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.
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?
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.
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.
Various informal discussions
Full Facts website
Health Campaigns Together