Below is the Doctors in Unite repose to the Peers Inquiry which has asked for an open consultation from the public and professionals in the wake of the coronavirus pandemic.

We welcome the opportunity to feed into the Peers Inquiry into Public Service Lessons from Coronavirus.

We are Doctors in Unite, the doctor’s branch of Unite the Union. Our members are from all branches of practice and public health across the UK. Our website can be accessed at https://doctorsinunite.com.  We have written extensively during the Covid19 pandemic. Our articles can be found on our website.

We believe that the end of the Lockdown is only the end of phase 1. We must act quickly, learning lessons from other countries’ experience, to prevent a second wave or surge and we need to be preparing for next winter when we can expect the return of seasonal flu and the usual winter bed crisis. These in combination with unfettered COVID 19 would be catastrophic

The Committee is seeking input on the following questions:

General

  1. What have been the main areas of public service success and failure during the Covid-19 outbreak?

Health and social care staff have embraced the challenges and worked flat out to care for the public. They have done this despite lack of adequate personal protective equipment (PPE), we will never know how many have lost their lives as a direct result of this.

The massive decrease in air and road traffic and hence in air pollution is also something to be celebrated along with the decrease in mortality from respiratory illnesses (excluding COVID). Many people report enjoying the reduced levels of noise and being able to hear bird song. 

The implementation of free transport on London’s buses will have encouraged some people not to drive, further diminishing emission of pollutants, but we must not forget that this was driven by the unacceptably high mortality from COVID of London’s bus drivers. They should not have had to die, they should have been issued with adequate PPE. We believe that free bus travel should continue as a fitting legacy to them and as one tool in the fight to combat climate change.

The decrease in traffic and the reluctance of people to use crowded public transport has led to a significant increase in cycling. It is welcome that the Mayor of London, Sadiq Khan, has chosen to capitalise on this and improve cycling infrastructure in the capital. The health and environmental benefits from the increase of active transport must not be squandered.

The level of failure has been legion. 

The Westminster Government responded extremely slowly to the approach of the virus. They squandered weeks, when it was obvious that COVID was heading our way. Time when they should have been making preparations including sourcing appropriate PPE and setting up test, trace, isolate and support systems. We believe that these delays can only be explained by ideological dogma overcoming sound public health advice and established good practice.

It is increasingly widely held that if lockdown had happened a week earlier that thousands of lives could have been saved.

https://www.bbc.co.uk/news/health-52995064

There should also have been a plan, under the aegis of Directors of Public Health, to reduce transmission in care homes and a plan for treatment within homes where necessary. This could have included the provision of oxygen and outreach medical and nursing teams.

Massive cuts in the Public Health budget during the last decade of austerity have severely curtailed the ability of local teams to respond to the pandemic and set up time honoured infectious disease control processes of test, trace, isolate and support. Countries that have adopted these methods have had far fewer deaths per head of population from COVID 19 than the UK which is in the ignominious position of having one of the highest death tolls in the world. We regard the premature abandonment of contract tracing along with the failure to curtail mass public events as major strategic errors. The Governments promise to set up a national test, track and trace programme by the beginning of June has been beset with problems and the official start date has been repeatedly postponed. It is now unlikely to be ready by the end of June, if then, yet local councils are holding back on developing local schemes putting their faith in the national one. Independent SAGE are clear that locally based test, trace, isolate and support is the way forward

  1. How have public attitudes to public services changed as a result of the Covid-19 outbreak?

The public have behaved extremely well. They have understood the seriousness of COVID 19 for some people and the pressures on the NHS and Social Care. During the peak of the pandemic attendances for non COVID related illnesses were much lower than expected. This however brings its own problems in that mortality and morbidity from non COVID conditions will be higher than usual leaving a massive legacy of unmet need. Lessons must be learned from this. Health and social care capacity must be invested in so that this backlog can be quickly addressed. Investment must be maintained so that we are never in the situation again that we found ourselves in with COVID 19 where there was no slack in the system to enable us to cope.

COVID has shown that the public are willing to accept huge changes if there is an existential threat. Government should acknowledge this and be much bolder in their attempts to tackle climate chang

Resource, efficiency and workforce

  1. Did resource problems or capacity issues limit the ability of public services to respond to the crisis? Are there lessons to be learnt from the pandemic on how resources can be better allocated and public service resilience improved?

The NHS has been decimated by cuts and privatisation over the last two decades but there is still some semblance of central coordination of a still largely, though shrinking, publicly provided service. This has enabled some level of planning. Social Care, on the other hand is nearly all privately provided and as a result so fragmented that there is little if any central planning of that sector. The tragic catastrophe of the thousands of deaths in care homes where low paid staff, many of whom work on precarious contracts through agencies is a damning indictment of the policy of privatisation of this sector which, lacking resilience, has become heavily dependent on the public sector for survival. In this context we note the Welsh Government intervened early on and arranged for regular PPE supplies to its care sector.

Social Care should be brought back into public ownership and the NHS should be restored to the comprehensive, publicly funded, publicly provided service, free at the point of delivery that it was in 1948. The NHS was founded to give everyone equal access to health and social care, doing away with the need for the funds to pay for it or the reliance on charity. There must be no return to workhouse mentality, charity and privatisation has no place in the provision of health and social care.

Despite Operation Cygnus finding in 2016 that “The UK’s preparedness and response, in terms of its plans, policies and capability, is currently not sufficient to cope with the extreme demands of a severe pandemic that will have a nationwide impact across all sectors,” the then Health Secretary Jeremy Hunt refused to implement its’ recommendations.

 We believe that the COVID 19 pandemic has highlighted how essential it is to have a comprehensive NHS which is publicly funded from general taxation, publicly provided and free to all at the point of delivery. Public Health and Social Care should be included in this because to provide effective health care the three must work together.

https://www.theguardian.com/world/2020/apr/19/government-under-fire-failing-pandemic-recommendations

https://www.theguardian.com/world/2020/may/07/revealed-the-secret-report-that-gave-ministers-warning-of-care-home-coronavirus-crisis

Pandemics usually lead to increases in morbidity and mortality from other non pandemic conditions. A decade of austerity, where the NHS has been forced to work at full capacity so that there is no slack in the system has made this worse. The shocking drop in the number of GP referrals for cancer treatment – down 60 percent from last year, and GP referrals to specialist care – down three quarters from last year, is incredibly concerning. Hospital bed occupancy of 85% is the upper limited that is deemed safe, but for years many hospital trusts have run at levels well above 90% leaving no room to respond to emergencies such as COVID 19.

https://nhsproviders.org/news-blogs/news/winter-bed-occupancy-rates-threaten-patient-safety

https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/bed-occupancy-in-the-nhs

https://www.nhsconfed.org/news/2020/06/performance-figures-reveal-unseen-impact-of-coronavirus

https://www.bma.org.uk/news-and-opinion/nhs-stats-highlight-brutal-impact-of-covid-19-on-healthcare-services-and-patient-care-says-bma

  1. Did workforce pressures preceding the crisis, such as difficulties in the recruitment or retention of workers, limit the ability of public services to meet people’s needs during the lockdown? How effectively, if at all, have these issues been addressed during the Covid-19 outbreak? Do public services require a new approach to staff wellbeing?

Please see answer to (3) above. The effect of cuts in the NHS and Social Care has seriously damaged the capacity to respond to the pandemic.

We welcome the Government’s decision to remove the NHS tariff for overseas health and social care staff (though we note there are delays in its implementation) but we regard it as reprehensible that the UK Government still treats many health and social care staff as being low skill and that they will be subject to strict migration restrictions.

  1. Why have some public services been able to achieve goals within a much shorter timeframe than typically would have been expected before the Covid-19 outbreak – for example, the increase in NHS capacity? What lessons can be learnt?

This is mainly due to the dedication of public sector staff who have worked flat out to protect and care for the public.

Technology, data and innovation

  1. Has the delivery of public services changed as a result of coronavirus? For example, have any services adopted new methods of meeting people’s needs in response to the outbreak? What lessons can be learnt from innovation during coronavirus?

Health services, especially General Practice have embraced remote working and largely consult through telephone or video in order to keep patients safe by minimising exposure to Covid 19. However this is not a panacea and care must be taken before this becomes the new norm. Many people, especially in deprived areas, do not have reliable access to the internet. There is a considerable amount of digital poverty. This must not be allowed to become an additional barrier to the vulnerable accessing care. Nor is it necessarily a better and more efficient way to deliver care. There is no evidence that on line consulting is quicker and it robs the clinician of valuable cues from the patient that are only available in face to face settings.

  1. How effectively have different public services shared data during the outbreak?

Others will be better qualified to comment on this question than we are.

  1. Did public services have the digital skills and technology necessary to respond to the crisis? Can you provide examples of services that were able to innovate with digital technology during lockdown? How can these changes be integrated in the future?

See answer to question 6.

Inequalities 

  1. Have public services been effective in identifying and meeting the needs of vulnerable groups during the Covid-19 outbreak? For example, were services able to identify vulnerable children during lockdown to ensure that they were attending school or receiving support from statutory services? How have adults with complex needs been supported?

Lockdown has led to an increase in domestic violence, this is yet another sector that has suffered huge cuts in the last ten years so that support services are unable to cope with demand.

https://www.theguardian.com/society/2020/apr/24/charges-and-cautions-for-domestic-violence-rise-by-24-in-london

https://www.independent.co.uk/news/uk/home-news/domestic-abuse-refuges-government-funding-announcement-a9166691.html

  1. Were groups with protected characteristics (for example BAME groups and the Gypsy, Roma and Traveller community), or people living in areas of deprivation, less able to access the services that they needed during lockdown? Have inequalities worsened as a result of the lockdown? If so, what new pressures will this place on public services?

The Governments hostile environment has been a deterrent to overseas migrants seeking the health care that they need. Many Overseas migrants are not eligible for routine NHS secondary care, though COVID, along with other conditions is exempt from charging. This policy causes overseas migrants to fear that seeking health care will either lead to destitution due to bills that they cannot pay, or deportation if their status is undocumented and seeking health care flags them to the home office. The policy is complex and many do not understand that some conditions are exempt, leading them to fail to seek any sort of health care. This is inhumane and the policy should be scrapped, but in addition it adds to the level of circulating virus in the community that is present to infect others.

https://www.independent.co.uk/news/uk/home-news/coronavirus-undocumented-migrants-deaths-cases-nhs-matt-hancock-a9470581.html

Another effect of the Government’s hostile environment is that many undocumented migrants work in low paid roles in the care sector and lack employment rights. They are financially compelled to work even when unwell and if out of work they have no recourse to benefits.

  1. Are there lessons to be learnt for reducing inequalities from the new approaches adopted by services during the Covid-19 outbreak?

We note the high level of death and illness that afflicted health and social care staff, predominantly affected those from a BAME background.

COVID 19 has laid bare the inequalities in UK society. Mortality has disproportionately affected the poor and vulnerable, particularly the BAME community. The PHE report  into disparities in outcome for COVID has been widely criticised for giving no recommendations for action.

During normal times the life expectancy and the healthy life expectancy of the richest in society is years greater than for the poorest. Poverty, poor nutrition and lack of control over one’s life lead to the poor health outcomes and disproportionate incidence of chronic long term conditions amongst the poorest in society. COVID 19 disproportionately kills off those with chronic long term conditions. This is not news, the Black Report in the 1980s and more recently Sir Michael Marmot’s reports of 2010 and this year’s ten years on, clearly show the problems and identify solutions. That their recommendations have not been acted on has meant that the poorest in society have disproportionately died.

http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report-pdf.pdf

https://www.health.org.uk/publications/reports/the-marmot-review-10-years-on

Despite these inequalities having been well documented for decades the public policy response over the last decade has been to move in an opposite direction. We have seen recent governments pursue policies to reduce the role of the state even though it is the major instrument to redistribute services and opportunity in modern British society. Within the public sector resources have been dramatically moved away from local authorities and other public bodies serving communities and groups with the greatest social need.  With this loss of publicly funded support and resilience it is not surprising that these communities have suffered the most in the present Covid-19 crisis. The words of the UN Special Rapporteur are a damning indictment of these policies.

https://www.bbc.co.uk/news/uk-48354692

Integration of services

  1. A criticism often levelled at service delivery is that public services operate in silos – collaboration is said to be disincentivised by narrow targets from central Government departments, distinct funding and commissioning systems, and service-specific regulatory intervention. Would you agree, and if so, did such a framework limit the ability of public services to respond to people’s needs during the Covid-19 outbreak?

We fully support that health and social care should work seamlessly. We are concerned however that in many instances patients were transferred to care homes without their Covid-19 status being firmly established. This is not acceptable and leaves a vulnerable section of the population exposed to a virulent infection.

For the future there needs to be proper transitional and quarantine provision in place between the NHS and Social Care and within Social Care itself.

We note the proportion of care homes that became affected by Covid-19 varied considerably – almost 60% of Scottish homes had Covid-19 compared to 40% in England and 25% in Wales. This variation should be examined to see if there are any lessons to be learned.

https://www.theguardian.com/world/2020/jun/02/covid-19-spilling-out-of-hospitals-and-care-homes/says-uk-expert

  1. Were some local areas, where services were well integrated before the crisis, better able to respond to the outbreak than areas where integration was less developed? Can you provide examples?

The three devolved administrations, who largely embraced a public services response, seemed to provide a more coherent and integrated response than the fragmented, cocktail approach in England which was over-dependent on out-sourcing and ad-hoc arrangements with private companies. These experiences also highlighted the desirability for more local responses – and in the English context the London-centric leadership did not allow a more tailored response to the local need across the country.

We also commend the Welsh Government’s decision to provide front line care staff with a bonus of £500 in recognition of loyal and dedicated service. It is a pity that the Treasury has not seen fit to exempt this sum from tax and national insurance liabilities.

  1. Are there any examples of services collaborating in new and effective ways as a result of Covid-19? Are there lessons to be learnt for central Government and national regulators in supporting the integration of services?

See response to question 3. Years of privatisation, fragmentation and cuts, with the added difficulty of enshrining competition into the NHS with the 2012 Health and Social Care Act have severely undermined the ability to provide integrated services across the system. Removing these barriers and facilitating sensible system wide planning around the needs of those who need to be cared for rather than the constant push for “efficiency savings” in a sector that has been subjected to an unprecedented financial squeeze during the last decade of austerity would help enormously.

https://www.kingsfund.org.uk/projects/positions/nhs-funding

https://www.england.nhs.uk/2019/04/staff-praised-as-nhs-productivity-grows/

  1. What does the experience of public services during the outbreak tell us about services’ ability to collaborate to provide “person-centred care”?

See answers to previous questions, cuts, privatisation and consequent fragmentation with competitive procurement processes have severely undermined the ability of public services to collaborate and provide person centred care. Any good practice is down to the willingness and dedication of health and social care staff to go above and beyond the call of duty.

The relationship between central Government and local government, and national and local services

  1. How well did central and local government, and national and local services, work together to coordinate public services during the outbreak? For example, how effectively have national and local agencies shared data?

While we agree that there should be a “Four Nation” response to the pandemic across the UK, each devolved administration should retain the ability and capacity to respond to its own needs where necessary.

If a “Four Nation” response is to work more effectively it requires Westminster to engage in a regular and consistent dialogue with the devolved administrations. Pandemics do not need permission to cross borders.  This has not always the case during Covid-19 to date.  There are opportunities for shared procurement practices across the UK but we are concerned to hear that some supply contracts agreed with devolved administrations were “gazumped” by Westminster. There is also a need to revisit how professional advice is secured and commissioned. Bodies such as SAGE are predominately under the wing of Whitehall and the UK Government with devolved governments having a very secondary role. This can mean that crucial strategic decisions are made at a “Whitehall pace” rather than that which might be more appropriate to the devolved parts of the UK.

Community contact tracing is an area which should be locally driven to provide the best outcomes. However the Westminster Government have insisted on a nationally driven programme, which has been beset with problems and has been described by ISAGE as being unfit for purpose. This insistence on a national solution has hindered the setting up of local test, trace, isolate and support systems which have been proven to be effective in disease control. See also answer to question 18.

  1. How effectively were public services coordinated across the borders of the devolved administrations? Did people living close to the border experience difficulties in accessing services?

See answer to question 13.

  1. Can you provide any examples of how public services worked effectively with a local community to meet the unique needs of the people in the area (i.e. taking a “place-based approach” to delivering services) during the Covid-19 outbreak?

Places where community test, trace, isolate and support have been piloted have given insights into how they can be made to work. Ceredigion, Sheffield and Northern Ireland, for example, have successfully instituted local schemes.

https://www.walesonline.co.uk/news/wales-news/area-wales-missed-coronavirus-simple-18348215

https://www.theguardian.com/world/2020/may/21/uk-first-coronavirus-contact-tracing-group-warns-of-difficulties

Lack of properly coordinated local schemes will lead to avoidable deaths as lockdown is eased and people begin to move around more freely. The app promised by Hancock is clearly beset with major problems

https://apple.news/AnQsy9rXJSrajZJtKjLUW6A

https://www.newscientist.com/article/2241041-there-are-many-reasons-why-covid-19-contact-tracing-apps-may-not-work/https://www.wired.co.uk/article/contact-tracing-app-isle-of-wight-trial

  1. Would local communities benefit from public services focusing on prevention, as opposed to prioritising harm mitigation? Were some local areas able to reduce harm during coronavirus by having prevention-focused public health strategies in place, for example on obesity, substance abuse or mental health?

The rise in foodbank usage shows how desperately close to poverty are so many in our population. This situation could, and should, be prevented in future by an adequate benefits system, or universal minimum income, and a significant rise in statutory sick pay to at least the minimum living wage. This support is vital in view of the particular vulnerability of disadvantaged and marginalised communities.

Role of the private sector, charities, volunteers and community groups

  1. What lessons might be learnt about the role of charities, volunteers and the community sector from the crisis? Can you provide examples of public services collaborating in new ways with the voluntary sector during lockdown? How could the sectors be better integrated into local systems going forward?

Mutual Aid groups were quickly set up across the country and people undertook their social responsibility to forgo freedoms in order to protect others and save lives. This is potentially an important future asset and we urge both national and local government to explore ways of supporting this important reservoir of social solidarity and community cohesion.

It is a scandal that care home workers needed to access charities to be able to afford to eat if they were sick or needed to self isolate. (see also answer to 19 above).

  1. How effectively has the Government worked with the private sector to ensure services have continued to operate during the Covid-19 outbreak?

The involvement of the private sector has led to an only too familiar string of unfortunate events.

Unipart did not have the workforce to distribute the PPE that was available. https://www.hsj.co.uk/finance-and-efficiency/system-failure-on-personal-protective-equipment/7027207.article

https://unitetheunion.org/news-events/news/2020/april/government-cuts-to-nhs-supply-chain-causing-hospital-ppe-delays-and-must-be-reversed/

Serco had a serious data breach where they revealed the email addresses of hundreds of contact tracing call handlers to each other.

https://www.theguardian.com/business/2020/may/20/serco-accidentally-shares-contact-tracers-email-addresses-covid-19

Capita took weeks to process the applications of retired GPs and other staff who were willing to return to work to help with pandemic management.

http://www.pulsetoday.co.uk/clinical/clinical-specialties/respiratory-/gps-giving-up-on-month-long-process-to-join-covid-assessment-phone-line/20040776.article

Privately run testing centres, such as those of Deloittes, are difficult to access, results have gone missing and have not been communicated to GPs.

https://www.theguardian.com/world/2020/apr/23/hospitals-sound-alarm-over-privately-run-test-centre-in-surrey

Virus testing occurs in ‘super labs’ bypassing existing NHS facilities which have much quicker turnaround times and good links to the local General Practices that they serve. Testing in NHS labs would have kept GPs in the loop, vital for community contact tracing.

https://lowdownnhs.info/comment/why-bypass-nhs-labs-for-mass-testing-concerns-over-new-super-labs/

Private hospitals were thrown a life line when the Government struck a deal to pay them £2,400,000 per day to rent 800 beds, without this these hospitals would have struggled for business. Few of the beds were used, but the private hospitals were paid the money anyway.

https://lowdownnhs.info/news/nhs-englands-deal-a-life-saver-even-for-private-hospitals/

It is our view that private capacity should have been requisitioned, not rented out. £2,400,000 per day would have been far better spent on the NHS and Social Care provision.

CONCLUSION

In conclusion we would like to reiterate that we believe that the COVID 19 pandemic has highlighted that it is essential to have a comprehensive NHS which is publicly funded from general taxation, publicly provided and free to all at the point of delivery. Public Health and Social Care should be included in this because to provide effective health care the three must work together for the needs of the patient and not for profit.