Speech by Dr Jackie Applebee, Chair of Doctors in Unite to the BMA Annual Representative Meeting, 15 September 2020

Dr Applebee proposed the motion by TOWER HAMLETS DIVISION of the BMA: That this meeting, in response to COVID 19, demands that government:

i) ensure that workers are not under pressure to attend work either for financial or workforce reasons while they are unwell or self-isolating and at risk of inadvertently passing on the disease;

ii) provide the equivalent of day-one statutory sick pay to those on zero hours contracts;

iii) allow the NHS to requisition private health care facilities to accommodate effective COVID-19 treatment and quarantine provision if needed;

iv) ensure workers are paid in full while they are unwell or self-isolating.

With respect to point iii)

The COVID 19 pandemic has surely blown the myth that private is good and public is bad.

We have heard repeatedly today how the NHS has stepped up to the plate to deal with the crisis, though years of an unprecedented funding squeeze has led to the collateral damage that Chaand (Dr Chaand Nagpaul, Chair of the Council of BMA) referred to earlier of  those whose other health needs could not be met due to the lack of slack in the system.

On the other hand outsourcing to the likes of Deloitte and Serco has led not to the world beating test trace isolate and support system trumpeted by Boris Johnson, but a wholesale fiasco where people are having to drive miles to get a COVID test and where, despite the billions spent, the global multinationals cannot do as well with contact tracing as the very poor relation that are local public health departments.

Private hospitals were handed hundreds of millions back in March to increase capacity to deal with COVID 19 but they were largely unused, gifting a nice windfall to their shareholders at a time when their usual work had all but dried up.

Now they are likely to commissioned to help with the backlog of NHS care. Don’t get me wrong the backlog needs to be cleared, patients need their treatment, but the private sector should not be able to profit from this. They should be brought into the NHS family and their activity now should be offset against the money they were given in March. There must be value for public money spent.

The fact that the NHS had to shut down everything except dealing with COVID in March is a stark illustration of the chronic underfunding and that there has to be spare capacity inbuilt into the system to deal with crises. The extra money thrown at the system should have been thrown at the NHS not the private sector.

With respect to points i), ii) and iv):

If we are going to crush COVID, really get on top of it, we need people to be able to afford to stay at home and isolate if they are in contact with an index case. If there is enough money in the economy to subsidise eating out there is surely enough to guarantee that if someone is in quarantine that they are paid in full.

Many of the lowest paid, for example cleaners, refuse collectors and care workers, many of whom have looked after patients with COVID, often of precarious zero hours contracts, cannot work from home, and to make ends meet many of them have two jobs. They need to be reassured that they wont’ lose out financially if they stay off work otherwise they will have no choice but to go in and the virus will continue to spread.

Covid is with us but Government could do so much more to minimise it’s devastating impact.

The pandemic has surely underlined the huge value of publicly funded, publicly provided health service which is free at the point of delivery and the demonstrated the dedication of the staff who work within the NHS and Social Care.

As has been said today already, we have an opportunity to reshape the future, it’s up to us whether we grasp the nettle.

Please support this motion in all it’s parts.

The Motion was passed with overwhelming support from delegates

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.

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

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

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

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

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

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

You can read the original letter here:

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

NHS 72nd Birthday

5th July 2020

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

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

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

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

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

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

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

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

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

Our exit from lockdown must be safe and sustainable

The UK has been in lockdown since March 23rd 2020 in an attempt to slow down the spread of COVID-19. Six weeks on the number of new cases per day has begun to decrease and the government and businesses are clamouring to restart the UK economy. We believe that people’s health should come before profit and that there should be no return to work until it is safe to do so.

The UK has the highest death toll from COVID-19 in Europe. Data does not support that it is yet safe to relax physical distancing.

We may have reached the peak, but there were still nearly five thousand new cases diagnosed on May 3rd. As access to testing has been so poor it is impossible to know how many other people in the community are infectious.

We cannot undertake any meaningful planning for an exit strategy from the current lockdown without an understanding of COVID-19’s prevalence and our current levels of immunity.

On April 2nd Health Secretary Matt Hancock promised to test 100,000 people daily by the end of the month. The government claims to have reached their target though there are allegations that the tally was artificially boosted.

Testing must be safe, freely available and reliable and must be accompanied by rigorous contact tracing.

True prevalence is proving hard to predict. Where one study suggests 75% of people infected may be asymptomatic, another reports a very low rate of current infection – less than 1% of the tested population.

The only way out of this is to gather data and learn the truth.

Epidemiological studies of appropriately sized, randomised cohorts repeated every few weeks would chart the progress of the disease.

Cuts to public health have made it virtually impossible to mount coordinated local responses to COVID-19 with testing, isolating and contact tracing. Restoring and updating local communicable disease control is an integral part of properly funded, publicly provided health and social care.

The lack of appropriate PPE is an ongoing problem in public facing jobs and this will only be exacerbated as more people return to work. Industry must be immediately repurposed to produce appropriate PPE in sufficient quantities.

If people are to return to work it must be safe for them to do so, including during their commute.  

Each workplace should undergo appropriate risk assessment to prevent unnecessary transmission of the virus. We do not believe that the government can be trusted to do this. Trade unions must have oversight. For example, it should be up to the education trade unions to determine whether it is safe to open schools and the criteria that will need to be met. Schools must not be seen by the government and businesses as convenient childcare to enable a kick-start to the economy. We support the NEU’s demands that schools should only be opened when it is safe to do so.

COVID-19 has highlighted the importance of a nationally coordinated, publicly provided health and social care service. The NHS has excelled itself in coping with the crisis whereas the largely privatised, for profit care home sector, which has no central coordination, has been tragically unable to prevent COVID-19 from taking a huge toll on its residents.

It is well known that there is a spike in morbidity and mortality from all causes when a pandemic hits and services focus on the crisis in hand. 

The private health sector must not be allowed to profit from this. The private sector should be requisitioned if they are needed to help to clear the backlog. Matt Hancock, Secretary of State for Health and Social Care promised that “we’ll give the NHS whatever it needs and we’ll do whatever it takes”. 

The NHS needs investment to deal in-house with the waiting lists inevitably generated by the crisis, and investment must be ongoing to preserve NHS resilience. One of the lessons from COVID-19, and most winter flu epidemics, is that the NHS cannot be run flat out all year round without headroom and spare capacity to cope with peaks in demand.

New infrastructure, such as software for arranging work rotas, is increasingly outsourced to the private sector. This is unnecessary and could easily be managed within the NHS.

Neither must health care be rationed to cope with the backlog. We reject the blanket use of the term ‘Procedures of Limited Clinical Value’. Patient care must be decided individually on clinical need and not restricted due to financial pressures.

Deprived populations have very high death rates. Society’s response to COVID-19 has disproportionately affected those from BAME communities, the poor and vulnerable.

The UK is one of the most unequal societies in the world. While the more affluent are able to isolate in comfortable homes with plenty of outside space the poorest often have to share beds and go without food – for them physical distancing is impossible. Many epidemiologists, including Sir Michael Marmot, have demonstrated that the more unequal a society is the less healthy it is for everyone, including the richest. Health Equity in England: The Marmot Review 10 Years On, published only two months ago by The Health Foundation, is a damning indictment of Government policy. 

Many other commentators suggest ways to redress the imbalance, but successive Tory governments have largely ignored them. If these measures had been introduced it would have been much easier to contain COVID 19. We demand that Marmot’s original recommendations to be fully implemented.

We believe that people’s health must not be sacrificed in the interests of profits. There should be no return to work until it is safe to do so. Ordinary people must not be made to pay for the crisis – there must be no return to austerity. The UK is a rich country and there is plenty of money in society to ensure that everyone’s needs are met. If the banks could be bailed out in 2008 the people can be supported properly now. A Green New Deal would help to provide a more sustainable economy and a Universal Basic Income would help orientate us towards a fairer society based on need not profit.

Before lock down ends there must be:

  • Freely available testing with contact tracing which is rigorously followed up, and the restoration and updating of local communicable disease control.
  • Frequent epidemiological studies of appropriately sized, randomised community cohorts to determine the prevalence of COVID-19. 
  • Sufficient supplies of appropriate PPE for all public facing workers.
  • Trade union oversight on the safety of return to a particular workplace, and trade union control of the safety aspects such as physical distancing.

Longer term there must be:

  • A sustainable, green economy based on need not profit, with no return to austerity.
  • No exploitation of the backlog in care by the private sector to boost their profits.
  • A comprehensive national health and social care service, publicly funded, publicly provided and free at the point of delivery for all in the UK with adequate investment and an end to outsourcing, privatisation and fragmentation.