Hilary Cave has produced a fine article entitled "The Covid pandemic and health". Whilst it recognises the fine work undertaken by NHS staff in tackling the plight of those hit by the pandemic, she fully reveals the massive shortcomings in current NHS staffing arrangements and in its scope of operations where "Over the last ten years the UK has lost 100,000 doctors and nurses, together with 17000 beds". She deals with the avenues which are needed to overcome such damaging shortcomings and reaches the following conclusion -
"Poverty is the factor most closely reflected in the health of the people. We already know that people have many fewer years of good health, and much earlier ages of death, in poorer areas. The more lethal toll of Covid19 on poor areas is absolutely in line with what has been going on for a long time. If a government slashes benefits; if it reduces migrants and many workers to homelessness and destitution; if it allows zero-hours contracts and other abuses of human rights, then this is the result. The only good thing to be said for this newly-publicised situation is that it may force more of us to confront the terrible inequalities that have existed for a long time. We need now to work out how to step up our campaign for a fairer, more equal society. If we are to defend the NHS in order to protect and improve the health of our people, we must take action to bring about radical change."
The full article is some 6,000 words long and can be found below. It is well worth reading, absorbing and supporting.
Updated
11 p.m. 17 May 2020
The
Covid 19 pandemic crisis and health
Inadequate
funding over a long period
Across
Europe and the world, many right-wing parties or dictators have
gained power. In Europe it appears that neo-liberalism has led many
governments, like ours, to neglect their health services in order to
spend less. In the United States President Trump, egged on by wealthy
health insurance companies, has declared the idea of even modest
forms of state insurance for healthcare to be a dangerous threat to
American liberties. Consequently the US population has some of the
worst health outcomes in the world across a range of measures,
despite living in the world’s wealthiest country.
Early
in its life our NHS provided convalescent beds for adults and
children. Later on community hospitals were developed, but over the
last few years these have been systematically closed down. Over
the last ten years the UK has lost 100,000 doctors and nurses,
together with 17000 beds.
The overall UK shortage of nurses and doctors was already an enormous
problem before the pandemic. Another austerity policy, the scrapping
of nurse training bursaries, has contributed greatly to this problem.
Following public pressure, the supposed remedy of introduction by
Government of a student nurse loan scheme to cover only part of a
student’s costs, was never going to repair that damage. In
Derbyshire the CCGs worked for several years to cut 523 hospital beds
in both acute and community hospitals. Much more recently, after a
great deal of damage had been done, NHS
England admitted that these bed cuts had gone too far.
Since
2005 our Government’s National
Security Risk Assessment Committee has been categorising an epidemic
as the top threat that faced our country, along with natural
disasters such as flooding. The
nuclear war threat was graded time after time as a lower risk. Blair
boasted in 2005 that the World Health Organisation (WHO) had
recognised the UK as one of the better nations in preparing for a
pandemic. How have we sunk from a country well-prepared for epidemics
into one that has failed conspicuously in this pandemic, having what
may be the highest death rate in Europe?
In
general, the Coalition
Government from 2010, and every Conservative administration since,
have systematically starved the NHS of the funding required
to keep up with the needs of our increasingly elderly population as
well as technological and pharmacological advances in medical care.
We now have fewer hospital beds than similar countries, but continue
to expend vast sums on weapons of war. Lack of funding has not been
the only cause of our poor performance, though.
Legal
and structural changes: 2012 Health and Social Care Act
During
the decades straddling the end of the twentieth and start of the
twenty first centuries, various governments had encouraged private
companies to enter the field of healthcare.sThis process was
accelerated dramatically during the period of Coalition by the 2012
Act, authored by the Conservatives’ Andrew Lansley, Secretary of
State for Health. The 2012 Act established Public Health England
(PHE) as a new executive agency of the Department of Health.
Executive agencies are distinct from their departments, having their
own budgets and managements. Some observers say agencies have proved
more responsive, while others think they produce gaps between policy
and its delivery. Whichever view is more accurate, a Government
Agency seems less accountable than a Department whose minister is
answerable to Parliament.
This
Act created the biggest change in our NHS since its inception in
1948. For the first time the Secretary of State was not obliged to
provide for the health of citizens.
The new structure abolished primary care trusts and strategic health
authorities, establishing instead clinical commissioning groups
(CCGs) covering much larger areas. Although ostensibly giving power
to GPs, according to the Co-chair of the NHS Consultants’
Association, CCGs would provide a major point of access for private
providers. After comparing the new structures with academic studies
of privatisation, he concluded that privatisation would be an
inevitable consequence of the Act. Although Lansley dismissed such
views as “ludicrous scaremongering”, we can see the advance of
privatisation up and down the country. The
2012 Act obliged CCGs to make their commissioned services open to
tendering, so enabling private companies to provide services. This
has fragmented the NHS. Even
some NHS service providers have set up wholly-owned companies in
order to save money. One of the factors in this process is the unfair
rule that forces NHS to pay VAT while private companies do not. For
instance cleaners, porters, and security staff at Chesterfield Royal
Hospital no longer work for the NHS, but for a private company that
is already employing new starters on inferior terms and conditions.
In
theory, the NHS
long-term Plan issued in 2019
is said to mark official abandonment of the policy of competition in
NHS England. However, it
does not prevent private providers being given contracts: it
merely does not force this to happen.
NHS England,
now merged with NHS Improvement, seems to be on a zigzag course,
though: behind the scenes it has teamed up with NHS Shared Business
Services (SBS), inviting companies to tender for an NHS
“framework contract”. Through
this mechanism, trusts
can then buy in services without going through a full procurement
process. John
Lister has described this as “batch privatisation”, fearing that
whole units or services delivering patient care might be quickly
outsourced in this way. In
recent weeks ministers have begun to use special powers to bypass
even normal tendering patterns. Contracts
have been awarded to private companies and management consultants
without open competition. Serco and G4S will apparently undertake
much of the contact-tracing work, recruiting 15000 call-centre staff,
with plans to offer them a whole day of training before starting
work. Yet Serco had previously been fined nearly £23 million as
part of a settlement with the Serious Fraud Office. It and G4S had
been accused of billing the Government for electronic tagging of
offenders when some were dead, some were in prison and some had left
the country. Presumably the firms accepted their wrongdoing, or they
would not have agreed to pay the fines without a court
hearing.Deloitte, Sodexo, KPMG and other giants now have contracts
for running drive-in testing centres, purchasing PPE, and building
the Nightingale Hospitals. At the London Nightingale, services such
as cleaning are provided by private companies, who will presumably
sack their workers now the hospital is being mothballed. Capita is
running the vetting service for retired doctors volunteering to
return.
The
PPE debacle
Between
2008 and 2011 funding for stockpiled goods in case of emergencies was
increased, but since
2013 the value of our stockpiles has fallen.
As such goods deteriorate over time, they need replacement. Between
2016 and 2019 the stockpile value fell by more than £200million. A
Departmental spokesperson said that this did not represent a drop in
stock held, suggesting that efficiencies were responsible for this.
Now
that the COVID 19 pandemic is wreaking such a toll on lives,
livelihoods and living conditions, there is a general agreement
among commentators and many politicians that some sort of
inquiry will
be needed at a later date about
how Government and public services performed during the crisis.
As we endure bereavements and the impossibility of living normal
lives, more
and more voters may come to realise how seriously the NHS has been
starved of resources since 2010.
In 2016
a three-day epidemic simulation, Exercise
Cygnus, was
carried out here. Although that uncovered
a critical shortage of PPE, critical care beds and morgue capacity,
these shortcomings were not addressed.
Its full report has not been published by Government, despite Freedom
of Information requests to do so. Government has admitted that,
although warned in 2019 that gowns were missing from epidemic
stockpiles, they did not address this issue.
More
recently the Government missed out on the opportunity to join the
EU-wide attempt to bulk-buy ventilators
because they wanted no part of any EU initiative. When that leaked
out and was badly-received by commentators, a new explanation was
offered: there was said to have been some confusion over an email,
causing an inadvertent missing of the deadline for agreeing to join
this process. On April 21 2020 a very senior civil servant told the
House of Commons Foreign Affairs Select Committee that in fact the
decision not to opt in to this particular purchasing initiative had
been made on political grounds. Yet before the day was out that same
civil servant issued a letter saying that his previous statement had
been wrong: it had not in fact been a political decision. For a
senior civil servant to have issued two mutually exclusive statements
within a few hours is probably unprecedented. Was he pressured in
some way? On the following day, April 22, EU
spokespersons declared themselves “astounded” by our Government’s
explanation of
an email gone astray as the reason we had not joined that procurement
scheme. The saga continues.
Department
of Health has sent a letter instructing
NHS provider trusts to stop purchasing their own Personal protective
Equipment (PPE,) ventilators and some other items, as these will now
be procured centrally.
This was originally supposed to be happening through the Department’s
central procuring system, but as that system was failing abysmally,
hospital procurement managers felt obliged to begin sourcing PPE
themselves. The situation is therefore very confused. An observer
said that the NHS central team do not know what the hospitals are
doing; the Cabinet Office team do not know what the NHS is doing; and
the army, brought in to help with logistics, are tearing their hair
out. One
procurement manager has blamed NHS Supply Chain Co-ordination Ltd, a
company owned by the Department of Health. This has been managing
procurement of goods for NHS. Apparently
it had no previous experience of procuring goods from overseas. At
the end of March, the body representing health procurement
professionals discovered for the first time that gowns to protect
health staff had not been included in PPE stockpiles. Deloitte seems
likely to be given the task of centralised procurement of PPE.
Tony
O’Sullivan, retired paediatrician and co-chair of Keep Our NHS
Public (KONP) has stated that the crisis
has highlighted a decade of underfunding for the NHS.
He added that centralising
decision-making while outsourcing to private companies such huge
responsibilities for the safety of our people is simply adding to the
mistakes the Government has already made.
Private
hospitals
John
Lister has suggested that in future some larger private hospitals
situated near NHS hospitals might be nationalised to create extra
capacity. Private
hospitals have often benefited from long NHS waiting times for
elective surgery,
while they
also rely on affluent patients travelling from abroad in order to
access healthcare in Britain. As elective operations have been
suspended for now, and as overseas travel is difficult or impossible,
these hospitals were facing lean times. There is no need to weep for
them: the cavalry has arrived. The Government
has not requisitioned, but commissioned, 8000 private hospital beds
at an estimated rate of £300 per bed per day. In an agreement
reached in March, 20,000 nurses and 700 doctors have also been taken
over “at cost” for at least 14 weeks. As
£1 million per annum is not unusually high pay for a Chief Executive
of privately-owned hospitals, NHS campaigners may feel uneasy about
such large sums of public money going into deep private pockets. All
is well, though, as the Chief Executive of Spire Healthcare will for
the next three months receive 20% less than his usual annual salary
of £1million per annum. There will be limits on shareholders’
dividends too, but only for the duration of the deal. No wonder this
private sector rescue package has caused the price of Spire shares to
surge on the London Stock Exchange.
Other
concerns about privatisation are international in scope. The
Chancellor of the Exchequer announced that £13.4 billion of historic
NHS debt will be wiped out. This sounds reassuring until we place it
in the context of current trade talks with USA. Although
Johnson had promised that the NHS will not be on the table at these
talks, two sources of information give cause for concern.
Firstly, the newly-published UK document dealing with our approach to
the trade talks does not appear to protect the NHS. Secondly, the US,
among other aims, wants to secure an agreement that will force us to
pay as high a price for their drugs as the Americans themselves pay.
This will cost us a great deal more. The
US documents appear to state that there will be court jurisdiction
over foreign state-owned enterprises that interfere commercially with
the interests of American corporations. Could
Johnson be trying to tempt the US into starting to allow their
private companies to take over some of our NHS services by offering
up an NHS that is newly freed of debt?
Scientific
advice
Throughout
this crisis, government ministers have maintained that they are
“following the science”, as though there is a single scientific
opinion. Government relies on the Scientific Advisory Group (SAGE).
Journalists’ investigations have revealed that 13 of the 23 known
SAGE participants are paid employees of Government, including the
Prime Minister’s senior adviser Dominic Cummings. No minutes of
these meetings are published. There
is concern that supposedly objective scientific opinion may be being
influenced by political considerations.
Other experts too are concerned about SAGE and possible political
influence. Prof.
Sir David King, a former Chief Scientific Adviser to government, has
set up a panel to act as an independent alternative to SAGE. It
will broadcast live on YouTube, taking evidence from global experts,
and will formally submit its recommendations to the Health and Social
Care Select Committee of the House of Commons. Prof. King is worried
that the Government might take us out of lockdown too early, so
risking a second peak of infection.
There
are other concerns about SAGE, too, according to Prof. Anthony
Costello, a former WHO Director,
now
Professor of Global Health at University College London. He
considers that SAGE lacks expertise in public health, primary care
and intensive care. The
official SAGE
committee comprises 16 men and 7 women, with only one ethnic minority
person. Community testing and contact tracing were apparently not
included in decision-making about possible choice of strategies by
the committee because not enough tests were available. PHE
stopped testing on 12 March, apparently
because of lack of capacity, not least in contact-tracing.
Public health specialists were surprised by this abandonment of WHO
advice to test, trace and isolate in order to get the pandemic under
control. The
huge Cheltenham horse-racing festival took place while WHO was urging
governments to promote social distancing as early as possible. Local
Authorities in England already have Environmental Health Officers who
are trained in contact-tracing, yet a parallel centralised system was
created. Costello has argued that Local Authority expertise and
capacity should have been brought in for contact tracing. One nurse
who responded to the call for people to step forward so they could be
trained as contact tracers has complained to national news channels
that the online system has not allowed her to book in for training,
nor have her phone calls received any useful response. The
centralised system seems to be in chaos. Sir David King’s
independent SAGE group issued a statement on May 12 urging Government
to move to decentralised testing, tracing and isolating across the
UK, rather than the centralised testing alone, which was heavily
reliant on the private sector.
Independent
SAGE argued that the latest Government “Stay alert” message was
unclear, while “Control the virus” was an empty slogan. Their
report went on to predict that Government strategy would result in a
more rapid return of local epidemics, causing more deaths and
possible further national or partial lockdowns. On 16 April
government figures seemed to show a slight increase in infections.
Prof. David Hunter, an Oxford epidemiologist, made this point too. He
pointed out that countries which had successfully tackled the virus
had all focused on test, trace and isolate. He and other experts have
noted that GPs have not been enlisted to play a key part in combating
the virus either, as NHS 111has been made the contact for people who
may have the illness. This means that the knowledge held by GPs of
their local areas is not being used.
Poor
Government performance
Allyson
Pollock and Peter Roderick maintain that testing,
contact tracing and purchasing of equipment, all classic public
health measures for controlling communicable disease, should be
handled through regional authorities rather than central government.
Responsibility
for public health, together with staff, and budgets that were not
ring-fenced, had been passed from NHS to local authorities.
Public
health then suffered its share of budget cuts, as local authorities
lost 49.1% of their funding in real terms between 2010 and 2018.
Public Health England (PHE) reduced its budget by £500m over five
years in “efficiency savings”. It is not clear whether this was
forced by Government. Prof. Carl Heneghan, Director of Oxford
University’s Centre for Evidence-based Medicine, insisted that we
have to invest, to create over-capacity that will be required in
times of crisis. “We’ve already cut to the bone in this country
far too much.”
Testing
for the virus was almost unobtainable at first, then difficult, as
NHS workers with symptoms were expected to undertake long drives
after lengthy shifts. Because of public criticism, Matt Hancock
promised large numbers of tests would be available daily. Although as
April ended it was claimed that the target had been reached on time,
it has not been reached in succeeding days. The First Minister for
Wales has pointed out that targets should be integrated into a plan
for how to use the results to improve the situation: testing is not
an end in itself. Finally testing has been opened up to workers in
social care and to care home residents, some of whom have died of the
virus.
Some
hospital patients are being discharged into nursing or care homes,
usually privately-owned. These homes are being starved of protective
equipment and are full of frail elderly residents: a group known to
be particularly vulnerable to the virus. The latest figures, probably
an underestimate, indicate 2400 deaths from Corona virus in care
homes each week. Dying people in care homes and hospitals are often
of necessity being separated from their loved ones, even in their
last moments of life. For the dying person it must be agonising to go
without loved ones by their side. For families, the pain of
bereavement is compounded by these circumstances, as bereaved people
often find some comfort in being present at the death of their loved
one. A prime duty of any government is to keep its people safe.
During a pandemic this is not always possible, but years
of cost-cutting; moves towards smaller government and more
privatisation, leading to more fragmentation in the health service;
together with Government bungling, have vastly increased the number
of deaths.
Despite
Johnson’s claim that we have passed the peak of infection, that is
not true for care homes. Just
think how useful community hospitals would have been in the current
situation, had there not been determined action to close them down.
Some community hospitals such as Bolsover, owned by Derbyshire
Community Health Service, have been sold off with their land, at a
time when draconian measures were being taken by the CCG to reduce
expenditure. The Bolsover site was sold to Homes England for
house-building, following strenuous efforts by Government to
“encourage” such sales so that houses subsequently built on
former NHS sites would contribute to national Government
house-building targets.
Dangerous
working practices in the NHS
At
the end of April the BBC Panorama programme revealed that the Health
and Safety Executive (HSE)
requires face-covering visors, eye protection, gowns and gloves for
those working in a situation with risk of “high-consequence
infection”.
This clearly relates to health and social care workers in contact
with Covid19 patients. However, Government
has very recently downgraded Covid19 from that category of
“high-consequence infection”, meaning
that such personal protective equipment is no longer mandatory.
Government claims that SAGE advised the downgrading of Covid19. The
Panorama programme maintained that a source (possibly from SAGE?)
indicated the scientific advice was “pragmatic” because there are
simply not enough items of the correct grade of PPE to fulfil legal
requirements. So the lack
of PPE is determining legal protection for front-line workers, rather
than legal requirements determining what PPE is provided to them.
Considering
that recent figures show Covid19 patients admitted to hospital are
just as likely to die as those admitted during an outbreak of the
deadly Ebola, it is hard to imagine an infection of higher
consequence than Covid19.
Doctors
and nurses, working
long shifts in a high-risk situation with personal protection that is
often scandalously inadequate, are
dying in substantial numbers.
Some other healthcare staff are dying too. Quite rightly they are
frightened for themselves and their families, and they are angry.
Added to that, they are grieving for dead colleagues and for the
large number of their patients who are dying. Altogether they are
bearing a tremendous physical and psychological burden that may leave
them, even if they survive, with post-traumatic stress disorder or
other forms of mental ill-health. It is perfectly reasonable to
conclude that, despite politicians’ rhetoric, healthcare workers
are essentially being treated as though they are disposable. This
puts them in a similar position to many manual workers who, over the
decades, have been placed in so much danger at work that they die.
Emergency
projects
Great
acclaim accompanied the rapid building of the first “Nightingale
Hospital” in East London, being followed by other facilities around
the UK. The London
Nightingale has taken only 54 patients. In
fact it seems to have been used as a “step down” facility for
small numbers of those patients who are starting to improve. London
hospitals apparently did not require as much overspill capacity as
had been expected, possibly because of staff ingenuity and
adaptation. Now the Nightingale is to be mothballed, along with other
Nightingale facilities. As the Nightingale’s support services such
as cleaning are being supplied by private companies, it seems likely
that those workers, hailed as heroes by Government ministers, will
now be sacked. Some of the other Nightingale facilities have never
been used.
Health
and social care
The
NHS should not be viewed in isolation from the field of social and
nursing care, which is now a patchwork of providers dominated by the
private sector. The crisis in social care, together with the
unfairness of NHS funding for some, but not all, residents of care
homes, has remained unaddressed for many years,
despite promises from a string of Prime Ministers. Many of the
private care homes form part of large chains that are in turn owned
by private equity funds. These funds exist solely to produce profits.
Therefore they remove money from the care home chains; often taking
ownership of the buildings, then charging high rents, thus saddling
the homes with large debts. As less and less public money, in real
terms, is being paid by Local Authorities for care costs, this
process sank the Southern Cross chain of homes a few years ago. That
forced disruption, and possibly earlier death, on many confused,
frail elderly residents. The Four Seasons chain is currently thought
to be in similar danger.
Dan
Poulter, a Tory ex-minister of health who is also a practising NHS
psychiatrist, has recently argued in a newspaper article that health
and social care should be integrated through a single commissioning
model, with social care, like health, free at the point of need. Many
NHS campaigners might want to jettison that commissioning model, with
its private firms and its overload of NHS accountants and managers,
in order to revert to a simpler structure of publicly-owned and
controlled direct health provision. Still, Poulter’s call is one
indicator of pressure for change that might beset our government in
the near future.
In
April 2020 public
anger is growing as we become increasingly aware of the lack of
Government attention and concern for the social and residential care
sector. There is extreme concern about the fact that one third of
COVID 19 deaths are happening within the social care sector. The
dead include both residents, who are not being counted accurately,
and care workers who, like NHS workers, are being starved of
protective equipment. The Office for National Statistics (ONS) has
now published data showing that healthcare workers have not had a
higher death rate than the general population. However,
social care workers have had significantly higher rates of Covid 19
deaths than the general population: 23.4 male deaths and 9.6 female
deaths per 100,000.
Varying
death tolls in different communities
The
dramatically large
proportion of deceased health staff from black and minority ethnic
groups needs objective investigation. Although
the causes are probably much more complex than a straightforward
cause and effect relationship with racism, we might remember that our
Prime Minister described black children in a newspaper article as
“piccaninnies with water-melon smiles”. As he refused to
apologise, his attitude does not inspire confidence that the possible
role of racism as part of the present carnage will be dealt with in a
proactive way once the results
of investigations require remedial action.
Many
people have been shocked by the dramatic disparities in COVID 19
death rates. People
in the poorest areas are dying at twice the rate of those in affluent
areas. While deplorable, this is exactly in line with facts
well-known for years:
that the inequalities
in our society are literally deadly.
The last Labour Governments required the NHS to tackle health
inequalities. Today, while Public Health England espouses this aim,
many
Government policies work in the opposite direction, increasing
inequality.
There
has been a great deal of research, with a variety of models
constructed to show many
factors that are determinants of health:
housing and the built environment, clean air and water, good food
rather than hunger, social or family networks and so on. (We now know
that higher levels of air pollution seem to be linked to higher rates
of death from Covid 19.) Personal behaviour is not necessarily at the
forefront of this range of health determinants. Poverty
is the factor most closely reflected in the health of the people. We
already know that people have many fewer years of good health, and
much earlier ages of death, in poorer areas.
The more
lethal toll of Covid19 on poor areas is absolutely in line with what
has been going on for a long time. If
a government slashes benefits; if it reduces migrants and many
workers to homelessness and destitution; if it allows zero-hours
contracts and other abuses of human rights, then this is the result.
The only good thing to be said for this newly-publicised situation is
that it may
force more of us to confront the terrible inequalities that have
existed for a long time.
We need now to work out how to step up our campaign for a fairer,
more equal society. If we are to defend the NHS in order to protect
and improve the health of our people, we
must take action to bring about radical change.
Sources
Various
informal discussions
Financial
Times
Full
Facts website
Government
websites
Guardian
Health
Campaigns Together
Morning
Star
Observer
Private
Eye
Wikipedia
