Government ineptitude has undoubtedly led to many unnecessary deaths – they must be held to account

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 epidemiology of COVID-19: count, divide, compare, discuss differences

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

Doctors in Unite statement on retired health workers returning to work during the coronavirus pandemic

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.

They should:

  • 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 [1], [2], [3], [4] and GMC [5] guidance includes: 

  • Suitable pay and remuneration.
  • Six month contracts of employment.
  • Annual leave.
  • Employment by one organisation.
  • Pension protection.
  • Death in service benefits.
  • Free government indemnity cover with advice and support from defence unions [6].
  • 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.

[1]    https://www.england.nhs.uk/coronavirus/returning-clinicians/faqs-doctors/#do-i-need-to-be-included-on-the-nhs-england-medical-performers-list-the-list-to-work-as-an-emergency-registered-practitioner-erp-in-primary-care

[2]    https://gov.wales/doctors-returning-nhs-assist-covid-19-guidance-html

[3]    https://www.gov.scot/publications/coronavirus—returning-to-registered-professional-practice-guidance/

[4]    https://www.health-ni.gov.uk/Covid-19-returning-professionals

[5]    https://www.gmc-uk.org/registration-and-licensing/temporary-registration/information-for-doctors-granted-temporary-registration/returning-to-work

[6]    https://bma-mail.org.uk/JVX-6TQS5-S0FWOA-40RGIL-1/c.aspx

Medical ethics during the coronavirus pandemic

Treatment without prejudice

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. 

Secondary harms

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.

Telemedicine

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.

Unsafe working

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.

Immunity

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.

Despite coronavirus and clapping, the Tories remain hostile to a public NHS

In recent weeks we have among others seen Boris Johnson, Matt Hancock and members of the Royal family (all of whom it’s safe to guess have never used the NHS) joining in the public applause for key workers. Additionally, there have been a number of structural changes and commitments to increased funding that make it feel as if the strengths of a truly public National Health Service are now being acknowledged, together with an implied criticism of many of the reforms of the last near decade.

Taking over CCGs

On March 23rd it was announced that NHS England was taking on extensive special powers normally held by clinical commissioning groups to support efforts in the face of coronavirus. Dr. Tony O’Sullivan (co-chair of Keep Our NHS Public) commented on the NHS England website: “at this time of national tragedy, we should remember the function of a national health service and how politicians and the seismic restructuring policies in the Long Term Plan have weakened the NHS. I hope that this ends the fragmentation into 42 separate commissioning units and integrated care systems. How wrong that strategy has been. As we welcome some steps towards the re-integration of the NHS in our hour of need, let us not forget the follies that weakened it and that have put NHS staff and the public at risk. We need the NHS to go forward as a single coordinated public service, there for everyone in time of ‘war’ and nurtured once again in post-COVID-19 peacetime.”

Taking over the private sector?

These special powers will be in place until at least the end of 2020, and one of the principal reasons for them was to gain access to independent sector beds. Taking over the independent sector in times of national need is to be applauded. Spain for example has just requisitioned its large private sector. In stark contrast, however, the UK government is paying private hospitals £300 per bed per day. Business analysts have observed that this is a huge boost to independent hospitals. A private hospital working on an NHS tariff at 100% capacity is far better than conducting private medical insurance work at 50% capacity.

Abolishing debt?

The government announced that from April 1st it would “write-off” £13bn of historic debt across the NHS. In recent years financially struggling trusts have been routinely forced to seek emergency bailout loans from the Department of Health and Social Care. Last year, trusts’ total debts reached £14bn, of which £10bn was related to emergency loans. While Matt Hancock declared this a “landmark step” made by himself to help the NHS COVID-19 response, the plans had in fact already been discussed at a January meeting called by NHS England and NHS Improvement, and had been under consideration for at least 20 months. 

As tax expert Richard Murphy explains, the government has not written off hospital debt. “All it did was make a book-keeping adjustment. What it actually did was allow NHS trusts to record the sums they had spent for the populations they served as having been funded by central government when previously the government were claiming they had overspent.”

John Lister writing for the KONP website also noted that “it’s like a gang of burglars seeking gratitude after handing back some of the jewels they have stolen. £13.4bn averages to a refund of just £1.3bn per year for the last ten years – far less than the real terms cuts that have been imposed by the virtual freeze on funding while the population and its health needs have grown.” It would be much more valuable to the NHS if the government were to write off the huge outstanding payments for new buildings paid for through the Private Finance Initiative, but strangely, Rishi Sunak does not seem to be stepping forward with this proposal.

Xenophobia is alive and well

Before the pandemic, the UK had only 4100 critical care beds, 6.6/100,000 population compared with Germany’s 29.2. An urgent need to find more ventilators was identified at the start of the outbreak, yet Downing Street chose not to participate in an EU scheme to source such vital equipment, leading to the charge of putting “brexit over breathing”. The government’s attempts to justify this through claims of having accidentally missed a deadline due to communication errors were quickly exposed as groundless by EU officials.

Despite the need for both trust and a unified response to the crisis by members of the public, it is notable that the hostile environment in the NHS has not been lifted. As one member of KONP writing in the British Medical Journal observed, “it is simply not good enough for the UK to add the novel coronavirus to its list of exemptions from charges, which few people will know. To tackle this epidemic and protect everyone’s health, all barriers to accessing NHS treatment – including charges and reporting of debt to the Home Office – should be suspended immediately.”

References to COVID-19 as the ‘Chinese virus’ and promising a reckoning with China after the pandemic are diversions of attention from the failings of our government ministers. Zoonoses (infectious diseases that spread from animals to humans) are linked to climate change and intensive farming methods among other things, and are destined to be a recurrent event. Michael Gove would do well to reflect that not long ago Bovine Spongioform Encephalopathy resulted in the slaughter of 4.4 million cows in the UK and was responsible for variant Creutzfeldt-Jakob disease in humans. The World Health Organisation has warned against use of the term ‘Chinese virus’ saying that it could lead to racial profiling against Asians when “there is no blame in this”. In the UK we have already seen reports of Asian people being physically attacked in the street. 

What next?

Writing in the nineteenth century in his book The Housing Question, Frederick Engels made a highly relevant comment on the self-interest that motivates those who are in control of society through virtue of their wealth and position. “Capitalist rule cannot allow itself the pleasure of creating epidemic diseases among the working class with impunity; the consequences fall back on it and the angel of death rages in its ranks as ruthlessly as in the ranks of the workers.” 

Having said that, the competence of the ruling elite in preventing and controlling epidemics is always in doubt, since their desire for profit is in opposition to any inclination to spend money on public services until it is too late. Thus an opportunity to avert a crisis is lost, and a pandemic that could have been limited if planning advice had been implemented and intervention had been timely must instead run its miserable course. We have known for the past 13 years, for example, that a pandemic at least as lethal as coronavirus represented an ever present major threat.

At the same time we can be sure that history will be busily rewritten in order to exculpate ministers and make sure any temporary steps towards ‘nationalisation’ of services are quickly reversed. There may even be calls to continue the restrictions on civil liberty for much longer than the medical situation necessitates. 

Charles Moore (former editor of the Daily Telegraph, where he was Boris Johnson’s exasperated boss) is jockeying for position in this vanguard, explaining to readers that it is in fact deficiencies in the public sector that has brought the country to lockdown. In a sense Moore is correct, but for the wrong reasons. It is the underfunding and weakening of the NHS at the hands of the Tories that has made it much less able to deal with the current crisis, making lockdown even more crucial in order to limit demand. We can also expect to hear from other ideologues about how our small and parasitic private sector came to the rescue of the NHS in its time of need.

However much the Tories are now clapping for our NHS, we must remember that they are fundamentally opposed to public services, and will soon forget their panic and revert to form. A former Tory insider, now disillusioned with the world view that anything funded by the state is wrong (except of course infrastructure that furthers the interests of the rich), has written a tell-all piece stating as much.

Our job as health campaigners is to now make sure the right lessons are learned during the coming weeks and months. We need to keep the Tories on the hook, and harness the public anger which will no doubt grow over time. We must rally the vast majority of society around our vision of a health and social care service that exemplifies a more just, equal and caring society. 

Dr John Puntis is a consultant paediatric gastroenterologist, the co-chair of Keep Our NHS Public, and a member of Doctors In Unite.

Demands in response to COVID-19


The challenge of coronavirus requires a radical response. We will overcome this virus, but current legislation falls short – much more must be done. We demand:

Full PPE

This must include FFP3 masks, visors/protective spectacles, fluid resistant gowns with sleeves and gloves for all health and social care workers dealing with patients and service users who have or are suspected to be infected with COVID-19. This is vital to prevent staff going off sick en-masse leaving no one to care for patients.

Widespread testing

Whole population testing for COVID-19 is essential, with particular attention paid to health and social care workers. Isolation and follow up of identified cases with rigorous contact tracing is crucial.

Laboratories in hospitals

Full pathology laboratories should return to hospitals. Cuts and privatisation of labs have reduced the capacity for testing so that when they are needed the system cannot cope.

Public control of private hospitals

Private health care facilities must be taken under public control and made available to assist the NHS in caring for ill patients.

Public control of industry

Key industries must be taken under public control and repurposed to manufacture equipment that is essential to deal with the outbreak of COVID-19, such as PPE, ventilators and antibiotics. 

An end to needless competition

The protection of intellectual property rights for key equipment such as ventilators must end, so that companies can collaborate to produce them. There is no place for the pursuit of profit and competition between companies during a national crisis. 

Support for staff to work remotely 

Guidance on confidentiality and data security should be rapidly produced. Investment in IT should take place to enable all those who need to work from home to do so. 

Protection and recompense for retired workers returning to work

Retired workers returning to the NHS deserve the proper provision of PPE and COVID-19 testing. Older people are more vulnerable to the virus, and will need thorough protection. 

Full pay when self-isolating

All UK workers who are off sick or self isolating due to COVID-19 should be paid as if they were in work. No one should be under financial pressure to work when government advice is that they should be at home. Previous record of days off sick should not be an impediment to this principle.

Universal basic income

Universal basic income must be made available for all in line with the living wage for the period of the crisis. This would be in place of all other benefits, universal credits or employment support.

Retraining for the newly unemployed

Those who have lost their jobs should be offered free retraining in roles that support our society and infrastructure during the pandemic. This could include medication delivery, care work, and supporting the socially isolated.

Universal access to essential services

Everyone should to be able to access the essentials that they need, including food and shelter. The homeless should be accommodated in empty hotels and houses. Supermarket stocks should be centrally managed and provisions distributed so that everyone can have what they need. 

Proportionate, time limited emergency laws subject to regular review

While being clear that everyone must be able to access what they need, there is a fine balance between ensuring equity of distribution and infringements of people’s reasonable rights and liberties. All new legislation that curtails civil rights must be limited in scope, be regularly reviewed, and should include a sunset clause.

Comprehensive support for vulnerable health groups

Services for the homeless and those who suffer from substance misuse must be maintained. These are vulnerable groups who are at high risk of complications from COVID-19 infection. They are often hard to reach and should be provided with phones so that key workers can maintain contact while working remotely.

Comprehensive social care

Disabled people are vulnerable and their needs must be properly met. They are at particular risk if their carers become unwell. Those who have accepted personal budgets are particularly at risk. Services must continue for them in all circumstances. 

An end to overseas charging

NHS eligibility checks for migrants leads to them not accessing healthcare as frequently. It is vital that during a pandemic, everyone gets the care they need. Charging overseas visitors for NHS care must be stopped and the legislation that allows this abolished.

Extended rent and mortgage payment holidays

Suspend rent and mortgage payments for all NHS and social care staff. No health or social care worker should be anxious about living costs. Many are at risk of losing household income if their partner loses their job. The current three month mortgage holiday should be extended to at least six months.

Psychological support for health and social care workers

Psychological support services should be provided at no cost for NHS and social care staff caring for patients during the period of the pandemic crisis.


We the undersigned support these demands and urge their adoption by the government as quickly as possible: