One Stop Shops – trick or treat?

The media recently highlighted the fact that NHS England has announced:

The NHS is set to radically overhaul the way MRI, CT and other diagnostic services are delivered for patients . . . . Community diagnostic hubs or ‘one stop shops’ should be created across the country, away from hospitals, so that patients can receive life-saving checks close to their homes. The centres could be set up in free space on the high street or retail parks.”

“The need for reform of NHS diagnostics was recognised in the Long Term Plan” – so begins the recent report by Professor Sir Mike Richards, ‘Diagnostics. Recovery and Renewal’.

The key recommendations are:

  • Acute and elective diagnostics should be separated wherever possible to increase efficiency.
  • Acute diagnostic services (for A&E and inpatient care) should be improved so that patients who require CT scanning or ultrasound from A&E can be imaged without delay. Inpatients needing CT or MRI should be able to be scanned on the day of request.
  • Community diagnostic hubs should be established away from acute hospital sites and kept as clear of Covid-19 as possible.
  • Diagnostic services should be organised so that as far as possible patients only have to attend once and, where appropriate, they should be tested for Covid-19 before diagnostic tests are undertaken.
  • Community phlebotomy services should be improved, so that all patients can have blood samples taken close to their homes, at least six days a week, without needing to come to acute hospitals.

Motherhood and apple pie

On the surface of it, these are laudable aims that have been welcomed by hospital bosses. The COVID-19 pandemic has had a devastating effect on management of non-covid conditions with, for example, a 75% reduction in cancer referrals and a reduction in 210,000 imaging procedures each week. Before the pandemic there were 30,000 patients who had waited longer than 6 weeks for a diagnostic test, a figure that has now increased to 580,000. Urgent consideration must be given both to how the NHS is put back on its feet and how it addresses the huge backlog of problems as well as the ongoing pandemic. There is logic in separating acute and non-acute service provision into covid and covid free areas, and who could object to patients having convenient and rapid access to the best available technology? This does of course depend on many factors, not least having an efficient coronavirus testing system at some point in the future, but raises other crucial issues.

Where will the staff be found?

The plan as set out requires the recruitment of around 11,000 staff including 2000 radiologists, 500 Advanced Practitioner radiographers, 3,500 radiographers, 2,500 assistant practitioners, 2,670 administrative staff and 220 physicists. Bear in mind the current staffing crisis on the NHS, with around 140,000 vacancies across the board exacerbated by low pay and workplace stress. Cancer Research estimated that staff would need to double by 2027 to meet demand, with one in ten posts in diagnostics unfilled at the start of the pandemic. Furthermore, massive investment in equipment will be needed. The report points out that in relation to the 20 other countries making up the Organisation for Economic Cooperation and Development, the UK ranks bottom for CT and 3rd from last for MRI scanners. The Clinical Imaging Board claims that nearly 30 per cent of the UK’s MRI stock is at least ten years old, with no replacement plans for almost 40 per cent of systems more than seven years old.

All that’s left to find – money and staff

The last settlement for the NHS was £20.5 bn, which over a five year period amounted to an annual increase in budget of 3.4%. This did not include funding for training and employing the staff of the future. Most commentators thought a minimum 4% increase in funding was needed, and the Office for Budget Responsibility put the figure at 4.3% in order to meet increasing demand. COVID-19 has now blown all these estimates out of the water with the additional costs of restarting and sustaining the service, dealing with COVID-19 long term and developing and implementing a workforce transformation.

Private sector – the spectre lurking in the wings

In Simon Stevens’s letter to health care providers in July this year, he mandated:

Ensuring that sufficient diagnostic capacity is in place in Covid19-secure environments, including through the use of independent sector facilities, and the development of Community Diagnostic Hubs and Rapid Diagnostic Centres”.

As pointed out in The Lowdown in a comment on diagnostic hubs:

“References . . . to high street and retail park sites are possibly of no real concern – perhaps they’re more about exploiting cheap-to-rent locations during the pandemic-driven economic recession than a push to link-up with high-profile brand sponsors – but the well-established presence of private sector interests operating in the diagnostic and pathology arena suggests there may be rich pickings on offer somewhere in the hub programme, if only until the backlog is cleared”.

In fact the privatisation of diagnostic and laboratory facilities is already well underway. There is no comfort here in Professor Richard’s report which even cites as a case study:

The East Midlands Radiology Consortium (EMRAD) was launched in 2013 to create a common digital radiology system. Pioneering work led to the development of a Cloud-based image-sharing system through which the seven NHS trusts involved in the partnership could share diagnostic images, such as X-rays and scans. In 2018, EMRAD formed a partnership with two UK-based AI companies, Faculty and Kheiron Medical, to help develop and test AI tools in the breast cancer screening programme in the East Midlands.”

There is no mention of the fact that EMRAD paid £30m for the picture archiving and communication system from GE Healthcare but refused to pay full service costs until GE sorted out chronic problems causing a dangerous backlog of CT and MRI images.

Like many of the aspirational service developments contained within the Long Term Plan, ‘one stop shops’ could offer real value to patients. As the report by Professor Richards recognises:

These new services will require major investment in facilities, equipment and workforce, alongside replacement of obsolete equipment. Training of additional highly skilled staff will take time but should start as soon as possible. International recruitment should be prioritized.”  

This is no small ask and needs to be part of a generous new funding settlement for the NHS by government.  This should be an investment in the NHS as a public service rather than a source of rich pickings for private companies.

This article was written by John Puntis for Keep Our NHS Public

COVID-19 update 7 September 2020 – still stumbling along

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.

3. Disillusionment

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.

8. Treatments

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.

9. Vaccine

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.

Private providers must serve the public interest

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

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

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

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

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

There must be no profiteering from Covid-19.

We demand:

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

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

Doctors in Unite statement 28/06/20

Thoughtlessly placed DNARs do harm to patients and doctors

Doctors in Unite reiterate our opposition to any scoring system being used as a blanket cut-off to people accessing hospital care. We understand that conversations with patients about their wishes with regard to treatment and end of life care can be very helpful to ensure dignity in dying, but these must be undertaken with the utmost sensitivity, and with the best interests of the patient and their loved ones at its core.  These conversations must never be a means of rationing care or of ticking a box in a care plan.

We are increasingly concerned to hear of incidents across the country during the COVID-19 pandemic, where patients who score above a threshold on various frailty indices have had conversations with health care workers in which the patient felt pressurised to agree to a DNAR and to give up the right to be admitted to hospital. Health care workers often feel that they are responding to official guidance and that they have no choice but to comply. This is fundamentally wrong. Health care workers must always place the interests of their patients as their main obligation and duty.

Of course not everyone will benefit from intensive procedures such as ventilation, but even the most frail may benefit from less interventionist treatment such as specialist assessment, symptom control, antibiotics or oxygen. It has been reported that the bed occupancy in some NHS facilities is lower than usual. Despite this thousands of people are dying in care homes, some of whom may have benefitted from hospital admission.

We restate our conviction that every life is of equal value. There must be no arbitrary thresholds above which treatment is withheld, and no one must feel coerced into forgoing treatment which is their right out of guilt that there are not enough NHS services to go around, especially when there is reported to be capacity in NHS hospitals.

Dr Jackie Applebee is the chair of Doctors in Unite

Doctors in Unite statement on payouts for those who die in service with COVID-19

It is an insult for the government to claim that a life assurance pay out of £60,000 to the families of a health or social care worker who dies of COVID-19 in any way compensates for the loss of life.

Despite their protestations that they “will do whatever it takes”, this again shows the scant regard the government has for frontline workers.

It follows the abject failure to ensure that staff are properly protected at work, and a testing and contract tracing regimen that is too little, too late. The government has now neglected to correct historic inequalities in the provision of death in service benefits.

On April 27th Matt Hancock announced the £60,000 payout. But the conditions that go with it are an insult to those who are lost and those left behind.

One of the criteria is that the deceased must have been in work within two weeks of developing symptoms.

We do not yet know enough about COVID-19 to be able to confidently state that the longest period from exposure to symptoms is fourteen days.

Many health and social care workers do not qualify for full death in service benefits. These include people who have opted out of the NHS pension scheme due to an inability to afford contributions, or because their jobs have been outsourced to the private sector. 

GP locums who die on a day they are not in work, and retired health and social care workers who have generously returned to work during the pandemic are also not eligible for the full amount.

Widowers will also only receive a pension based on their spouses membership of the pension scheme after 6th April 1988.

Families of those with less than two years membership of the pension scheme will receive no short term pension or long term adult dependants/child’s pension.

Full death in service benefits should extend to all health and social care workers regardless of bureaucratic caveats. The criteria that the deceased must have been in work two weeks before developing symptoms should be dropped.