THE ROLE OF AIRBORNE SPREAD IN FACTORY OUTBREAKS OF COVID-19

Workers and local communities are not to blame; responsibility lies with employers, regulatory agencies and government

Summary

It seems nearly every day there is another outbreak of Covid-19 in Britain’s factories, in the food processing industry, in the garment industry and elsewhere.  It is increasingly clear that working conditions in the factories are largely responsible for the outbreaks, in particular by means of airborne spread of Covid-19.  In contrast spread between workers outside the factory and in local communities plays only a small part.  The timing, circumstances and pattern of the outbreaks, points to them being typical “super-spreader events”, caused by airborne spread of the virus within the same enclosed indoor space of the factory, from one or two infected individuals to large numbers of other workers.  The actions of workers themselves play only a minor role in these outbreaks; the task before us is to urgently take measures to address the airborne route of spread, not only in factories but in all workplaces and schools, if we are to reduce outbreaks.   

The spread of Covid-19 in indoor spaces is extremely difficult to prevent entirely.  There is in reality no such thing as a “Covid-safe” workplace or school, unless transmission in the community is eliminated.  The rate of community transmission will determine what happens in our workplaces and schools and a national “Zero Covid” strategy is therefore essential.  We can make indoor spaces safer by hygiene measures, distancing, wearing masks and proper ventilation.  We should be spending as much time talking about ventilation as we do the other measures.  The Health and Safety Executive, the Food Standards Authority and other regulatory authorities have a crucial role in ensuring this is done properly; so far we have heard very little from them during the whole of the Covid-19 pandemic.

This briefing discusses airborne spread and the lessons we need to learn from super-spreading events which have occurred here and in other countries.  This is all the more urgent as we head into autumn and winter when we all move indoors to a much greater extent. 

Contents

  1. Airborne spread of Covid-19
  2. Greencore outbreak
  3. Tönnies meat packing plant study
  4. Preventive measures taken by Tönnies and lessons learned
  5. Growing evidence and consensus around aerosol spread
  6. Workers and local communities are being scapegoated for factory outbreaks caused by airborne spread
  7. Epidemiological studies
  8. A trade union programme
  9. Doctors in Unite
  10. References

1. Airborne spread of covid-19

The British Medical Journal published a leading article on 22 August on airborne spread of Covid-19  [1], which summarises what is now very convincing evidence for aerosol transmission through the air.  The article says that current official guidance, which says transmission occurs only through contact and droplet spread and that aerosols are produced only during so called “aerosol generating procedures” in hospitals, does not withstand scrutiny, and gets in the way of much needed measures to combat the virus.  The authors state, “Heavy breathing, coughing, talking, and singing all generate aerosols……This has important practical implications for infection control, the prevention of outbreaks and superspreading events, and for the new social behaviours that are being implemented in an effort to control the pandemic.”  

The article states that airborne spread is now the plausible cause of super-spreader events, and it seems very likely that several outbreaks here in the UK, for example Greencore in Northampton, the garment factories in Leicester, meat and poultry packing plants in Wales and West Yorkshire and Coupar Angus in Scotland have been just such events.  It is striking that according to press reports, in some of the outbreaks employers insist they have been fully implementing all recommended workplace safety measures. Greencore is a case in point: the company stated, “All of Greencore’s sites have wide-ranging social-distancing measures, stringent hygiene procedures and regular temperature checking in place”.  Yet nearly 300 people working there were still infected. 

2. Greencore outbreak

It is instructive to look at the Greencore outbreak in some detail, to ascertain how the virus spread.  It is unlikely that a large number workers breached handwashing and distancing measures at the factory all within a few days, especially as management says they are so careful.  It is also implausable that community transmission carried infection into the factory to such a large extent.  This would mean a large number of discrete, small outbreaks in the community all at the same time, and very many more cases in the community outside the factory, which does not appear to have happened.  In fact, the BBC reports [2] that “Testing data and analysis from the Joint Biosecurity Centre shows the spike is “almost solely down” to the outbreak at Moulton Park-based Greencore, which employs 2,100 people”.  The timing of the outbreak indicates instead a typical super-spreader event.  The graphs below demonstrate this clearly; one is of the Greencore outbreak: there was a low and steady number of cases in the Northampton area until mid-August when there was an abrupt jump in cases – over 200 within 3 days; a typical super-spreader pattern.  The second graph is of the super-spreading event in a call centre in Seoul in March 2020, and shows a similar pattern: 94 out of 216 employees working in an open plan office on the same floor became infected over a few days in this outbreak.

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Seoul call centre outbreak early March 2020 Source: Park et al, Emerging Infectious Diseases CDC https://wwwnc.cdc.gov/eid/article/26/8/20-1274-f1

We have appended below a press photograph of the Greencore factory floor: assuming this accurately portrays current working conditions, there are lots of people sharing the same, indoor space for many hours at a time each day.  We have no information about the ventilation in the factory, but food processing plants are usually kept cool for hygiene reasons, and colder temperatures favour the survival of the SARS-CoV-2 virus.  The ventilation often also involves recirculation of colder air in such plants, at least in part, rather than complete air changes with fresh outside air.  Even with several air changes per hour it seems that some live virus can still be present in the air indoors (see below).  And the direction of ventilation and air flow within the space is also important; it may carry the virus from an infected worker towards others. This is thought to have happened in the well documented restaurant outbreak in Guangzhou. [13]  

We do not know if the photograph reflects recent practise, but if so, the lack of mask wearing is striking. Greencore workers told the local press they were “terrified” of being required to work while they awaited test results for Covid-19, and were told it was up to them if they wanted to wear a face mask or not. [14]

3. Tönnies meat packing plant studyIt is helpful to look at a detailed study of a similar super-spreading event also in the food processing industry – at the Tönnies meat packing plant in Germany in June. [3 – not peer reviewed as yet]. The study analysed a range of possible factors involved in the outbreak, including the timing of infection events, spatial relationship between workers in the meat processing plant, climate and ventilation conditions, sharing of living quarters and transport, and performed full viral genome sequences (i.e. genetic fingerprinting) from virus recovered from PCR-confirmed SARS-CoV-2 cases. The viral sequencing established that spread was from a single index case within the factory to other workers, and not from multiple entry points by different workers bringing infection into the plant.  It also established that shared accommodation and transport did not play a material role in the outbreak.  Over a 3 day period, 29 workers out of 147 who worked the same shift as the index case became infected before the index case was quarantined.  60% of workers within an 8m radius of the index case became infected.  In addition, before the workers caught in the first outbreak were quarantined, they had had contact with others elsewhere in the factory, which led to a secondary outbreak leading to over 1500 workers becoming infected in the Tönnies factory overall.  This led to a lockdown of a large area in the North Rhine-Westphalia region in western Germany.

3. Tönnies meat packing plant study

It is helpful to look at a detailed study of a similar super-spreading event also in the food processing industry – at the Tönnies meat packing plant in Germany in June. [3 – not peer reviewed as yet]. The study analysed a range of possible factors involved in the outbreak, including the timing of infection events, spatial relationship between workers in the meat processing plant, climate and ventilation conditions, sharing of living quarters and transport, and performed full viral genome sequences (i.e. genetic fingerprinting) from virus recovered from PCR-confirmed SARS-CoV-2 cases. The viral sequencing established that spread was from a single index case within the factory to other workers, and not from multiple entry points by different workers bringing infection into the plant.  It also established that shared accommodation and transport did not play a material role in the outbreak.  Over a 3 day period, 29 workers out of 147 who worked the same shift as the index case became infected before the index case was quarantined.  60% of workers within an 8m radius of the index case became infected.  In addition, before the workers caught in the first outbreak were quarantined, they had had contact with others elsewhere in the factory, which led to a secondary outbreak leading to over 1500 workers becoming infected in the Tönnies factory overall.  This led to a lockdown of a large area in the North Rhine-Westphalia region in western Germany. 

The diagrams below are reproduced from the study and show:  A: the distance between the index case (B1) and spread to other workers; diagram B shows the relationship of distance to infection risk and diagram C shows that spread within the factory was the cause of the outbreak and not shared accommodation or car pools.  A full description of these findings is in the paper at reference [3].

It is worth quoting from this study at length:

“Aerosols are believed to be particularly important in cases where a single source transmits the virus toa large number of individuals, so-called super spreading events. Whereas droplets typically travel no farther than 2 m, aerosols can stay in the air for prolonged periods of time and may deliver infectious viral particles substantially beyond 2m distances, especially in indoor settings with low fresh air exchange rates. Factors such as temperature, humidity and air circulation are thought to significantly influence stability and transport of droplets and aerosols and consequently transmission efficiency.

Meat processing plants have recently emerged as hotspots of SARS-CoV-2 around the world. This is thought to result not only from operational practices (e.g. close proximity of workers in the production line combined with physically demanding work that promotes heavy breathing), but also from sharing of housing and transportation that may facilitate viral transmission. The requirement to operate at low temperature in an environment with low air exchange rates is another factor that may promote spread of the virus among workers.

Transmission occurred in a confined area of (the) meat processing plant in which air is constantly recirculated and cooled to 10°C. ……. Analyzing housing and commuting parameters, along with spatial and climate conditions in the work area, this study provides evidence that transmission occurred over a radius of at least 8 meters around the index case…… Physical work and relatively low fresh air exchange rates together with continuous re-circulation of cooled air may have favoured the transmission of SARS-CoV-2…

The universal point of potential contact among all cases was work in the early shift of the beef processing plant. The shift comprises 147 individuals, most of whom work at fixed positions in a conveyor-belt processing line……

….. while some secondary infections may have occurred within apartments, bedrooms or carpools, our collective data strongly suggest that the majority of transmissions occurred within the beef processing facility, with (index) case B1 being at the root of the cluster.

Our findings indicate that a physical distance of 2 meters does not suffice to prevent transmission in environmental conditions such as those studied here; additional measures such as improved ventilation and airflow, installation of filtering devices or use of high-quality face masks are required to reduce the infection risk in these environments.

Our findings suggest that the facilities’ environmental conditions, including low temperature, low air exchange rates, and constant air re-circularization, together with relatively close distance between workers and demanding physical work, created an unfavourable mix of factors promoting efficient aerosol transmission of SARS-CoV-2 particles.

It is very likely that these or similar factors are also responsible for current worldwide ongoing outbreaks in other meat or fish processing facilities. The recurrent emergence of such outbreaks suggests that employees in meat or fish processing facilities need to be frequently and systematically screened to prevent future SARSCoV-2 outbreaks. Furthermore, immediate action needs to be taken to quarantine all workers in a radius around an infected individual that may significantly extend beyond 2m.

In contrast to work-related exposure, shared apartments, bedrooms, or carpools appear not to have played a major role in the initial outbreak described in this study. Nevertheless, later viral transmission within shared living quarters or work rides very well may have been a confounding factor in context of the second, larger outbreak occurring one month after the first outbreak. Our genotyping results are fully compatible with the hypothesis that this second outbreak was seeded by cases related to the initial cluster.

The significance of this study is imminent for the meat and fish processing industry but might well reach beyond these industries, and points to the importance of air quality/flow in confined spaces to prevent future superspreading events

Common operational conditions in industrial meat processing plants promote the risk of SARS-CoV-2 superspreading events. Additional measures such as improved ventilation, optimized airflow management, installation of filtering or ultraviolet light devices or the use of high-quality face masks are required to reduce the infection risk in these environments.”

Community spread and spread among workers outside the factory have been pointed to as the cause of the Greencore outbreak.    This seems to be mere supposition rather than any evidence-based assessment for such spread.  The Tönnies study involved a similar group of workers, i.e. workers sharing accommodation and transport, and specifically looked at these issues and disproved them as the reason for the outbreak.  There is a lack of awareness and therefore no consideration of the role of indoor aerosol spread driving factory outbreaks, which perhaps explains why the press, public and even health experts look for possible explanations outside the factory gates.

4. Preventive measures taken by Tönnies and lessons learned

The study reports that the company took the following measures after the outbreak:

  • Hygiene regulations and one-way traffic in hallways were reinforced.
  • An internal multi-lingual information campaign was started to raise awareness for all staff of prevention and self-detection of early COVID-19 symptoms.
  • Temperature checks were set up to check all employees entering the building.
  • Workers were made aware of the availability of testing and were motivated to report any events where they see themselves being at risk. Staff were tested based on self-reported symptoms, possible contacts to other infected persons, returning to work after more than 96 hours absence from work, or possible work place contact with infected colleagues.
  • Work place assessments were performed to see if it was possible to extend distances between workers.
  • Simple one-layer face masks were made compulsory.
  • Regulations to prohibit rotation between working places were imposed.  (Shift workers were employed by an outsourcing company who had changed their workplaces according to demand by the employer.)
  • Measures in the canteen were imposed to reduce physical contact and to ensure that workers would spend their break times exclusively with workers from their own shift.
  • Implementation of the measures was audited within a month by unannounced inspections of the Occupational Health and Safety Experts of the competent authority. 

There are a number of important lessons from this study:

  • Airborne spread is particularly important in super-spreader events;
  • Aerosols can carry virus much further than 2m indoors;
  • Temperature, humidity and air circulation (fresh air exchange rates) significantly affect stability and transport of droplets and aerosols and therefore transmission;
  • Close proximity of workers on the production line doing physically demanding work and therefore breathing heavily also facilitate transmission. (Other studies have pointed to rapid “line speeds” as an additional contributing factor);
  • Early quarantine of possible contacts is essential to limit spread;
  • Shared accommodation and transport did not play a significant role in this outbreak; the common factor was working together on the factory floor under these conditions;
  • Improved ventilation and airflow, installation of filtering devices, and use of face masks are required to reduce the infection risk in these environments, and in other workplaces which have enclosed indoor spaces.
  • Large secondary outbreaks can occur from an initial outbreak in a factory.  Press reports indicated an increased number of cases in the surrounding community as well (but this may have been due to increased testing).
  • There is a need for surveillance testing in high risk environments like food processing plants, given the large number of super-spreading events which have occurred in them.
  • In addition to measures like hygiene, social distancing and temperature monitoring, multi-lingual information campaigns, compulsory face masks and rapid access to testing are important.
  • Inspection by regulatory authorities is important to ensure compliance.

While there have also been numerous outbreaks in the hospitality sector, especially linked to pubs, the workplace appears to have now become the frontline in the battle against Covid-19, both here and across the EU. [4]  [5] 

5. Growing evidence and consensus around aerosol spread

Aerosol scientists, mainly in the US but also in Australia and elsewhere, and here in the UK (e.g. Professor Catherine Noakes at the University of Leeds, who sits on SAGE), have been convinced for some time that aerosol spread is a major route of transmission.  In July, 239 scientists wrote to the World Health Organisation (WHO) asking it to recognise airborne spread and amend its guidance.  WHO did shift its previous rejection of the idea and said aerosol spread “cannot be ruled out”.  Since then there has been further evidence, including the successful culturing of live virus from the air up to 4.8m from infected patients in hospital rooms.  (A surprising and concerning finding was that the rooms had fairly good ventilation rates as well as UV light air sterilisation, but live virus was still able to be cultured from the air.)  [6]

Meanwhile official documents from SAGE have referred to aerosol transmission on a number of occasions, [7] [8] and some professional associations’ guidelines now include advice on the risks of aerosol spread; for example, the Primary Care Respiratory Society says that routine assessments of patients by means of spirometry should be avoided due to the risk of droplet and aerosol spread.  [9]

Aerosol spread is officially recognised in Germany and Japan and recently the French employment minister, Elisabeth Borne, stated that compulsory mask wearing from 31 August in France, “reflects a growing scientific consensus that the virus is transmitted not only in big drops projected when a person coughs or sneezes, but also in smaller ones suspended in the air breathed out by infected people that accumulates in enclosed spaces”. [10].  Nicola Sturgeon spoke of the risk of aerosol spread in schools in Scotland on 24 August, stating her government was considering face coverings for secondary school students in communal areas.  [11]

In the US a number of institutions are actively looking at ventilation requirements in indoor spaces, using CO2 monitors as a proxy measure for adequacy of ventilation, and the addition of portable air filters to make indoor spaces safer, including in schools and universities.  A clear and practical article on this from the University of Colorado is at reference [12]. 

6. Workers and local communities are being scapegoated for factory outbreaks caused by airborne spread

We have seen in Leicester and other areas of the Midlands, accusations that outbreaks in factories have been due to workers and/or local communities failing to observe social distancing measures.  There has been racist scapegoating of Asian communities, blaming them for local spikes in infection caused by factory outbreaks (in the Leicester garment factories for example), which very likely have involved airborne transmission.  We have seen a social media post about the Greencore workers saying, “I don’t feel bad for most of the staff. The Eastern Europeans never followed regulations like distancing and not mixing in large groups in lockdown in March onwards. They don’t care.”  The role of airborne spread needs to be understood, and communicated to all concerned during these outbreaks.  Ignorance of how Covid-19 spreads is leading to victim-blaming of people who become infected, when attention should be directed to employers, public health officials and government for solutions.

It is notable that in many of these large outbreaks, workers are poorly paid and are on insecure short-term contracts.  Many receive only Statutory Sick Pay; as a result they have had to rely on food banks, and some have lost their homes as they could not afford to pay rent.  All workers forced to take time off due to having Covid-19 or having been a close contact of an infected person should receive full pay while isolating.  Not doing so is inhumane, and is obviously also self-defeating, as some workers will go to work like those who were made to do so at Greencore while awaiting test results, and thereby compromise efforts to curtail the outbreaks.  The government’s recent derisory offer of £13 per day for workers having to isolate is clearly wholly inadequate. It has been described as “a slap in the face” by a Council leader, and also only applies to areas with already high infection rates.  This is clearly wrong, we want to prevent infection rates going up, not reacting when they have already become high.  A proactive, preventive approach is needed.

7. Epidemiological studies

We believe it would be also be very helpful if detailed epidemiological studies, like the one done in the Tonnes meat packing plant, could be conducted in future outbreaks here in the UK, to better understand and learn from them.  Hopefully some are being done but we have yet to see any of these.

8. A trade union programme

  • Employers must recognise airborne spread as a covid-19 risk and take action to assess and minimise risk.
  • Improved ventilation and airflow, installation of filtering devices, and use of face masks are required to reduce the infection risk in these environments, alongside other safety measures against Covid-19.
  • Trade union supervision and control of workplace safety.
  • Weekly surveillance testing on site of all workers, including management, in addition to easily accessible testing for anyone with symptoms or in contact with Covid-19.
  • All workers forced to take time off due to having Covid-19 or having been in contact with it should receive full pay while isolating.  No-one should have to work while awaiting test results for symptomatic or contact testing.

9. Doctors in Unite

We are a national doctors’ trade union within Unite the Union; our members include working and retired GPs and hospital doctors and dentists from a range of specialties, as well as public health doctors and non-medical public health specialists, from across the four nations of the UK.  We are party to the BMA negotiating machinery by virtue of an agreement with the BMA dating from 1950 and are the only medical trade union recognised in local government. We have been involved throughout the pandemic, both in our day jobs, and also raising issues around PPE, “Covid-safe” workplaces and campaigning on the critically important requirement for locally based ‘Find, Test, Trace, Isolate and Support’ services run by the DPH in each borough.

We will also continue to lobby for a change to official guidance around transmission of Covid-19, although with the abrupt axing of PHE this may be difficult.   

10. References

[1] https://www.bmj.com/content/370/bmj.m3206

[2] https://www.bbc.co.uk/news/uk-england-northamptonshire-53860426

[3] https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3654517

[4] https://www.ecdc.europa.eu/en/publications-data/covid-19-clusters-and-outbreaks-occupational-settings-eueea-and-uk 

[5] https://www.thelocal.fr/20200803/office-not-parties-biggest-source-of-coronavirus-contagion-in-france 

[6] https://www.medrxiv.org/content/10.1101/2020.08.03.20167395v1

[7]https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/887618/EMG_Environmental_transmission-_02052020__1_.pdf

[8]https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/894961/6.6731_CO_Review_of_two_metre_Social_Distancing_Guidance_FINAL_v3_WEB_240620.pdf

[9] https://www.pcrs-uk.org/sites/pcrs-uk.org/files/Diagnosis%20of%20asthma%20and%20COPD%20during%20Covid.pdf

[10] https://www.theguardian.com/world/2020/aug/18/global-report-france-tightens-mask-rules-as-covid-cases-rise-europe

[11] https://www.theguardian.com/uk-news/2020/aug/24/seventeen-teachers-at-dundee-school-contract-covid-19

[12] https://theconversation.com/how-to-use-ventilation-and-air-filtration-to-prevent-the-spread-of-coronavirus-indoors-143732

[13] https://wwwnc.cdc.gov/eid/article/26/7/20-0764_article#tnF1

[14] https://www.northantslive.news/news/northamptonshire-news/greencore-staff-lift-lid-fears-4443310?fbclid=IwAR3ZzlExqOP-JzOXanlJgmeQTr7zqmhomNfEtjdRm3bSCigTKRxfyioYxig

Exam results post-COVID: DiU Statement

Doctors in Unite (formerly the Medical Practitioners Union) are extremely concerned that thousands of young people, disproportionately from disadvantaged back grounds, have been awarded A level grades, in many cases two grades lower, than those predicted by their teachers. 

It is grossly unfair that young people from areas already hardest hit by the ravages of COVID 19 should have the fact that the virus has prevented them from taking their exams add a further barrier to their ability to achieve and to their life chances. 

We are appalled that many of the young people who expected to go on to higher education have been let down by an algorithm which takes little account of individual potential, placing more emphasis on the historic performance of the school, handing further advantage to those from more affluent areas.

In particular, as doctors, we are worried that young people who live in working class areas will fail to get the places in medical school which should have been theirs. Diversity within the medical profession is vitally important so that as doctors we can effectively represent the patients that we serve. The algorithm threatens the level of diversity amongst our colleagues of the future and many of today’s doctors would not be practicing if they had been subjected to such a system..

We call on Gavin Williamson to work with the teacher’s unions, immediately scrap the algorithm and to award young people A level grades based on the predictions of their teachers. To fail to do this will rob thousands of young people of the futures they deserve and quite rightly expect.

Doctors in Unite, 17/08/2020

We need a Zero coid-19 strategy now: say over 200 health and social care workers

Over 200 health and social care workers, from across the entire spectrum of specialties and grades of staff have signed an open letter addressed to Boris Johnson, calling on him to set out a coherent strategy that will effectively tackle the Covid-19 pandemic in England.  They include professors, consultants, GPs, nurses, therapists, administration staff, theatre porters, paediatricians, psychiatrists and mental health nurses, obstetricians and midwives, haematologists, laboratory staff, radiologists, respiratory physicians; healthcare assistants, psychotherapists, administrators, chief executives, occupational therapists, pharmacists, immunological researchers, clinical directors, senior lecturers, social workers, palliative care specialists, speech and language therapists.

The letter states that slogans like “stay alert”, “control the virus” and “whac-a-mole” do not constitute a strategy.  Given the terrible cost of the pandemic, both in terms of lives lost and lasting damage to the economy, we call on you urgently to set out an explicit strategy in relation to Covid-19”.  The letter says there is a clear choice, between mitigation, i.e. accepting ongoing infections and deaths indefinitely until a vaccine or cure is found, or suppression, i.e. aiming to eliminate the virus.  The letter says that the latter course clearly represents the best strategy in terms of both public health and protecting the economy.

The letter goes on, “This means having a much more ambitious target of suppressing the number of new cases to zero as soon as possible, and keeping it there.  This requires continuing public health measures, such as maintaining social distancing, universal use of face masks in enclosed spaces, sensible travel restrictions, and setting up countrywide community based, efficient and rapid ‘find, test, trace, isolate and support’ infrastructure across the country, including at our borders.  If done effectively and comprehensively this would successfully suppress the virus in a matter of weeks, and then keep it there.”

Dr Jackie Applebee, Chair of Doctors in Unite, the group who organised the letter, said “We cannot continue to drift on this rudderless course any longer.  Flare ups like Leicester and in the meat and poultry packing plants show the dangers of this approach and if there are enough of these there will be a second wave, forcing us all back into lockdown.”  Independent SAGE have called for a “Zero Covid” strategy; it is perfectly possible to suppress the virus in England as they have done in Scotland, with the right approach. For that to happen though we need an effective test, trace, isolate and support service, based in the community and run by Directors of Public Health, not the ineffective privatised and separate service we have now.

We ask the government, yet again, what is your strategy?

You can read the original letter here:

https://doctorsinunite.com/2020/06/21/open-letter-to-the-prime-minister-about-the-uks-covid-19-strategy-from-nhs-and-social-care-workers/?fbclid=IwAR0cIjKXS54H4cEFZHnfOW3WWG_SGe72ZS13T9bgjCjeeq-yHzbYi6nigpM

NHS 72nd Birthday

5th July 2020

The 72nd birthday of the NHS takes place in the shadow of the COVID 19 pandemic.

The progress of the virus underlines the absolute importance of having an NHS as Bevan intended when it was founded in 1948, a comprehensive health service, publicly funded from general taxation, publicly provided and free at the point of delivery for all. The aim was to end inequalities in access to healthcare and July 5th 1948 famously saw queues of people round the block in a powerful demonstration of the size of the previous unmet need.

Since 1948, and accelerated since 1990, the founding ethos of the NHS has been under threat. One of the most cost-effective health care systems in the developed world, the NHS is nevertheless subject to repeated cuts and calls for efficiency savings, along with privatisation, fragmentation and competition, which was enshrined into NHS procurement by Andrew Lansley’s dastardly 2012 Health and Social Care Act. Public Health departments have been hollowed out and side-lined, at huge cost to their vital functions.

COVID 19 has laid bare the disastrous effects of the undermining of the NHS. People of BAME origin and the poor are far more likely to die of the virus. Years of NHS underfunding and outsourcing to the private sector has left it without the spare capacity to cope with the challenges of the pandemic. There has been insufficient appropriate PPE for health and social care workers, testing for the virus has been chaotic and outsourced to the private sector with no coordination with GP services, community contact tracing that has served well countries such as New Zealand, South Korea, Iceland and even Liberia, where they are used to dealing with Ebola so know what needs to be done, has been side-lined in the UK with reliance on a national system which has been deemed by Independent SAGE as not fit for purpose.

The result of this is that the UK has the ignominious honour of having the highest death toll from COVID in Europe, and, as I write, the third highest in the world, behind Brazil and the US.

BAME staff have died disproportionately yet they are the backbone of the NHS, often employed in the lowest paid of jobs on precarious contracts. To add insult to injury the hostile environment makes some of them ineligible for free NHS care. The Tories have done a U turn and said that the health surcharge will not apply to health workers, they have yet to implement this so the pressure needs to be maintained, but it does show what can be achieved through sustained campaigning.

A publicly run health service with adequate funding and planning based on need not profit, would have mitigated many of the challenges that COVID 19 has presented.

So, on this the 72nd birthday of our NHS we must keep fighting to have it restored into public ownership. The Black Lives Matter movement chimes with the disproportionate death toll amongst our BAME brothers and sisters, everyone should have equality of opportunity in life and equal access to health care. This can only be achieved in a society based on need not profit.

We have a job to do. If we fight, we can win.

Peers Inquiry into Public Service Lessons from Coronavirus: Full Report

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.

Private providers must serve the public interest

In the middle of March 2020, it was clear that the NHS would not have the capacity to deal with the increased demands of the Covid-19 epidemic. This lack of spare capacity is clear evidence of continuing government failure to invest in the NHS to provide the required flexibility to meet unplanned needs.  As a necessary but panic measure to deal with the threat of COVID 19, Johnson’s Government struck a deal with the private hospital sector to rent beds from them at a cost of £2,400,000 per day.

By the end of June, after approximately one hundred days this will already have cost the NHS a quarter of a billion pounds. It is clear that the Government can find funds when they are needed and that their default position is to throw money at the private sector despite the shocking record of commercial organisations in providing health and social care.

This is a disgrace which has thrown a lifeline to the private health providers who would have not been able to operate normally during the pandemic and would have lost huge quantities of money but for this.

NHS hospitals have largely coped with the first wave of the COVID 19 pandemic by ceasing all other activity and by the public co-operating with a country-wide lockdown. The extra capacity has been mostly unused. Effectively the private hospitals have received tens of millions of pounds of public money, and rising, to do nothing.

As the NHS begins to deal with the huge backlog of non COVID care these private hospitals must be obliged to make their facilities available to help with the catch up in care and they must do so taking into account the windfall they have obtained to date.

There must be no profiteering from Covid-19.

We demand:

  • Private hospitals must provide value for the money already paid to them and make their facilities available to help clear the backlog of NHS care for no extra charge.
  • There must be full scrutiny and open book accounting to ensure that taxpayers can see that they are getting value for money.
  • Commercial organisations must not be permitted to cherry pick their way to bigger profits at a time of great national emergency.

https://www.independent.co.uk/news/health/coronavirus-nhs-waiting-times-surgery-privatisation-a9550831.html?amp

Doctors in Unite statement 28/06/20