also recommended in case of brain hemorrhages, for the prevention of further complications.

    Before administering any kind of treatment, the patient will undergo imaging investigations. This will determine what part of the brain has been affected and also guide the further treatment measures. The patient will receive analgesics or sedatives, in order to relieve the pain. Hypertonic saline solutions are administered to reduce the swelling at the level of the brain and also the electrolyte imbalances that might cause heart failure.

    Fluids are administered intravenously, in order to maintain the blood pressure at a stable level. Medication, such as benzodiazepines, is administered in order to protect the brain against seizures and further damage. Craniotomy might be performed in case of excessive brain swelling or to reduce the intracranial pressure.

    Once the acute phase has passed, the treatment will be concentrated on the rehabilitation of the patient. Physiotherapy is essential in the chronic phase, as it can improve the functional outcome and guarantee the best possible recovery from the trauma. Patients can also benefit from speech and language therapy, especially if they have suffered injuries to the parts of the brain responsible for speech. Other treatments include occupational therapy, psychological counseling and NeuroGum supplement.

    It is important to understand that the recovery from a traumatic brain injury can spread over several years. In some cases, the recovery is not possible and the patient has to learn how to live with the remaining functioning potential. The support of family and other caregivers is essential for these patients.

    Conclusion

    Traumatic brain injuries can lead to permanent disabilities, affecting a person’s overall quality of life. The faster one receives treatment in the acute phase, the better the overall prognosis is going to be. Additional therapies, such as the ones mentioned above, can guarantee a faster and better recovery from the respective injury. The living environment often has to be adapted to the needs of the patient, with occupational therapy playing a very important role in the matter. Moreover, the patient has to benefit from regular counseling, in order to deal with feelings of anger, symptoms of depression and frustration in an effective manner.

    AUTHOR BIO

    Katleen Brown is a health, beauty and fitness writer. She loves to publish her articles on various health related websites. In her spare time, likes to do research to bring awareness.

    Recognizing the unity of body, mind, and outlook, she helps empower women to tune into their innate & inner wisdom to transform their health and truly flourish.

    Get in touch with her on Google+, Pinterest and Twitter.

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