Doctors in Unite sent the letter below to Professor Allyson Pollock and colleagues, in support of their letter to Liverpool MPs questioning the rationale for mass testing of the people of Liverpool. A link to their letter, and a BMJ blogpost by Dr Angela Raffle, Consultant in Public Health appears below our letter.
9th November 2020
To: Allyson Pollock, Professor of Public Health, Newcastle University; Anthony J. Brooks, Professor of Genomics and Bioinformatics, Leicester University; Louisa Harding-Edgar, General Practitioner and Academic Fellow in General Practice, Glasgow University; Angela E. Raffle, Consultant in Public Health, Honorary Senior Lecturer in Public Health, Bristol Medical School Department of Population Health Sciences, University of Bristol; Stuart Hogarth, Lecturer, Department of Sociology, University of Cambridge.
CC: Dr Matt Ashton, Director of Public Health, Liverpool.
Dear Allyson, Prof Brooks, Dr Harding-Edgar, Dr Raffle and Dr Hogarth,
Doctors in Unite would like to support your letter expressing concerns about the mass testing for COVID 19 in Liverpool.
We are surprised that Dr Ashton, Director of Public Health for Liverpool is enthusiastic about the pilot and would be interested to hear his reasoning. If there is more detailed information which has led him to this conclusion, that we are not party to, we would be willing to reconsider our position in the light of any such evidence.
We believe that there is a place for testing of a sufficiently-sized random sample of individuals if it is to determine more accurately the prevalence of COVID 19 in society, in fact we called for this early on in the pandemic, it is in place nationally and could usefully be augmented to generate local results. However opening the testing to everybody detracts from the randomness of the sample, which becomes self-selected, and creates a significant issue of false negative test results which needs to be considered.
Mass testing with the aim of suppressing the virus, without adequate Test, Track, Trace, Isolate and Support is in our view unlikely to be successful. As you point out even a very small false positive rate will mean that people who are not infected will be told to self-isolate and there will be a larger number of these individuals and their families the more people who are tested. Without income protection many people are likely to decline to be involved.
We believe that the Westminster Government response to the COVID 19 pandemic has been appalling and that many lives have been unnecessarily lost. It is time for the Government to abandon their populist approach and to start to be led by the science.
A review of where the UK is in its response to the Covid-19 pandemic
1. Policy failure
Richard Horton, editor of the prestigious medical journal ‘The Lancet’, described the management of COVID-19 as the “greatest science policy failure for a generation” in his book on the pandemic. Currently the numbers of newly diagnosed patients are steeply rising with many wondering if the government has completely lost its grip. So – four months after Johnson showed his remarkable grasp of the scientific narrative by declaring: “If this virus were a physical assailant, an unexpected and invisible mugger (which I can tell you from personal experience it is), then this is the moment when we have begun together to wrestle it to the floor” – where do things stand?
2. Increasing number of positive test results
In July, the lowest number of daily new positive tests recorded was 574; by 6th September 2020, this had risen alarmingly to nearly 3000 on each of two successive days, showing a sudden increase of around 50% just as schools were reopening and more workers being coaxed back into workplaces. Over the preceding few weeks, European countries such as France, Germany, Spain and the Netherlands had all seen a sharp rise in new cases, with 40% being in the younger age group. In the UK, the change in new diagnoses from predominantly elderly people to the young was even more apparent, with two thirds being in this demographic, including the steepest increase seen in 10 – 19 year olds accused of not observing social distancing.
Meanwhile those with symptoms were often being told they will have to drive long distances, sometimes over a hundred miles, just to get a test. For many, this is simply not feasible, while for those who do make such a journey there is the risk of spreading infection further. At the same time statisticians have started to model the effects of NHS winter pressure combined with a second peak of coronavirus and predict that more than 100 acute hospital trusts will be operating at or above full capacity. A survey by the Doctors’ Association UK found that over 1,000 doctors were planning to quit the NHS through disillusion with the government’s management of the pandemic and frustration over pay. Recent national demonstrations calling for pay rises suggest many other NHS staff share these concerns and are prepared to take action.
4. Coronavirus endemic in some cities
A new public health report leaked to the press highlighted that COVID-19 was entrenched in some northern cities, and that case numbers had never really fallen to low levels during initial lockdown. This situation was strongly associated with deprivation, poor and overcrowded accommodation and ethnicity. New cases diagnosed per 100,000 population/week varied widely round the country at 98 in Bolton (topping the league), 37 in Manchester, 29 in Leeds, and only 3 in Southampton. The implication was that local lockdown measures were not likely to be any more effective in suppressing new infections and that there was an urgent need for a new strategy including better and locally tailored responses. These should include effective ‘find, test, trace, isolate and support’ (FTTIS) systems under the control of local authorities, many of which are in despair over their poor funding, and the hopeless performance of national ‘test and trace’. Given over at huge cost to the private companies Serco and Sitel, these are still only successfully contacting 50% of contacts of known cases, a figure that, according to the official Scientific Advisory Group for Emergencies, should be at least 80%, with all these contacts then going into isolation.
5. Broader lessons
Other lessons to be learned relate to financial support for workers and isolation of those living in overcrowded housing. It is simply no good (i.e. it is ineffective as an infection control measure) to expect low paid workers often with little or no financial reserves to self isolate for two weeks with either no pay or derisory statutory sick pay – full pay must be given by employer or government. In addition, people in densely packed housing cannot effectively self isolate, and as in some other countries, need to be temporarily housed in suitable alternative accommodation. This might be reopened hotels, or the almost unused Nightingale hospitals for those with mild symptoms.
6. is london different
One question of interest is why figures have not jumped up in London where the number of new cases in different areas is between 6 and 18/100,000/week. Possible explanations are that London was initially hit very hard by COVID-19 and as a result people have remained more cautious. For example, many Londoners who are able to work from home have decided not to heed government advice to return to office buildings. Geographical disparities in numbers of cases probably also reflect the fact that in northern cities such as Bradford, Oldham, and Rochdale, there is a relatively higher proportion of the workforce in more public facing roles such as the National Health Service, taxi services, take away restaurants, etc. Antibody testing (carried out regularly on samples of the population) also indicates that something like 17.5% of Londoners have been infected compared with 5-7% in the rest of the country. Although this is far from ‘herd immunity’ (which would require about 70% of the population to have been infected) it may mean that rapid increases in numbers of infection is at least initially delayed.
7. Airborne spread
There is now considerable support for the idea that an infected person can spread the virus over long distances through the atmosphere, although at the early stage of the pandemic this notion was rejected (hence the 2 meter social distancing advocated as being safe). There is an increasing body of evidence confirming aerosol spread of virus, and this is well illustrated in food processing plants. Detailed investigation of the huge German meat factory outbreak showed spread of virus came from a single worker in the factory, with infection transmitted over 8 meters and more, and did not represent community acquired infection being brought in simultaneously by a large number of employees. The implication is that environmental conditions and effective ventilation are crucial to preventing spread of COVID-19, but unfortunately government guidelines as yet do not acknowledge this issue or provide appropriate guidance – a clear example of following far behind the science.
Government strategy is reliant on the development of effective treatments and a vaccine; this in part explains the half-hearted approach to contact tracing. Lessons learned in the pandemic have reduced the numbers of patients that die once admitted to hospital, and this relates to use of oxygen delivery via a tube in the nose rather than one in the windpipe requiring the patient to be paralysed with drugs and breathing performed by a ventilator machine. Studies have also shown that giving a powerful anti-inflammatory steroid drug improves survival. As the number of patients has fallen considerably, less pressured staff also have more time to give better quality care. There is no basis for the suggestion that coronavirus has become less virulent; if it were to mutate, there is also the possibility it may become more rather than less harmful. The most likely explanation for rising case numbers overall with little change in hospital admissions and deaths is the fact that new cases are now predominantly in younger, fit people, who are much less likely to develop severe disease.
A vaccine is being presented as a ‘silver bullet’ that is just around the corner, however this is not the right message to give. There are estimated to be 170 research teams working on developing a vaccine, and nine products have reached large scale trials. To frame vaccine development as some kind of race increases the risk that a vaccine which is not very effective or has serious side effects will be rushed into use and public trust destroyed as a consequence. This would be hugely damaging and illustrates the importance of good public health messaging and the imperative of not compromising on safety through political pressure to deliver or the thirst for company profit. More important to bear in mind, there has never been an effective vaccine against a coronavirus just as there has never been an effective vaccine developed against HIV.
10. Fairy tales and reality checks
The Westminster government continues to choose to stumble on through the pandemic in the hope that a vaccine or effective treatment will arrive like a knight in shining armour, effect a rescue and bring us back to what was once normality. There is precious little reason to think that this is a sound strategy. Its cavalier approach to managing this unprecedented health emergency has included closing down Public Health England on spurious grounds – likened to taking the wings off a malfunctioning aeroplane in mid-flight in order to ensure a safe landing. Basic demands from the public must continue to be for an effective FTTIS system, nationally coordinated but locally delivered and aimed at complete disease suppression; much improved testing, including local testing units and rapid turn around of results; investment in NHS infrastructure and ending the obsession with inefficient and expensive private contracts; honesty and transparency to win public trust and unite the young and old in a common purpose. Sadly, a conservative government characterised by antagonism to public services and one that prioritises business interests over public health is unlikely to be either self critical and learn from experience or to implement positive changes such as those outlined above. The price for wearing such ideological blinkers will be more suffering and more economic damage as COVID-19 once again inevitably spreads like wildfire through our communities. Perhaps it is only a massively increased death toll that will make it change course.
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.
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:
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.
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
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
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.
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.
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.
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
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.
How effectively have different public services shared data during the outbreak?
Others will be better qualified to comment on this question than we are.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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
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
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).
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.
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.
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.
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.
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.
We are writing to ask you urgently clarify our Covid-19 strategy. Herd immunity was abandoned early on as it became clear hundreds of thousands would die. We entered lockdown in order to “flatten the curve” under the slogan: “Stay at home – Protect the NHS – Save lives”. Despite high levels of ongoing viral transmission, lockdown is now being eased with the injunction: “Stay alert – control the virus – save lives”. Slogans, however, 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. We need an overall strategy for the UK, that is agreed with all the Devolved Nations. It must be flexible to allow for regional differences and decision making with a clear framework for how such decisions will be made.
Colleagues in Ireland, north and south, have set out a very clear vision of what must be done. We face the same choice: either live with the virus under a long-term mitigation / containment strategy waiting (possibly forever) for a vaccine or effective antiviral treatment, or suppress and eliminate new infections. They designate the latter approach “Crush the Curve”. Mitigation means accepting an ongoing toll of illness and lives lost, and living under the constant threat of local surges and possible national waves of infection and deaths. It also means public transport running at minimal capacity, insurmountable challenges for schools, businesses and services to run properly, indefinite restrictions on gatherings and socialising, and an NHS which will collapse under the combined weight of Covid-19 cases and the huge backlog of untreated patients with cancer and chronic conditions.
It appears to us that the Westminster government has chosen the path of mitigation, characterised by the analogy to the arcade game ‘Whac-a-mole’ where infection is expected to keep ‘popping up’ and those in charge do their best to guess where to put limited resources. Once more this is a slogan and not a strategy.
Many countries have successfully chosen to suppress the virus and eliminate infections, including South Korea, New Zealand, Australia, Austria, Greece, China and Iceland. Their people are once again using public transport, returning to school, going out to eat and to shop, with healthcare systems caring for all patients, not only those with Covid-19, and economies already recovering. They demonstrate very clearly that eliminating the infection represents the best strategy in terms of both public health and protecting the economy.
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.
We should be prepared to learn from other countries so that our people can also enjoy the considerably greater freedoms and prosperity this will bring. Travel, tourism, and trade with such states would be straightforward and beneficial. Our children will be back at school, vulnerable citizens and precious key workers protected. The sacrifices made so far have reduced the number of new cases and deaths significantly, but a nadir has been reached with current measures, and we may now even be seeing a rise in infections. The national R value is perilously close to one and it is a question of when, not if, flare ups will occur, or even worse a second wave engulf us once again.
We think it is time for the government to develop and communicate a clear strategy and declare which path all of the UK will follow at this critical juncture.
June 1 2020 heralded the official start of the easing of the lockdown that has been in place since 23rd March to try to contain the spread of Covid 19.
The current reality is that due to the Westminster Government’s repeatedly vague and confusing messaging, compounded by their unwavering support of the Prime Minister’s rule breaking Chief Advisor, Dominic Cummings, people are already relaxing social distancing.
We have now known about the threat from Covid 19 since January this year, and through the lens of the media watched it heading our way via Iran, Italy and other countries. The UK had more time than most to prepare, however this opportunity was squandered by the Westminster Government.
Instead of learning from the experience of other countries and making sure that key workers had sufficient personal protective equipment and that time honoured locally coordinated test, trace, isolate and support programmes were in place to contain the spread of the virus, Boris Johnson glibly announced that the UK’s strategy would be one of developing herd immunity (a form of indirect protection from disease that occurs when a large percentage of the population has become immune) and that we should prepare ourselves for our loved ones to die.
Soon after, Imperial College published modelling which showed the NHS would be overwhelmed by Covid cases if more stringent measures were not put in place.
The Government publicly abandoned their herd immunity strategy and the UK went into lockdown. Over two months later, following a shockingly high peak in early April, the daily death rate and reporting of new cases has declined significantly, but not enough to suppress the virus to a level that makes it safe to start to open up schools and businesses.
The much heralded national contact tracing scheme is beset with problems and unlikely to be up and running (let alone working well) before the end of June at the earliest. Meanwhile, local projects are being held back, starved of resources and undermined.
We must ask ourselves why our Government have careered from one position to another during the Covid 19 crisis, seemingly out of control and always on the back foot. They, like anyone else, can be forgiven for the odd mistake, but this has had the appearance of a complete shambles. They have the more conservative of the best scientific minds at their disposal and experience from other countries which were beset by the virus before the UK to draw on.
So why has their response been so seemingly incompetent and why are they now insisting that it is safe to ease lockdown when the evidence suggests that this will trigger another viral surge? Could this be construed as akin to corporate manslaughter?
We believe that the Westminster Government has been forced by events to address the health of the public in this crisis but has done so through gritted teeth because it is at odds with their ideological programme of dismantling the welfare state. For them the crisis is also an opportunity to expose more public services to privatisation. This is why they have so vigorously prevented NHS laboratories and local public health teams from expanding their services appropriately to meet the demands of the pandemic, instead choosing to contract with Tory-contributing, multinational, outsourcing agencies like SERCO despite the fact that these companies’ incompetence and corruption in providing health care are well known.
Easing lockdown may “stimulate” the economy, but in the process thousands, if not tens of thousands of lives, especially those of the elderly, will be sacrificed as the virus surges again.
This is disgraceful and callous. Lives are far more important than profit.
We have said before that lockdown should not be eased until
Proper locally coordinated test, track, isolate and support systems are in place and shown to be working
There is financial support so workers do not lose income if they need to isolate
There is adequate ongoing supply of appropriate PPE for all key workers
None of these things are yet adequately in place.
History shows that pandemics have lethal subsequent waves.
We believe that to end lockdown in the current circumstances will lead to huge numbers of avoidable deaths as the virus surges again. When these deaths occur the question must inevitably arise – ‘was this corporate manslaughter?’
There is no rationale to the behaviour of the Westminster Government other than to put profit before people – we demand a change in strategy to put the health of the people first.
Richard Horton, respected editor of the medical journal ‘the Lancet’, aptly summed up the current pandemic in the following words: “Coronavirus is the greatest global science policy failure in a generation. Austerity blunted the ambition and commitment of government to protect its people. The objective was to diminish the size and role of the state. The result was to leave the country fatally weakened”. China implemented a lockdown in Hubei province on 23rd January in response to a new and severe respiratory infection. One week later the World Health Organisation declared a global emergency in recognition of what had become a worldwide pandemic. It then took nearly two months for the UK government to grasp the seriousness of the problem and to implement social distancing and isolation. This delay has led to many unnecessary deaths.
Despite there being core public health principles of “test, isolate and contact trace” in response to an epidemic, this process has not been implemented in the UK. There was talk of ‘herd immunity’ as an alternative strategy, but scientists then pointed out this could mean hundreds of thousands of deaths before the infection was under control. A panicked government decided to abandon its irrational belief in ‘British exceptionalism’ and on 23rd March instituted a lock down of sorts, with people encouraged to stay at home, and most businesses closed down. News footage still showed London underground packed with people and construction workers as key workers were expected to turn up for work as usual.
Unrecognised dangers included the risk to the elderly living in care homes together with their carers, the risk to bus drivers and other key workers with public-facing roles in the community. The fact that many workers on zero hours contracts and those outsourced from the NHS and not entitled to sick pay would be forced to continue to go to work even if ill. Sick and elderly patients were discharged to care homes only to spread infection without having been tested for the virus, and outrageously, ‘do not attempt cardio-pulmonary resuscitation’ orders proliferated for pensioners and those with learning difficulties or disabilities often without discussion. The official death toll has gone up to above 20,000 – but these are confirmed deaths in hospital and there may be at least as many again in the community without a definitive diagnosis.
In the meantime, countries like Singapore, South Korea, New Zealand and Germany, which rapidly instituted widespread testing and contact tracing were demonstrating a much lower number of cases and deaths. While the UK government kept promising more testing, numbers grew painfully slowly. Centres specially created to test key staff were set up by the accountancy firm Deloitte, given the contract without it going out to tender under obscure legislation passed in 2015. As usual, reports of problems with lost samples and mis-communication of results followed, just as the privatisation of NHS logistics caused problems with distribution of personal protective equipment (PPE). Despite repeated reassurance from government ministers that stocks of PPE were available, this turned out not to be the case as week after week front line staff complained of being sent to war without the necessary armour. Around 132 NHS and care staff have now died from the disease and will be remembered along with many others on International Workers’ Memorial Day.
Worse still for government credibility were details of the unpublished Cygnus report from a 2016 pandemic planning exercise, and more from the 2019 National Security Risk Assessment, both showing that the government knew full well of the major risk posed by the likelihood of a new pandemic, and the need to stockpile PPE and equipment such as ventilators for intensive care, yet did nothing. As one commentator remarked: “We have been paying for a third-party fire and theft policy for a pandemic, not a comprehensive one. We have been caught out”.
Things which have assisted the pandemic response include the fact that we still have a ‘national’ health service and brilliant staff with a public service ethos. Things that have hindered the response include government reforms over recent years promoting marketisation, fragmentation, privatisation and outsourcing. NHS England has rightly taken over commissioning functions from Clinical Commissioning Groups, and government has wiped away the £14 billion hospital overspend to let Trusts focus attention on doing what was necessary to fight the infection. The small private sector capacity was harnessed to assist the NHS. However, the huge PFI debt millstones remain in place, and private hospitals are only too happy to be subsidised to the tune of £2.3 million/day through block contracts- one of the businesses that will not now go under in the coming recession.
The hostile environment aimed at those migrants with uncertain immigration status not only meant the end to universal health care under the NHS, but now fear of being reported to the home office or financially charged will undermines planned contact tracing. This charging needs to be abolished now, as does the yearly surcharge of £625 for members of NHS staff coming from abroad, and each of their family members.
Government policies left the NHS in a weak starting position, with over 100,000 staff vacancies, cuts in bed numbers of 17,000 since 2010, and near the bottom of the European league table in relation to intensive care beds (half as many as Italy and around one fifth of those in Germany). The government will be constructing a narrative portraying themselves as victims of a natural disaster, doing their best in impossible circumstances and leading us all to victory in the war against Covid-19; in this they will be aided by large sections of the media.
Trade unionists must make sure that ministerial incompetence, arrogance and callous disregard for human life are not forgotten and there is a holding to account. When the pandemic is over, we cannot go back to how things were before. We need to take the public with us in demanding a return to NHS founding principles, a publicly funded, managed and delivered health service with democratic control, linked to a national social care service. Renationalisation of the NHS; proper funding; an end to PFI, the Health and Social Care Act and the Long-Term Plan for the NHS; and an end to outsourcing and privatisation. We are witnessing a tragedy unfold and a government scandal of momentous incompetence. The right lessons must be learned.
Dr John Puntis is co-chair of the campaign group Keep Our NHS Public.
The basic principles of epidemiology are summarised by CDCD: count, divide, compare, then discuss differences. Unfortunately discussion of COVID-19 has widely ignored this approach.
First, we must count something. Examples of things you might count include deaths, cases of disease, uses of a health service, occurrence of a symptom, or the presence of a risk factor.
Then we divide by the population at risk to produce a rate, or ratio. This could be an incidence rate, where new cases are divided by the population at risk. It could be point prevalence, where the total number of cases at a given point in time is divided by the population at risk.
We can determine mortality rate by dividing the total number of deaths by the population at risk of getting the disease. Fatality rate is the total number of deaths divided by the total number of people who have caught the disease. The standardised mortality ratio is the total number of deaths divided by the number of deaths to be expected, by applying expected mortality rates to the population at risk.
We then must compare different populations, and different subsets of the population.
Finally we discuss the differences, considering not just the explanation that fits a particular, preconceived theory, but the wide range of possible confounding factors.
To count COVID-19 properly, we would need to test widely. It would be extremely helpful to repeatedly test a stratified sample of the population to measure the true incidence and prevalence of infection, and the changes over time within subgroups.
Some antibody tests have been judged not to be accurate enough for diagnostic use because of false positives and false negatives. However, they may be accurate enough for statistical use if the results are not going to influence the behaviour or treatment of individuals, and if the inaccurate results have a predictable and unimportant effect on the statistics.
Until we have some measure of the incidence in the total population, it is impossible to calculate the fatality rate, or to assess the reasons for the gender and ethnic differences that are emerging in mortality rates. That in turn makes it impossible to consider a rational strategy for exiting the lockdown.
News reporters presenting accounts of the number of cases country by country may have remembered to compare, but they seem to have forgotten how to divide.
It is being widely reported that the US is performing worse than the UK in the coronavirus epidemic because it has twice as many deaths. As it has five times the population this is actually a substantially lower mortality rate, not a higher one.
Of course, when we discuss this difference, we might conclude that the lower rate is not due to the US doing better but to it being behind us on the curve. It may also be because cases are not counted properly, or because the rate is higher in some parts of the country, but yet to spread to the rest.
Why is the fatality rate lower in Germany? It may be due to a greater proportion of cases being counted. However, that would lower the fatality rate but not the mortality rate, so why does Germany have fewer deaths?
If it is because the incidence rate is lower, why? It has been suggested that the lower case-fatality might be because a greater proportion of infections in Germany are in younger people, but if that is the explanation, we must consider whether Germany has a younger population (which it does not), or whether older people are better shielded (this may be the case).
Why do men have higher mortality rates from COVID-19 than women? Is it due to behavioural differences like smoking rates, or intrinsic sex differences? Are the apparent ethnic differences real, or are they due to confounding factors like deprivation or environment?
All of these questions have implications for how we manage the epidemic. Unless we remember to count, divide, compare and discuss differences we cannot answer them. There is a lot of comparing and discussing going on. It will be idle speculation until we remember to count and divide.
Dr Steve Watkins is the vice-president of Doctors in Unite
The UK government has asked the General Medical Council to contact doctors who have retired within the last six years and grant them temporary registration, a licence to practice and return to the GP performers list or secondary care equivalent.
Without consulting the individuals concerned the GMC passed their details to local health services. Tens of thousands of retired doctors will be contacted, encouraging them to return to practice.
Doctors are able to opt out, but if they do choose to start working again they must be assured of protection.
Complete a short survey to help determine skills.
Complete identity checks including a declaration of honesty letter, Disclosure and Barring Service declaration, and occupational health questionnaire.
Have a choice in what work to be involved in.
Expect to be tested for SARS-Cov2.
Not be expected to work if they choose not to for any reason.
Not be expected to work if they have co-morbidities.
Not be expected to work in direct patient facing roles. This recognises that increasing age is most likely an independent risk factor for severity of illness. Several retired health care workers who returned to work have died. Early epidemiological data suggests that BAME health care workers may also be at increased risk.
Suitable roles include:
Telephone support for NHS 111.
Helping in out-patients or GP surgeries by telephone.
Backfill for clinicians in direct patient facing roles.
Training other clinicians.
Psychological support and mentorship for clinicians on the front line.
Support for public health and community roles e.g. contact tracing.
Employment working conditions as laid out by the four devolved governments , , ,  and GMC  guidance includes:
Suitable pay and remuneration.
Six month contracts of employment.
Employment by one organisation.
Death in service benefits.
Free government indemnity cover with advice and support from defence unions .
No need for revalidation.
Induction and suitable training including Information Technology.
Provision of suitable equipment including IT, laptops, mobile phones, smartcards and passwords.
Proper home working facilities.
Suitable Personal Protection Equipment (PPE).
The expectation to work within limits of competency and the right to leave at anytime by submitting a notice period of no more than a week.
We believe that all people are of equal value. Whether old or young, rich or poor, disabled or not disabled, we all share a common humanity. This was true before the coronavirus pandemic, and it remains true today.
Coronavirus is affecting different people in different ways. Many have a mild illness, but for some, it threatens their life. When severe disease strikes, there will be a choice about the types of treatment doctors offer. These decisions, though difficult, are made every day in hospitals and clinics across the country. Will a drug work? Will an intervention succeed? Or, will the side effects, the negative consequences, and the harms, outweigh the potential benefit to a person’s life?
Intensive care will not work for some patients. Ventilator support will sometimes not succeed. Doctors must judge who is most likely to improve with these measures, and who is not.
These decisions have previously always been made on a case-by-case basis, where the risks and benefits to an individual patient are carefully considered. The arbitrary condemnation of one group or another is inexcusable. Being old, living in a care home, or having a pre-existing disability should not lead to an automatic exclusion from possible treatment. Blanket categorisation of large groups of people in such a way is prejudice. There is no place for it in the NHS.
Rationing of care
There may come a time where our healthcare system is overwhelmed. But we have not yet reached that point. How we act now affects whether the country runs out of ventilators, oxygen, protective equipment, and medication. The single priority for all UK manufacturing must be the production of these goods. There is nothing more important. We must never reach the point where a person goes without a lifesaving treatment only because it is in too short supply.
The needs of those without coronavirus, but with other acute medical problems, remain despite the new pandemic. Their health must not be squandered while our attention is focussed elsewhere.
Informal palliative care
Families must never be placed in the position to go without the support of either community-based, hospice, or hospital-based palliative care for a dying relative. Many already act as carers for their loved ones. They should not shoulder the further responsibility of administering palliative care that would otherwise only be conducted by a trained healthcare professional. Palliative care staff should not be routinely redeployed to other parts of the health service during the pandemic.
The necessary shift to telephone and internet consultation presents a challenge in ascertaining objective measures of health. In normal times, a record of oxygen saturation would be a routine examination for a respiratory illness. It should be no different now. Pulse oximeters should be made widely available to all patients with coronavirus symptoms other than the most mild cases.
It is immoral to request that a health or social care worker looks after patients without appropriate personal protective equipment. It jeopardises the health of the worker and their patients.
Volunteers and the newly unemployed
Volunteers are not a substitute for qualified staff. Their generosity is humbling, but they must only be offered jobs that maintain their safety and the safety of patients.
The expertise of those now without work should not be squandered. Those with life support training and other transferrable experience may be utilised as key workers. Appropriate training, well-defined roles and written contracts must be always provided.
The immune response to COVID-19 is not yet fully understood. Immunity may be relatively short lived. Any policy that relaxes social distancing and isolation measures must be based on robust understanding. Using ‘immunity passports’ without evidence will be futile.
The improved civil liberties for those perceived to be immune would likely create social disharmony, and those still susceptible may seek out infection in order to resume their previous lives. This may well lead to many unintended harms.