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    “Thanks to all those who continue to provide rapid feedback from their frontline experience. Also for the forensic questions you provide. You are helping the Labour Party challenge where needed”.

    Brian Fisher ( SHA Chair )

    EXPERIENCE FROM THE FRONTLINE 26 4 20

    Social distancing at the Stanlow / Ellesmere Port petrochemicals plant is impossible as the staff need to work in pairs or larger teams to do their work, often one on top of another, that’s the nature of the work.  My contact thinks much of that work is un-necessary at this time, it is not just about securing the site etc.., but workers are threatened with losing their jobs if they don’t come in.  I have seen photographs of lunch or tea breaks during this emergency, with staff in high vis clothing sitting sardined together on benches at refectory type tables.

    Even those with asthmatic conditions have been refused time out.  It looks to be completely irresponsible of management.  I understand similar situations are to be found at similar plants elsewhere in the country

    Guide dog training has been stopped, so people waiting for a replacement dog or to have one for the first time cannot.  I know several elderly blind or partially sighted people in this situation who are now trapped at home, probably indefinitely.  They are aware that if they stop walking they may never start again as muscle tone and bone mass are soon lost without exercise

    PPE

    Masks for the public when going into public spaces. The govt appear frightened of this because of concerns that it will divert surgical masks away from hospitals. They are confounding PPE, expensive, scarce and required by carers to prevent their catching the virus, with simple face coverings, in cotton or linen, cheap, washable and effective at reducing onward transmission. Trisha Greenhalgh has done an excellent explainer that sets out the evidence on this:  https://www.fast.ai/2020/04/13/masks-summary/   It is endorsed as policy by the CDC   https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover.html

    Sadiq Khan has also been ahead on this promoting cloth masks for the public on London transport.  There will need to be a lot of them – but textile companies are not selling many clothes and could churn out millions pretty quickly –  but they need to be asked. Govt thinks public not grown up enough to understand advice for cloth not surgical masks.  My view is that masking up in public will have to be an important component of any exit strategy – and they need to get on with it.


    Locally I find from contacts that those who are doing care support in the homes do not seemingly have any kind of PPE at all which is not surprising but also alarming.

    LA councillor

    TESTING

    We are waiting for ‘test test test’ but that is feeling as though it will be a very long wait.  While we are waiting we need to recruit and train an army of contact tracers.  This needs to start now, almost certainly through local authorities.


    We shall have to do case detection syndromically if the necessary volume of testing is not available when transmission has fallen significantly through the lockdown, with whatever limited testing support is available. This will be easier as we leave the seasonal respiratory viruses behind.  It is not perfect, but perfection is not necessary, just reducing the transmission rate.


    Given that TESTS are supposed to be the start of this action” chain “ it less than clear where this chain is supposed to start and how it will relate to any denominator population / geographical community. It is clear that Ag and Ab tests are not going to be available in local communities  through the 7500 GP practices in England in the foreseeable future .

    So it looks like Govt expect the management of the pandemic, exit from lock down and the inevitable second pandemic wave to be done via:

    • our 50 mass drive in test centres – [ ie for that segment of the population which has cars ]  – so our understanding and contact tracing for spread will be the ill defined catchment areas of these test centres
    • and / or through home based test kits …..in which case it could be completely random / Brownian in shape / dynamics

    How will home-based tests connect with the new army of contact tracers which is being recruited by PHE – and their “assault “ on the spread of the virus  in local communities but it seems essential to involve general practice in our response to  COVID . I suppose it depends on how important you believe community spread generated though care and nursing homes is at periods of high community transmission in which case Public Health England may get a grip with additional support.

    It appears that there are currently no  plans nationally to use our unique infrastructure of 7500  general practices to do Covid 19 testing. In Birmingham during swine flu in 2009, GP consultations and reports provided public health / health protection agency with “ hot knowledge “ about new cases ;  did swab tests and  gave us insight into the geography of spread across the city during the containment phase.

    Apparently Ribera Salud integrated health care model in Valencia Spain has been able to mobilise and use flexibly all health care staff [ public health , primary care and hospitals ] during this crisis.

     

    QUESTIONS

    Is the government prepared to cope with the wave of mental health problems which are about to hit us as we pass the peak? I work as a mentor of GPs and keep in touch with issues on the front line. I am actually more concerned about care workers who have not been trained in the same way as doctors and nurses. If doctors are struggling with what they are seeing, how will a care worker cope with the loss of their charges in the homes from this terrifyingly overwhelming illness? What support will be available for their mental health?

    Have the 3 RAF aircrafts returned from Turkey with the PPE? Did the government lie / mislead the country last Friday? Can the government confirm when the order was placed? It’s been reported that the Turkish government say the order wasn’t placed until Sunday.

    Can the Government confirm whether the story in the Telegraph today about a British firm exporting 750k pieces of PPE because the Government hadn’t got back to them is correct or not

    Is there any country which has a reliable antibody test? 

    What is the preparation for accelerating the implementation of the postponed electives, treatments etc. as we transition to “normal”? Also, how to research the status of people who have avoided presenting themselves to their GP or A&E? These need to be well managed.

    Apparently 15,000 a day are flying into the country with little regulation while we are all self isolating at home. Not to mention the rich arriving at private airports. How can we not be restricting air traffic at this time?

    What arrangements is the minister putting in place to strengthen local and regional public health management of continuing cases to prevent subsequent new waves of the epidemic? The containment phase was ended in Mid-March and  lockdown applied nationally, despite considerable variation of reported disease transmission regionally throughout the UK.

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

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    From Stephen Watkins, retired Director of Public Health, Stockport.

    Based on 119 deaths in a patient-facing workforce of about 800,000, the Health Service Journal (HSJ) suggests that death rates in NHS staff are no higher than in the general population.

    It is important to remember the difference between mortality rate (deaths per 100,000 people at risk) and fatality rate (proportion of deaths in those actually infected).

    It is not possible to draw an accurate conclusion without age-specific mortality rates (not fatality rates) for the general population and for NHS patient facing staff. The crude mortality rate for NHS staff based on the HSJ figures would seem to be about 14 per 100,000 per current duration of epidemic. (“Crude” means not adjusted for age and sex).

    Based on the Lancet article by Verity et al[1], the age-specific fatality rates in people of working age, based mainly on Chinese figures, appear to be between 0.03% in people aged 20-29 and 0.59% in people aged 50-59, then increasing to 1.93% in people aged 60-69. Assuming a reasonably even spread of ages between 20 and 65 the average would be 0.3%.

    Applying this to the 14 per 100,000 mortality rate would equate to 4,666 cases per 100,000.

    Therefore assuming the accuracy of the Chinese fatality rates, and assuming an even spread of ages between 20 and 65 in the NHS workforce, the mortality rate in the NHS population is what would be expected if the death rates were the same as the general population if 4.6% of the working age population has been infected to date.

    If fewer than 4.6% of the working age population has so far been infected, the rates in NHS staff are higher. If more than 4.6% of the working age population has so far been infected,  the rates in NHS staff are lower. We do not however have accurate age-specific incidence rates for the general population from which to make an accurate assessment.

    However, if there were a 4.6% incidence rate in the general population there would now have been 2,990,000 cases and the Government is not quoting anything like that figure.

    Subject to caveats about the inaccuracy of the data and the extreme approximations made in the calculation, it would appear that rates in NHS staff are significantly higher than in the general population. This may, however, not be true if the rates of infection in the general population are being grossly understated, which could well be the case.

    [1] Robert Verity et al, “Estimates of the severity of coronavirus disease 2019: a model-based analysis”, The Lancet online 30. 03.20.

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    We are being fed a narrative. The story is that “we are all in it together.” Like the “spirit of the Blitz”. But we are not. The Government is spinning a story to make itself look like the helpless victim of events outside its control, at worst. And in a superhuman flight of fancy, actually IN control at best. Meanwhile it has been systematically cutting NHS funding to the bone, ignored the findings of its own pandemic drill, Exercise Cygnus, and preferentially awarding contracts to firms which are big Tory Party donors, as we have reported in previous blogs.

    We are not “all in it together” any more than, during World War II, our parents, grandparents and great-grandparents were. No wonder those who had borne the brunt of the war elected a government in 1945 that would introduce the National Health Service, the Welfare State and free education for all (to the age of 24 or more  for those who could benefit from it, thereby benefitting the country at the same time).

    The Tory line is that everyone in the world wants PPE and ventilators, and it’s not the Government’s fault that there are shortages. “It’s a competitive market out there,” said Dominic Raab. Yes. But why then did the Government behave as though it had all the time in the world in January, and in February, and in March? On 13th April, The Guardian listed THIRTEEN occasions when the UK was invited to meetings with EU countries to share “bulk-buying” procurement of necessary items, and either attended but did not join in the shared action, or did not attend at all.

    Meanwhile, the Government (finally) asks British Industry to help in the production of 30,000 more ventilators and the BBC reports on 26th March, that the Government has ordered from  Dyson (which makes vacuum cleaners). Rather than a firm in the medical equipment industry which already makes ventilators. The technology for sucking up dirt is quite different from that required for ventilating people whose lungs are not properly functioning, as I explained in an earlier blog; but Dyson is a friend and donor of the Tory party.

    NHS budgets have been cut relentlessly since Thatcher was Prime Minister. Following the forecasting Exercise Cygnus, the government’s advisers recommended that in the event of a pandemic , personal protective equipment (PPE) should be provided “for all hospital, community, ambulance and social care staff who have close contact with pandemic influenza patients”. But recorded minutes of a then-Department of Health (now Dept Health and Social Care) meeting, quoted by The Guardian on 27th March, have revealed that in 2017 the advisers were told to “reconsider their advice” because of the cost involved: “following these recommendations would substantially increase the cost of the PPE component of the pandemic stockpile four-to six-fold”.

    Then reports of deaths of frontline workers from Covid-19 start appearing in the press and on TV and Radio news. On 10th April Hancock says “PPE must be treated as a precious resource.” Can he be blaming the medical profession for wasting PPE? On 11th April nineteen deaths are recorded among health care workers. This is the day after the press were told that it was inappropriate to record such information.

    17th April BBC News announces medics have been asked to re-use gowns. Some hospitals report that they will run out in 24 hours. Then the following day Sky News also reports that NHS staff were advised to “re-use PPE ahead of the expected weekend shortage.”

    Public Health England (PHE) guidelines until now were that doctors and nurses treating Covid-19 patients should work with protective, waterproof, full length surgical gowns, plus a mask, a visor or goggles and double gloves – so that droplets containing the virus did not get into their mouths or noses.

    These guidelines have now been reversed and doctors and nurses asked to wear washable medical gowns, or non fluid-repellent equipment, with a thin plastic apron when proper gowns run out.

    An anaesthetist after a shift reported to us that Intensive Therapy Unit (ITU) nurses were still using bin-liners as improvised PPE. And that a lot of the outsourced staff had totally inadequate protection. He confirmed that the big issue was PPE and the other consumables: drugs, infusion equipment, breathing systems, and body bags – as well as experienced ITU nurses, and hardware like haemofilters” (which are used to do the work of the kidneys in intensive care in the case of renal failure).

    Although the Guardian is the main source of our timescale, the same newspaper gave Chris Hopson of NHS Providers a platform to start re-framing the PPE shortages and to try and blame the shortages on China. Our informant told us that the shortages were predictable and avoidable, and far more widespread than we realised. It seemed to him that Number 10 was controlling the news agenda: stories about the nurses who took care of Johnson displaced criticism that could have been made when the death toll passed 10,000; and  deaths in New Hampshire displaced the news of dead NHS workers.

    No employer should ask staff to undertake work that is unsafe for them – and in the case of Covid-19, unsafe for patients. Doctors and nurses are within their rights to refuse to endanger themselves. Nursing Notes on 26th March reported that the British Medical Association’s Chair of Council, Dr Chaand Nagpaul had said: “A construction worker wouldn’t be allowed to work without a hard hat and proper boots. Even a bee-keeper wouldn’t inspect a hive without proper protective clothing. And yet this Government expects NHS staff to put themselves at risk of serious illness, or even death, by treating highly infectious Covid-19 patients without wearing proper protection. This is totally unacceptable.” So far, however, neither the BMA nor the Royal College of Nursing has called on workers to refuse to work without proper PPE.

    We – and they – must support staff who do refuse to run major risks, and place the blame where it lies.

    The anaesthetist we spoke to said that the Tories had mismanaged COVID on a monumental scale. The UK has far fewer ITU beds than other EU countries. He told us that Hancock thought putting ventilators next to beds created thousands more ITU beds: he didn’t realise you need other equipment and trained staff! (this is the Minister of Health.) And then he lied to the public, saying there were thousands of empty ITU beds. He doesn’t realise there’s more to intensive care than ventilators. The doctor told us they had run out of equipment, staff, drugs and PPE…. And his department agreed that they could not allow colleagues to be coerced into entering ITU areas without adequate PPE.

    Later he went on to say that that we never had the resources to provide intensive care on the scale required…. That rationing care was something nobody wanted to do, but that it was impossible to provide safe care on the scale required. This was always going to happen. It was already happening with haemofiltration. There are not enough machines for the number of patients with renal failure. They are now moving devices (intended for continuous use) around between patients, giving them intermittent filtration, which would be impossible to defend at an inquest.

    Hancock has tried to grandstand, with rhetoric about being on a war footing. It would have been better to have used eligibility criteria for organ support but the Tories worried about adverse PR and headlines eg about age discrimination. So instead of any criteria, it is a case of first come first served. The worst sort of rationing.

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    Dear friends of the NHS

    Despite the three week lock-down the government has failed to keep us safe.

    @DefendOurNHS is increasingly frustrated and angry at the inadequate government response to the crisis*.

    Our message is simple. We ask you to adopt it and share it as widely as possible.

    The message is Test! Trace! PPE!

    The hashtag on twitter is #TestTracePPE.

    Let’s try to have a Twitter ‘storm’ at 5:00pm on Wednesday.

    Please use this message at every opportunity when contacting family, friends and the wider public.

    You might also include the message in the rainbow posters appearing in windows. Examples you can use are on our Facebook page (in the ‘files’ section’).

    When you go outside to clap and bang pans on Thursday, please chant Test! Trace! PPE!

    This appeal is urgent. Help us to get the word out now!

    Thank you.

    On behalf of Defend Our NHS

     

    • Bottom of the international virus testing league table, no sign of systematic contact tracing, health and care staff pleading on social media (including our Facebook page) for supplies of personal protective equipment.

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    WHO COVID-19 Database

    WHO is gathering the latest international multilingual scientific findings and knowledge on COVID-19. The majority of citations referenced are published journal articles. The global literature cited in the WHO COVID-19 database is updated daily (Monday through Friday) from searches of bibliographic databases, hand searching, and the addition of other expert-referred scientific articles. Particular emphasis is placed on identifying literature from around the world. Multiple search strategies that are under continual revision are used to obtain this global perspective. New research is added regularly.

    Available since January 26th, a more powerful search interface has just been launched on the 14th of April and can be accessed at the following link:

    https://www.who.int/emergencies/diseases/novel-coronavirus-2019/global-research-on-novel-coronavirus-2019-ncov

    The WHO evidence retrieval sub-group has begun collaboration with key partners to enrich the citations and build a more comprehensive database with inclusion of other content. Future improvements are envisioned on improve the end user’s experience.  The database is built by BIREME, the Specialized Center of PAHO/AMRO and part of the Regional Office’s Department of Evidence and Intelligence for Action in Health.

    For further information or questions, please contact the WHO Library via Library@who.int

    Tomas ALLEN

    WHO Library

    World Health Organization

    Geneva, Switzerland

    Posted by Jean Smith on behalf of Tomas Allen with thanks to Sue Thomas.

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    The SHA started to publish its Covid-19 Blogs on the 17th March and since then have issued weekly blogs. It is extraordinary to reflect on this being our sixth commentary on the socialist health view of the unfolding global pandemic.

    In earlier Blogs we have covered many different topics and each Blog reflects on particular issues that have sprung up over the past week and identified as emerging issues. In this week’s Blog we will look at social care, testing, and possible steps out of lockdown.

    1. Social Care

    This has rightly hit the headlines over the past week as the plight of our care services and their residents have been under the media spotlight. We knew from the early data from China mid January that the C-19 virus seemed to particularly harm older people and particularly adults with underlying conditions such as obesity, diabetes, heart and lung disease. Mortality rates in these at risk groups is comparatively high and 90% of deaths in the UK have been in the over 60 year olds with half of these deaths being in people over 80 years old. This has led the UK government to define vulnerable groups and also those ‘very vulnerable’ people who need to be ‘shielded’ from exposure to the virus. The very vulnerable shielded groups are estimated to a number 1.5m and are self isolating indoors for 12 weeks. Many but not all of these very vulnerable people will be in residential or nursing homes.

    Having identified these at risk populations, attention needed to be directed towards those sub populations of older or vulnerable people who were living in residential or nursing homes. These institutions are high risk as ‘closed communities’ accommodating a group of high-risk individuals who would be at risk of an outbreak of C-19 within that setting.  Decisions have had to be made by the management of these residential and nursing homes to, in many cases,  exclude relatives from visiting.  Some brave and extremely committed care staff have decided to move themselves into the nursing or residential homes to reduce the risk of them bringing C-19 in from their own homes and local community. It cannot be a surprise to hear now about outbreaks in these establishments causing disease and death to workers and their residents. Again like other aspects of this pandemic response – we had early warnings from Italy and Spain about the isolation and risks that this sector faced. Did we do enough quick enough?

    SHA President Prof Allyson Pollock published an Editorial in the BMJ on the 14th April, which identified that social services in the UK are amongst the most privatised and fragmented in the world, and have been underfunded for decades. Between 2010 and 2018 local authority spending on social care in England fell by 49% in real terms. The UK has 5500 providers operating 11,300 care homes for older people and 83% of these care home beds are provided by the for-profit sector, it is more privatised than the US.

    She also reports that care services employ 1.6m care staff (1.1m full time equivalent) of which 78% are employed by the independent sector. Pay is low; 24% of people working in adult social care are on zero hours contracts, and in March 2019 around a quarter were being paid the national living wage of £7.83 an hour or less. The sector is 120,000 workers short, and agency staff, are commonly employed and move from care home to care home. Social care has been a low priority for PPE supplies despite the high risks for residents and staff.

    Valiant efforts have been made by the sector with heroism shown by these low paid workers as well as stoicism by residents, many of whom may well be bemused and depressed as to why they no longer have visitors as well as the unusual PPE equipment being used by staff. It will have been difficult to plan for the various contingencies when cases emerged in homes, to access testing of staff and residents, to successfully isolate cases and discuss whether residents should be moved to hospital to obtain extra levels of care. Such admissions to more resourced NHS facilities should be an option even if cases would not meet eligibility for ITU care or wishing to be subject to that level of intrusive care. There should be options available, rather than simply assuming appropriate care will be delivered in that setting by stretched staff with relatively few registered nurses, no medical presence on site and few resources of PPE and other equipment such as oxygen supplies, oxygen delivery equipment and monitors such as oximeters.

    The SHA has been concerned about the social care sector for years and has developed policies to transform the sector under the banner ‘rescuing social care’. At the 2019 Labour Party Conference the SHA called on a future Labour Government to legislate for a duty to provide a universal system of social care and support based on a universal right to independent living. This should be based on need and offering choice; be free at the point of use, universally provided and fully funded through progressive taxation. This new National Care Service (NCS) should ensure that there are nationally agreed qualifications for staff, a career structure and enhanced pay and conditions of service. Recognition of informal carers is needed too with clarity about rights and support. The policy proposal has many other facets and stops short of integrating the NCS with the NHS. However close working would be built in and integrating data and information into a common system would be expected.

    As for many of the issues that have arisen so far with the pandemic the social care sector has not been in a strong position to push back C-19. The underpaid staff, the high vacancies and the often unsuitable, adapted accommodation is rarely fit for modern care needs. The fragmentation of the sector with ‘for profit operators’ finding it hard with constrained funding has led to vulnerability in the sector as well as the residents. Maybe this will be the time that showed how, rather than a shiny green badge, the social care service should be taken into a publicly funded national care service.

    1. Tracking, Tracing, Testing, and Treating (isolating)

    One of the criticisms we have made of the Government’s pandemic response has been the decision on the 12th March to pull back from testing for cases in the community and contact tracing. It may turn out that this was a policy decision driven by the lack of availability of tests rather than a decision made not to control community spread. On the 24th February there had been 9 confirmed cases of C-19 in the UK and the WHO had announced that countries should ‘ prioritize active, exhaustive case finding and immediate testing and isolation, painstaking contact tracing and rigorous quarantining of close contacts

    By the 22nd March there were 5683 confirmed cases and yet even then the WHO advice was ‘ find those who are sick, those who have the virus and isolate them. Find their contacts and isolate them’.  In outbreaks you do not always have confirmatory tests available but can make public health decisions based on the history and observation in the context of the unfolding epidemic. We seem to have forgotten the cardinal symptoms of continuous cough and fever.

    We have pointed out in earlier Blogs that countries that have been successful so far in controlling C-19 such as South Korea and Taiwan have been ones that have used widespread testing, tracing contacts and quarantining them. Germany has also been an example of a Western European country that has used this traditional communicable disease control methodology to save lives and protect their health service. Such a public health approach is most important in epidemics like this where there is no vaccine and no effective therapeutics other than sophisticated intensive supportive care.

    It is symbolic that the data that is presented at the daily press briefings has in the main used hospital testing data, hospital admissions and until recently exclusively hospital deaths. TV crews have been crawling over ITUs to get extraordinary footage of these wonderful NHS teams doing outstanding and stressful work. The incredible success of building Nightingale Hospitals in record time has been a reminder of the extraordinary efforts made in Wuhan to meet urgent need.

    However outside hospitals we have had the social care sector relatively unprepared, people self isolating in their homes and having to gauge the seriousness of their symptoms with intermittent telephone calls to NHS111. The disease has been spreading across the country from London to other metropolitan centres and then into smaller towns and rural areas. We could and should have shutdown London earlier as this has been our Wuhan. Local surveillance is limited and active contact tracing thought to be irrelevant even when many areas across England, Wales and Scotland had few cases. Environmental Health Officers in Local Government have not been mobilised. An opportunity missed.

    We have also seemed content to keep our airports and seaports open with little if no border health security. Again other countries who have managed to control this pandemic stopped and controlled air traffic, quarantining arrivals from high risk areas and making basic investigation on history (?cough) and taking travellers temperatures. Not difficult to do and look at Australia and New Zealand for actions on this source of new infections of a virus with high levels of transmissibility. In the UK it is estimated that over 190,000 people flew into the UK from China between January and March with no testing/quarantining.

    1. Evidence of unpreparedness

    The UK seems set to be one of the countries in Western Europe with the worst outcome in regards to mortality rates from C-19 despite the effectiveness of the NHS, which has withstood the pressure. We are often said to have an exemplar emergency planning system, the government had a pandemic as No. 1 risk on the national risk register, kept stockpiles and has computer modellers of world class.

    Yet we do not seem to have acted on the emergency planning exercises such as the 2016 Operation Cygnus (‘swan’ flu). We are now aware that in Sept 2017 the National Risk Register of Civil Emergencies reported that “There is a high probability of a flu pandemic occurring with up to 50% of the UK population experiencing symptoms, potentially leading to between 20,000 and 750,000 fatalities and high levels of absence from work’.

    There have been disclosures recently that are worth referring to that set out the timelines which showed the Prime Minister distracted and absent from COBRA meetings in January/February (A comprehensive countdown to how Britain came to have one of the highest COVID-19 per capita death rates – http://www.bylines.com). Also there has been an Insight team report for the Sunday Times on the 19th April 2020 (Coronavirus: 38 days when Britain sleepwalked into disaster). The current Secretary of State is an actor in this drama and the former Secretary of State for Health Jeremy Hunt who has been a critic of some aspects of the Governments response was of course in power during this time. We are told that ‘pandemic planning became a casualty of the austerity years when there were more pressing needs’ and ‘preparations for a no-deal Brexit sucked all the blood out of pandemic planning’

    1. Getting out of lockdown

    There are various scenarios that are being set out about how to get out of lockdown once the number of new cases decline and the first wave is thought to be ‘over’. This is likely to take time as the curve is flat and the proportion of the population with resistance is thought to be quite low. The government are hesitating about setting out the scenario and talking too much about the delivery of an effective, safe and tested vaccine. This usually takes 12-18 months and can never be guaranteed. They also are talking up the possibility of an effective drug therapy but we all know that viral illness do not lend themselves to highly effective drug treatments as we know with the Tamiflu debate after the 2009 H1N1 pandemic. So really we should again consider more immediate and classic public health control measures that have been shown to work in this pandemic.

    This will need health scrutiny and effective border controls that New Zealand and Australia have used successfully. There will within the country need to be effective systems of testing, contact tracing and quarantining with every day life respecting physical distancing and the use of facemasks. South Korea has shown the way that this can be enhanced and made more bearable by using mobile phones loaded with new technologies. These will warn people if at risk and disclose red, amber or green status. This will allow the economy to restart and people begin to get out and about again. The very vulnerable will in the early phases of this need to be protected.

    Prof Pollock in a recent BMJ editorial (Covid-19: why is the UK government ignoring WHO’s advice) states that ‘this means instituting a massive, centrally co-ordinated, locally based programme of case finding, tracing, clinical observation, and testing. It requires large teams of people, including volunteers, using tried and tested methods updated with social media and mobile phones and adapting the guidance published from China’ and other countries who are implementing such systems.

    This will require a change of mindset in government and from their medical and scientific advisers but as J.M.Keynes said:

    When the facts change, I change my mind. What do you do?”

    20th April 2020

    Published by Jean Smith on behalf of the SHA Officers and Vice Chair’s

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    At Friday’s Health and Social Care Select Committee, West Lancashire MP and Committee Member Rosie Cooper questioned the Secretary of State for Health and Social Care Matt Hancock about whether the deaths of clinical staff who have died working in the NHS are being referred to the Health and Safety Executive for investigation.

    Responding, the Secretary of State said that investigations are being done by the NHS and the employers of the staff and will involve the Health Service Safety Investigations Body.

    Following ‘The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013’ it is a legal requirement to make a report when a worker dies.

    In response to this, Rosie Cooper MP has submitted a Parliamentary Question to the Secretary of State for Health, asking whether the NHS would be breaking the law by not reporting the deaths of staff following occupational exposure to coronavirus to the Health and Safety Executive.

    West Lancashire MP Rosie Cooper said:
    “I feel it is absolutely necessary for any investigation into these deaths to be carried out by a wholly independent body.

    “It is essential that these investigations are transparent and conducted independently of any organisation involved in the handling of this crisis as we cannot effectively have the employer investigating itself.

    “I have written to the Chief Executive of the Health & Safety Executive to explain that I believe it is imperative that the Health & Safety Executive investigates each and every one of these deaths, to ensure that the circumstances and any opportunity for learning are made public.”

    Update. The government have replied to Rosie’s questions.

     

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    Health Secretary Matt Hancock has announced that firefighters, police, prison staff and Department of Work and Pensions (DWP) workers will now be eligible for coronavirus testing, in a session of the Health and Social Care Committee.

    Responding to the announcement, Matt Wrack, Fire Brigades Union (FBU) general secretary, said:

    ‘We’re pleased to see that the government has listened to the FBU and finally agreed to open up some testing to other key workers, including fire and rescue personnel. However, it is a shame it has come this late, with thousands of firefighters already self-isolating – this is something that could have been easily avoided.

    ‘We are awaiting further details but it is clear that there are questions around the functioning of the scheme that is now open to more key workers . The health secretary said fewer NHS staff were coming forward to be tested than hoped, but this is surely an issue of accessibility, rather than frontline staff not wanting to be tested. Many of the testing centres are far out of town and require extended trips in a car – if this is a barrier to nursing staff, it will also be a barrier to other key workers.

    “It is also clear that this testing scheme will only identify the virus in those individuals presenting symptoms or living with others who are. Many key workers who have been exposed through their work will have contracted the virus yet remain asymptomatic. Frequent and accessible testing of key workers who are at high risk of exposure is also needed to reduce the risk of spread in workplaces.

    “To ensure that fire and rescue services, and other vital services can continue to operate in this crisis, we don’t just need access to these testing schemes, but to also see the capacity of the schemes themselves increase. There need to be more tests available full stop.”

    Joe Karp-Sawey, FBU communications officer

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    Firefighters across the UK could support the delivery of COVID-19 testing, including taking samples for antigen tests, in the latest agreement between the Fire Brigades Union (FBU), fire chiefs and fire service National Employers. After appropriate training, firefighters will be able to carry out swab tests on other fire and rescue personnel, their families, and the wider public if necessary.

    The update to the national agreement will now allow firefighters to drive ambulances to non-emergency outpatient appointments and to transport those in need of urgent care. Firefighters can also begin training non-emergency service personnel to drive ambulances to aid the coronavirus response.

    It follows an agreement last week between the union, fire service National Employers, and the National Fire Chiefs Council (NFCC), which has allowed firefighters to fit face masks and deliver vital PPE and medical supplies to NHS and care staff.

    Firefighters have already begun driving ambulances, delivering food and medicines to vulnerable people, and moving dead bodies in some areas, after an initial agreement was reached on 26 March.

    The FBU warned earlier this week that around 3,000 fire and rescue personnel were already in self-isolation due to coronavirus. The union says NHS and care staff are a priority but that testing must also be urgently made available to fire and rescue personnel.

    Matt Wrack, FBU general secretary, said:

    “While the government is lagging behind its own schedule to deliver testing, the number of tests that have long been promised may require assistance from outside of the NHS and we are here to help.

    “Firefighters are highly skilled and are able to take on new areas of work to assist in these extraordinary times – and this now includes carrying out antigen tests, driving ambulances to non-emergency incidents, and training other personnel to drive ambulances.

    “We’ve raised our concerns about the government’s mishandling of coronavirus testing and the impact it is already having on frontline services. Fire and rescue personnel are now able to assist in the national testing which is so urgently required.

    Joe Karp-Sawey, FBU communications officer

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    Unite national officer for health Colenzo Jarrett-Thorpe said: “Pressures on our ambulance members are unprecedented with the profession not currently being given the correct guidance as to whom they should take to hospital.
    “They are also not being given the correct level of personal protective equipment (PPE) if they suspect a patient has Covid-19.  Ambulance workers are putting their health, perhaps their lives, at risk, by not receiving the correct PPE and also by not receiving the correct fit test training to wear the PPE. 
    “On top of this, the lack of testing remains a stark and very serious issue – there are not enough tests to ensure ambulance staff are tested within the five-day window for testing.”
    “Unite is urgently calling for ambulance workers to be given clear guidance regarding triaging which patients should be taken to hospital and more action on PPE which needs to be supplied to paramedics, so they are able to do their essential duties.
    “Paramedics are terrified of making the wrong call and being sanctioned for this.
    “I think the public’s patience with ministers is wearing very thin as they continue to say that there is enough PPE in the system, when there are numerous reports from frontline staff that this is simply not the case.
    “It is humbling to see social media posts which show some NHS and social care staff risking their lives as they go to care for patients with coronavirus. The situation is even more dire in social care settings, as care staff do their utmost for the elderly with inadequate protective kit.
    “Unite has thousands of members who are part of the healthcare science workforce. These talented staff need to be engaged to provide the test that is required to ensure 100,000 people can be tested a day. 
    “Unite has over 100,000 members in the health and social care services and we will not rest until we ensure that all health and social care workers are secure in their individual roles in keeping us all safe and well – we are campaigning for that goal 24/7.
    “If these objectives are not met and NHS staff continue not to be protected, reluctantly NHS and social care staff could legitimately and lawfully decline to put themselves in further danger and risk of injury at work. Unite will defend NHS and social care staff.”

    Unite senior communications officer Shaun Noble

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    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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    News From The Frontline 13.04.20.

    By Vivien Walsh

    1. How the government lies with statistics.

    BBC news has reported 737 new coronavirus-related hospital deaths in a 24 hour period making the total so far 10,612. In a different report the BBC said that the real figure must be over 1000.

    These Department for Health and Social Care (DHSC) records do not give figures for deaths outside hospital, for example in care homes, nursing homes or people’s own homes. They are only reports for England, not Scotland or Wales or Northern Ireland. And they are only cases where COVID-19 is recorded as the primary cause of death. Some clinicians might record respiratory or renal failure or pneumonia as the primary cause of death, and may or may not include COVID-19 as a secondary cause.

    In any case these statistics only give deaths where the virus has been cited as the primary, not secondary, cause. In many cases a test for the virus may not have been done. It takes more than 48 hours to get the results from a test. No bereaved family wants to wait longer than necessary to make funeral arrangements. There are always understandable pressures to get a death certificate issued, and the death registered as quickly as possible.

    In addition, now that so many care homes are in the private sector and not only concerned about their reputations but under competitive pressure to attract patients, there may be concern to minimise the number of deaths recorded as being caused by COVID-19 for fear of losing potential paying clients.

    The number of deaths of people in their own homes include those who under other circumstances would have been in hospital, but have heeded advice from the government, from their GP practices, from NHS 111, from hospital A & E departments and countless ads on all media, to “stay home”.

    1. Massaging data

    We have been hearing about absolute numbers of deaths on the news, both here and for comparison in different countries. But age-standardised rates, which take account of demographic differences between populations, are better for international comparisons. Using information taking age profiles into account, from China, which had the earliest attack from the virus, and information about UK age profiles, The Lancet published a calculation that UK death rates from Covid-19 were 0.66% overall, but 7.8% for over 80s, and only 0.0016% for children under 10, when they adjusted their figures for the number of people in each age group of a population.

    One of our informants, a doctor, suggests that when the pandemic is over, the results from the UK and USA will be worse than in those countries that introduced protective measures more rapidly and whose health services were better funded and prepared. “That’s why Number 10 is blaming civil servants for duff advice, NHS-England for PPE shortages, the public for not staying home, and NHS staff for wasting PPE (which they now call “a precious resource)”.

    The USA is the only economically advanced country not to have a national health service available to the whole population. Britain’s NHS when properly resourced and as it was originally established, was still much more efficient in terms of what is provided relative to £ spent, per head of population, because the other national health services are funded by insurance systems, which has to be claimed back.

    1. They knew what would happen!

    But the Government failed to publish an early warning, let alone prepare for Covid-19. Exercise Cygnus was a pandemic drill involving all Government Departments that concluded in Oct 2016, three and a half years ago, but the Government suppressed its findings. These were that the NHS would be plunged into crisis if Britain were infected with a deadly disease. It predicted there would not be enough beds (especially in intensive care), not enough staff, not enough of the necessary equipment, and not even enough space in mortuaries or then cemetaries for the dead, following years of Tory cuts and financial “squeeze”. And the country would be plunged into economic crisis from the acute recession, and social crisis as a result of coping with so many deaths.

    Last week Jon Ashworth (shadow Health Minister) called on Ministers to publish the results of this drill. But we must do more. We need to scale-up our campaigns throughout the Labour Movement and in society generally, to immediately increase spending on the NHS for the long term, to implement Labour’s policy to re-nationalise all the many sections of the NHS that have been privatised, and to convince everyone who stayed home last Dec 12th (or voted Tory) to vote Labour in future.

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