Briefing on Privatisation within the NHS in London -examples based on reports from members of London KONP groups over the last few months 2021. [1]

Martin Blanchard July 2021

This briefing is not a detailed report of recent privatisation of healthcare in London, but rather examples of the type of privatisation that is occurring with links to details about the companies involved. If these examples are occurring in all five incipient ICSs (North West London -NWL, North Central London-NCL, North East London-NEL, South East London-SEL, and South West London-SWL) then they represent major changes in provision.

Private hospitals, Private Patient Units (PPUs) and hospitals developed through Private Finance Initiatives (PFIs) are generally well known and dealt with towards the end of this document. Less well known are the low-key private interests in community services and partnerships hidden behind the NHS brand.

The overriding wish to develop choice in health care provision in the Health Bill and the Provider selection regime will make it easier for ‘Any Qualified Providers’ to gain contracts- see also APMS contracts below. It seems very likely that private companies will continue to strengthen their roles in medical diagnostic services, community services, elective care, new models of primary care, and informatics- areas where investments are less risky and there are track records for making profit- see Centene below.

Examples of private company involvement in ICSs

1.Public Private Partnerships

North East London

Johnson & Johnson Managed Services, part of Johnson & Johnson Finance Limited2, and Guy’s and St Thomas’ NHS Foundation Trust have entered into a 15-year partnership to deliver an Orthopaedic Centre of Excellence at Guy’s Hospital’3.

North Central London

Hospital Corporation of America (HCA) at UCLH is HCA’s first joint venture, a partnership between HCA Healthcare UK and University College London Hospital which seems to be continuing to develop. HCA was founded in 1968 in Nashville, Tennessee. It has 186 hospitals, and approximately 2,000 sites of care located in 21 states and the United Kingdom. Its Revenue increased to $51.53 billion (2020) with a net income of $3.759 billion (2020). It has 280,000 employees (2020).

Health Services Laboratories LLP was set up as a partnership between UCLH NHS Foundation Trust, RFL NHS Foundation Trust and The Doctors Laboratory. The latter is owned by Sonic Healthcare, Australia4 a multinational corporation with a A$6.2 billion revenue.

South East London

From 1 April 2021, SYNLAB UK & Ireland became responsible for the delivery of Viapath’s day-to-day pathology services, which are at the core of the new partnership. Colleagues across SYNLAB5, Viapath and the NHS will work together over the next few months to develop plans to achieve the shared vision of developing an integrated, world-leading hub-and-spoke pathology network across South East London to be completed by 2024.

SYNLAB laboratories was founded in 2010. It’s headquarters are in Munich Germany and it produces 500 million tests per year in diagnostics services for human and veterinary medicine, environmental analysis and pharmaceutical industry. It’s revenue in 2018 was € 1.9 billion. It is owned by Cinven, a global private equity firm founded in 1977, with offices in nine international locations that acquires Europe and United States based corporations, and emerging market firms that fit with their core businesses. It purchased SYNLAB6 in 2015 as part of the €10.6 billion of assets it had under management.

2.Primary Care

Operose take over

The facts surrounding the take- over by Centene Corporation of some four dozen GP surgeries and hubs in London from AT medics and the associated lack of openness and transparency, and even misrepresentation, under cover of the pandemic, has been widely reported, locally and nationally. For more information see the letters sent to the Secretary of State by NHS campaigning organisations on 22 February 20217 and by leading councillors from 12 London boroughs on 19 March 20218. Both letters call for the Secretary of State to require the Care Quality Commission to investigate as provided by section 489 of the Health and Social Care Act 2008.

Centene’s takeover of the 49 GP locations across London10, their UK subsidiary Operose’s ex CEO Samantha Jones’ move to be the adviser on NHS integration for the Prime Minister11 (note that for some reason the Guardian forgets to mention that she is moving from Centene), and Centene’s purchasing control of Circle Health12 indicates their ambitions to become a major presence in the transformed health service and to be in a strong position to offer services to care manage ICSs.13 Please see the deputation by Dr Brant Mittler JD MD to Camden Health and Adult Social Care Scrutiny Committee April 2021 on the matter of corporate American healthcare management14.

Alternative Provider Medical Services (APMS) contracts

APMS contract numbers in primary care are set to grow. NHSE welcomes ‘digital priority’ private companies as Alternative Providers into underserved (deprived) areas (see NHS APMS Digital First New Market Entry Engagement Pack 2020). The increased entry of private providers into the NHS is felt to be necessary to promote patient choice. It will be mandatory for the Secretary of State, via regulations to impose standing rules on NHS England and ICBs about the arrangements they must make for enabling people receiving certain treatments to exercise choice in the Health and Social Care Bill 2021.

Further help for private specialist digital primary care has been provided as Babylon GP at Hand is able to gain access to local facilities if they recruit 1000 or more users in a CCG area/locality. They also state that NHSE have agreed that forty minutes travel to local primary care facilities is acceptable, so facilities for their service may not be required in every CCG area/borough.15

3.Community services

South West London

Wandsworth podiatry is provided by Healthshare16. They are owned by the BGF Group plc currently owned by Uberior Investments Ltd, RBS SME Investments Ltd, HSBC Investments Ltd and Barclays Funds Investments Ltd.17 Diabetic retinal screening is provided by Northgate Public Services18 which is owned by the Nippon Electric Company19 with a revenue of ¥2.9 trillion (2021), and which is owned by AT&T20via Western Electric with a revenue of $171.76 billion.

North West London

The Adult hearing service providers in Ealing are Specsavers, Scrivens and Hearbase. Specsavers Optical Group Ltd is a British multinational optical retail chain, which operates mainly in the UK, Ireland, Australasia and the Nordic countries with an annual revenue of £1.7bn. It is owned by the Perkins family.

Scrivens is a Birmingham based company with 113 branches across the midlands and SE England owned by the Georgevic family.

Hearbase is a growing Kent-based hearing company with 25 years experience. It recently obtained a contract from the NHS and has 50 stores across Kent and London.

Ealing Pharmacy IT and Ealing, Brent Central, West London and Hammersmith General Practices have support provided by First Data Bank (FDB) group21 which is owned by Hearst Communications22 a NY based corporation with a revenue of $11.4 billion.

Ealing, Brent, Central London, West London, and Hammersmith have GP diagnostics provided by Inhealth Ltd. This is one of sixteen diagnostic units in London. InHealth is a private company owned by The Damask Trust, the trustees of which are Ivan Bradbury and the Embleton Trust Corporation Ltd., which is in turn owned by MacFarlanes LLP with a revenue of £ 237.7million. InHealth’s services are provided from over 350 locations in the UK and Ireland and they work with a significant majority of NHS Trusts in the UK covering over 200 hospitals and over 80 community health clinics. For the financial year ending September 2019, according to Companies House, the company reported revenue of £120.6 million.23

Ealing cytology is provided by The Drs Laboratory (TDL) -see Sonic Healthcare above.

Hillingdon Teledermatology is provided by Concordia, now Omnes Healthcare ltd24.The Concordia company has had serious financial difficulties and had to withdraw from a contract with North East Essex with 5 days notice having moved its surviving assets into a new company the Omnes Group.

Ealing, Hounslow and Haringey have community ophthalmology services provided by Operose- see above.

Healthshare Ltd provide Central and West London with MSK physiotherapy and podiatry.

Clapham Junction general practice is run by Practice plus which belongs too Bridgepoint Advisers25 a London based private equity company with €18 billion of assets.

An Ealing General Practice is run by Totally PLC26 through its acquisition of Greenbrook Healthcare. Totally is headquartered in Mabledon Place, London. It has a revenue of £113.71 million.

4.Digitisation, informatics, analytics, Artificial Intelligence (AI)

Discovering what investments are being made in private corporate digital provision is important because these purchases invariably come with a promise to make our health and social care services not only better but also financially more ‘sustainable’ sometimes even with expressed ‘savings per patient’. They also come with ‘forever’ revenue costs.

The way that ‘improved’ services are usually provided is by using population data to identify people ‘at risk’ of requiring secondary care and then intervening with a less expensive , alternative provision to prevent referral or admission. The features improved services include are ease of communication and sharing of data, stratification of community clinical need, targeting of particular patient groups, standardisation of interventions that can be provided by less-skilled practitioners, ‘pull through’ of patients through a service, patient activation to increase prevention and self-care behaviours, and use of volunteers and families in caring roles. What is lost is the quality and continuity of any ‘provider -user’ relationship. From an informatics perspective there are ‘transformation’ capital costs (initial IT set up and future updates and developments) and revenue costs (software subscriptions, maintenance, training, storage, security), for the system and each of the partner organisations.

North Central London as an example

This information was obtained from North London (NL) Partner’s response to NHSEI in late 2019 re: actions taken to meet targets in the Longer Term Plan. Having found company names or systems being set up, a search for articles on company websites and in the Digital Health media, where they publicise the activity of IT corporations for interested investors, was carried out.

The NL Partners ICS investments:

  • a population health management platform: Cerner27 HealtheIntent is being deployed
  • Health Information Exchange ability provided by ATOS28 (information from a CCG meeting Chaired by the Accountable Officer)
  • an Analytics Board to lead and oversee the development and use of analytics across North Central London, ‘where it makes sense for us to work together’

Partners investments:

  • Royal Free London (RFL) Foundation Trust has fully implemented electronic patient records using Cerner Millennium at RFH, Barnet and Chase Farm Hospitals (the RF Group)

Meanwhile in other local hospitals:

  • University College London Hospitals (UCLH) Foundation Trust has implemented electronic patient records using Epic29 across all sites
  • North Middlesex University Hospital (NMUH) Trust and Whittington Health have implemented new functionality in their System C30 electronic health record. System C is owned by CVC Capital Partners a Luxembourg private equity company with $75 billion of assets.
  • Great Ormond Street Hospital NHS Foundation Trust has also implemented Epic.

From NL Partners:

‘We anticipate that as the electronic health records are developed, especially in the acute sector, this will be reflected in the overall digital maturity of NCL when a new assessment is undertaken’.

In June 2019, the NCL Chief Information Officer (CIO) Working Group took part in a London -wide initiative for assessing digital maturity on a system level, ran by Deloitte Touche Tohmatsu Limited 31. Digital maturity is an objective that has to be continuously assessed and maintained.

NL Partners data security

Data security is an ongoing concern that the entire informatics system of the ICS and all Partners will need to continually invest in and purchase from private providers. NL Partners aim to keep abreast of the latest cyber security developments and requirements. Their providers are well on their way to rollout Windows 10 and Microsoft Advanced Thread Protection, and all of the GP sites already meet these requirements. Their Trusts are well engaged and keen to be on the front foot in this regard, but progress is threatened by national capital spending reviews.

Furthermore, they use the Cyber Security Support Model (NHS SBS cyber security framework) with its list of accredited suppliers to raise their level of cyber protection. They are briefing their trust boards on cyber security awareness, implement cyber security tools, and have made significant progress towards achieving the ‘Cyber Essentials Plus certification’ with providers and primary care practitioners.

Their organisations are already making use of the Cyber Risk and Operations support package to continuously improve their cyber resilience.

Funding NCL’s Digital Transformation

‘There will be additional financial implications to connect more organisations to the HIE shared record and HealtheIntent population health management which are not included in current funding bids e.g. community pharmacists, out of hours services, dentists etc. Quality improvement support will be needed to maximise the benefits of HIE and HealtheIntent implementation across the system. We have already bid for all available funding that exists and are waiting for confirmation that we will receive funding for the projects that were originally approved’.

‘Our future challenges include the fact that the software licensing model is moving to a subscription service globally. This moves the cost from capital to revenue and may create challenges given the financial context in NCL.

Adding this to the year- on-year CIPs (Cost Improvement Programmes) trusts have to make on their revenue budgets only adds to the scale of the problem looming. NCL trusts will also need to make significant investments to maintain their current ‘level of maturity’, current operations, and to procure new licenses for out of support products and clinical systems as they reach their end of contract in the next years’.

The OneLondon programme

The OneLondon programme is enabled by Cerner32 ‘turning London into the most connected capital city from a health care perspective’ [in the world].

While such inter-connectivity of data has the clinical benefit of shared information, the huge financial significance of such accessible ‘big data’ for markets must be recognised. Creating a network of 8 million healthcare records may prove very tempting. Commentators such as Professor Shoshana Zuboff33 from the Harvard Business School believe that the use of human data for wealth creation, without clear permission for use, is theft akin to the trafficking of human organs. But until the law can catch-up with such activity it remains a frequent practice. It is the Artificial Intelligence algorithms applied to large volumes of human data that can predict behaviours, and in the context of online purchasing and marketing it has generated enormous increases in dividend returns for the giant social media corporations. These huge financial gains are seen as the main driver of ‘surveillance capitalism’. The growing ‘health markets’ are an important part of these developments- see below.

Some insights about Cerner and the growth of the Health Market

Matthew Swindells, a senior manager in the NHS, left to become the senior Vice-President of Cerner and then moved from that job back to the NHS as England’s National Director for Operations and Information from May 2016 to the end of 201934-as ICSs were developing. Cerner gained multiple contracts across NCL35, the rest of London and other areas in England, and a presence on the OneLondon database and the National Database36.

Cerner has systems in St Barts, Whipps Cross, UCL Institute of Digital Health, St George’s, Croydon Health, Imperial, Chelsea and Westminster, South London Healthcare NHS Trust at Queen Elizabeth and Princess Royal hospitals, Kingston Hospital, Newham University Hospital, London North West University Healthcare NHS Trust, The Hillingdon Hospitals NHS Foundation Trust and the list is growing….

Distie Profitt, Cerner UK Managing Director states that over the past few years Cerner has faced stiff competition in the UK from Epic, which has won a string of high -profile contracts at UCLH, GOSH, Guys and St Thomas’, and Frimely as well as big regional deals with Northern Ireland and Manchester. But Cerner has similarly high-profile clients, including Imperial, Oxford, Barts, the Royal Free and Newcastle. Additionally, they partner with a range of providers and enable whole health systems across the country. Looking ahead she says Cerner believes the future is about ‘building on baseline digitisation and integration to then enable the automation of workflows, underpinned by a commitment to interoperability’. Profitt also highlights ‘The Rise Of Consumer Healthcare’ with a high-profile example being when Oxford and Milton Keynesbecame the UK launch sites for Apple’s Health Records feature, linking data from the trust’s Millennium EPRs to people’s iPhones. In August, Cerner announced a partnership with Amazon’s new cloud linked fitness tracker Halo. The Amazon tie-up with Cerner, due to reach the UK in coming months, will enable people to share activity, sleep, body fat percentage and other important wellness data with their health and care providers. The future will be much more citizen-centric in the care process. So, it’s not just paying lip-service to the person but understanding the citizen. That’s where much bigger change will come. We will continue to experience the acceleration of consumer engagement and them being more demanding of how and where they gettheir care.

NHSX is currently bidding for up to £3 billion investment in provider digitisation. Although it would be a welcome slice of investment, Profitt says that there are still a sizeable number of trusts and social care that have not yet digitised, and £3 billion is still not a lot to complete provider digistisation.

5.Subsidiaries

In North Central London back in 2018 whilst trying to find contact details for hospital Governors of the Royal Free London NHS Foundation Trust campaigners found a brief note in the local Trust Board minutes about a subsidiary company. The Trust’s Group Strategy and Investment Committee (GSIC) that dealt with such matters did not meet in public or provide public minutes. At the same time Unison, as part of a national campaign, had sent an FOI to ask the Trust about payments to external advisors concerning subsidiaries, and the declared £400,000 bill pushed the campaigners to send in an FOI asking for information relevant to that expenditure. After refusals, complaints to the ICO, serial delays by the Trust, an appeal to the Tribunal, an Information Commissioner’s change of opinion, an agreement by the Trust to send most of the information, a recent Tribunal hearing decided that the public still could not see the legal advice to the Trust. Documents have recently been received which show that the major hospital provider group has set up a series of linked subsidiaries.

The Trust’s rationale for the creation of subsidiaries was that National funding for the NHS was forecast to grow annually at less than the 4% per annum a level that most commentators believe was required to maintain existing models of service delivery.

The trust had an underlying financial deficit of c.£94m per annum and required all departments to make significant year on year savings. The subsidiaries were aligned to the trust’s drive for continual improvement in the quality of services and were a response to the need for change so that services could be provided in a way that was sustainable going forward.

The subsidiaries reflected the national picture across the NHS, driven by the financial challenge, where trusts were reviewing how they could increase productivity and quality, whilst reducing costs to the healthcare economy. In 2018 there were 65 wholly owned NHS subsidiaries in England37.

With the subsidiaries the Trust was able to

  1. access alternative (non-NHS) capital to fund service development, to pump prime transformation, innovation and investment;
  2. develop a range of programme specific strategic partnerships with commercial partners in a corporate form more familiar to the corporate sector, including the ability to plan and deliver for multi-year budgets;
  • provide assurance and a strong governance framework to manage non-operational risk for the trust;
  • operate at scale and on a standardised manner in keeping with the trust’s intention to grow as a group of hospitals, and develop an income.
  • improve, attract and retain well qualified staff to deliver future programmes of work.

In addition, the Trust stated that the property subsidiary would allow increased opportunities for local Small and Medium Enterprises (SME) to do business with the new company. The current Standing Financial Instruction (SFI) rules used NHS criteria for doing business with SME’s and these were extremely strict and in most cases made it challenging /impossible for SME’s to tender for business. A subsidiary gave an opportunity to provide a huge boost to the local economy as well as providing potential growth in employment for other local businesses.

This turns out to be an essential ‘anchor’ activity of providers required by the ICS to use the market to try to reduce inequalities and improve Public Health. Also in the papers there was a wish for the Trust to emulate a group of subsidiaries developed just across the Thames called:

Essentia Trading Limited (SE London ICS) February 9th 2021 Controlled by Guys and St Thomas Enterprises Ltd, controlled by Guys and St Thomas FT as SSAFA GSTT Care LLP

An example of the business they are currently doing from the Business Press:

‘ETL’s Zero Carbon Delivery Framework provides a one stop shop allowing public sector entities such as hospitals, military, education, police/fire an expedited and compliant avenue for low and zero carbon infrastructure investments. And excitingly, UK Private and Listed companies are also able to utilise the ZCF to ensure best value……ETL is a subsidiary wholly owned by Guy’s and St Thomas’ NHS Foundation Trust and profits are invested back into the NHS. In 2018, ETL supported over 25 NHS Trusts with NHS Energy Efficiency Fund (NEEF) applications and the delivery of successful projects’.

Essentia is also a partner in Optimedis COBIC UK a German/British partnership accredited on the Health Systems Services Framework38. Note the HSSF now has 12 streams and nearly 200 mainly private firms accredited.

There is also a large subsidiary called Quality Trusted Solutions Ltd in the incipient NW London ICS that is wholly owned by Central North West London Trust (CNWL)39. It offers help in Asset Management, Management Information System (MIS), Soft and hard Facility Management, Capital Projects, Transport Management, Sustainability and Strategic Estate Management. If you are short of money they have access to private finance that ‘can help unlock schemes and deliver long term solutions’. From its accounts, its turnover for the year ending March 2019 was £30.9m.

6.Private hospital provision and financing in London40

There are 28 private hospitals and Private Patient Units (PPUs) in central London and 46 outside central London but within Greater London:

  • HCA has the largest presence in central London measured by number of in-patient facilities, including six hospitals it owns and one PPU it manages. It also manages one PPU in Greater London.
  • Centene/Circle owns four hospitals in central London and six hospitals in Greater London, it also manages three PPUs in Greater London.
  • Nuffield, Ramsey and Spire have no hospitals in central London. They have hospitals just outside Greater London: Nuffield Brentwood; Ramsay Ashtead and North Downs; and Spire Bushey and Hartswood.
  • Aspen has one hospital in central London (the Highgate Hospital) and one hospital in Greater London (the Parkside Hospital).
  • There are a number of independent private hospitals in central London: the BUPA Cromwell Hospital, the Hospital of St John and St Elizabeth, the King Edward VII’s Hospital Sister Agnes and The London Clinic (TLC). There are two independent private hospitals in Greater London: the New Victoria Hospital and St Anthony’s Hospital.
  • There are 11 PPUs in central London (excluding those operated by HCA and BMI). There are four PPUs in Greater London (excluding those operated by the above hospital operators).

Financial data on Private Finance Initiative (PFI) hospital/social care41

There are 29 hospital/social care PFI schemes in London with a capital value of £2.8bn.

Payments due to the PFI operators/companies: Unitary Payments (1992/93 – 2016/17): £5.4bn Unitary Payments (2017/18 – till end): £16.8bn

So this is a total of £22.2bn of payments (incl. services) for £2.8bn of capital over the lifetime of the contract.

Profit and tax savings

Of the 29 London PFI schemes, the Centre for Health and the Public Interest (CHPI) was able to review the financial accounts of 22. These 22 schemes had a capital value of £2.7bn and from 2008/09-2015/16 (the period for which profit data was available) they paid £3.5bn to the PFI companies.

Out of this £3.5bn the PFI operators made a profit before tax of £334.1m and on this profit made an estimated tax saving of £32.8m.

Conclusion

The amount of privatisation of healthcare provision in London is already extensive and much remains hidden from public view behind the NHS brand. With the Health and Social Care Bill 2021 it is set to grow.

Many will argue that general practice has always been privately contracted so why do the changes matter, but there is a massive difference between GP partnerships working to earn salaries, and transnational corporations or private equity companies created to extract wealth. It is surprising how many of the new providers when investigated prove to be owned by the latter. The NHS is moving from a state funded service to a public-private conglomerate, and along the way new markets and investment opportunities are being created.

This is exactly what the WEF redesign of health services called for following the 2008 crash in order to improve the global growth of capital42. The losers will be the English public and the staff of the NHS; profits and dividend payments have to come from somewhere, and it will be from our pockets, job experiences, and less access to, and poorer quality of care.

References

  1. There is no reason to believe that private companies are not gaining similar contracts in communities across the Capital.
  2. https://en.wikipedia.org/wiki/Johnson_%26_Johnson
  3. https://www.hospitalmanagement.net/news/new-orthopaedics-centre-excellence-opened-guys-hospital/
  4. https://en.wikipedia.org/wiki/Sonic_Healthcare
  5. https://sel.synlab.co.uk/laboratory-details/ https://sel.synlab.co.uk/overview/
  6. http://uk.reuters.com/article/us-cinven-m-a-idUKKBN0P51TZ20150625
  7. https://allysonpollock.com/wp-content/uploads/2021/02/Letter_SoS_HSC_Centene_22Feb2021.pdf
  8. https://twitter.com/SouthwarkLabour/status/1372973831678230530/photo/1
  9. https://www.legislation.gov.uk/ukpga/2008/14/section/48
  10. https://keepournhspublic.com/us-health-insurers-are-coming-for-the-nhs/
  11. https://www.theguardian.com/society/2021/apr/02/backlog-is-truly-frightening-former-nhs-chief-warns-of-vital-delays https://www.nhsforsale.info/conflict-of-interest/operose-ceo-moves-to-number-10-advisor-position/
  12. https://www.laingbuissonnews.com/healthcare-markets-content/circle-health-announces-major-investment-programme-as-us-centene-takes-controlling-stake/
  13. https://keepournhspublic.com/campaigns/legislative-changes/integrated-care/integrated-care-of healthcare-imperialism/ https://www.sochealth.co.uk/2021/05/10/centene-the-real-agenda/
  14. https://democracy.camden.gov.uk/documents/b27994/Supplementary%20Agenda%20-%20Deputations%2007th-Apr-2021%2018.30%20Health%20and%20Adult%20Social%20Care%20Scrutiny%20Commi.pdf?T=9
  15. https://assets.babylonhealth.com/press/20190927-Babylon-GP-at-Hand-response-to-new-NHS-policies-for-digital-first-primary-care.pdfhttps://healthshare.org.uk/about-healthshare/
  16. https://healthshare.org.uk/about-healthshare/
  17. https://find-and-update.company-information.service.gov.uk/company/10657226/persons-with-significant-control
  18. https://en.wikipedia.org/wiki/Northgate_Public_Services
  19. https://en.wikipedia.org/wiki/NEC
  20. https://en.wikipedia.org/wiki/AT%26T
  21. https://en.wikipedia.org/wiki/First_Databank
  22. https://en.wikipedia.org/wiki/Hearst_Communications
  23. https://www.nhsforsale.info/private-providers /inhealth-group-2/
  24. https://www.nhsforsale.info/private-providers/concordia-health-new/
  25. https://en.wikipedia.org/wiki/Bridgepoint_Advisers
  26. https://www.nhsforsale.info/private-providers/totally-plc-new/
  27. https://en.wikipedia.org/wiki/Cerner
  28. https://en.wikipedia.org/wiki/Atos
  29. https://www.epic.com https://en.wikipedia.org/wiki/Epic_Systems
  30. https://www.systemc.com https://en.wikipedia.org/wiki/CVC_Capital_Partners
  31. https://en.wikipedia.org/wiki/Deloitte
  32. https://www.cerner.com/gb/en/industry-perspectives/a-look-into-hie-adoption-across-england
  33. https://medium.com/iipp-blog/worker-organisation-and-the-challenge-of-shaping-markets-in-the-age-of-surveillance-capitalism-cc9dc4da37c5
  34. https://www.england.nhs.uk/author/matthew-swindells/ https://www.digitalhealth.net/2019/05/swindells-to-leave-nhs-england-private-sector/
  35. https://www.digitalhealth.net/2021/04/two-north-london-trusts-cerner-for-integrated-ehr/ https://www.digitalhealth.net/2020/11/the-challenges-of-leading-a-supplier-during-a-pandemic/
  36. https://www.digitalhealth.net/2018/03/london-csu-deliver-population-health-dashboard/
  37. Jan Savage, Marion Macalpine and Carol Saunders. How come we didn’t know about SubCos? The growing use of NHS-owned private companies. Pamphlet 2020.
  38. https://www.consultancy.uk/news/19206/the-professional-services-firms-that-are-helping-nhs-embrace-technology
  39. http://qts-llp.co.uk
  40. https://assets.publishing.service.gov.uk/media/5329dc1fed915d0e5d0000f5/130607_london.pdf
  41. https://chpi.org.uk/blog/londons-hospital-school-pfi-schemes/
  42. http://www3.weforum.org/docs/WEF_HE_SustainabilityHealthSystems_Report_2012.pdf

Revealed: Boris Johnson’s controversial policy chief leading secretive NHS task force

Munira Mirza heading up group meeting ‘daily or weekly’ to plan ‘radical NHS shakeup’. Open Democracy 19.11.20

Boris Johnson’s government has for the first time confirmed the existence of a prime ministerial task force which is reportedly planning a “radical shake-up of the NHS”.

Freedom of Information disclosures to openDemocracy show the new “No.10 Health and Social Care Taskforce” reports to a Steering Group chaired by Munira Mirza, the influential head of Boris Johnson’s policy unit, and that it “met weekly” from July to September with a further meeting in October.

Mirza, a political appointee who previously worked for Johnson when he was London mayor, has no background or policy experience in health.

The disclosures also reveal that whilst some Department of Health officials do attend the task force, it is led by four senior civil servants based at the Treasury, and none of whom are from the Department of Health.

The government has not published any information about the task force’s existence, work, terms of reference or membership – and has refused to answer questions about the nature of its work.

However in July, The Guardian reported that Boris Johnson was planning a “radical and politically risky reorganisation of the NHS” – in response to “frustration” with the NHS’s performance during the COVID crisis.

And in September, the Financial Times reported that inside sources had revealed an interdepartmental health task force with a wide remit, “determining what the health service’s goals should be”.

The government has previously claimed that rumours regarding the work of the task force are “pure speculation,” and did not even formally confirm its existence, insisting that instead: “As has been the case throughout the pandemic, our focus is on protecting the public, controlling the spread of the virus, and saving lives.”

Not only is the group now confirmed to exist, but Mirza’s leading role and the lack of leaders from the Department of Health suggest that its work is politically focused.

Jackie Applebee, Chair of Doctors in Unite, told openDemocracy, “It is shocking that people with no background in health are meeting regularly to determine the future of health and social care. COVID-19 has surely shown us that putting people with no health experience in charge of the NHS is a disaster.”

Meanwhile Tamasin Cave, a lobbying expert, has called Mirza “a political hire who is unqualified to mess around with the NHS”. She also questioned the timing: “Why are they doing this now, given how much the NHS – and the country – has on its plate already?”

The revelations come as concerns are mounting about post-COVID pressures on the NHS.

Kailash Chand, former deputy chair of the British Medical Association, told openDemocracy. “The waiting lists have built up to an awful level, and they’ll use that as an excuse to bring the private sector in, as they did under the previous Labour government.”

He described Boris Johnson as “dangerous” and having “no faith in public services.”

Secrecy ‘the worst possible way’ to do NHS reform

In their Freedom of Information responses, the Department of Health, the Treasury and Number 10 have all denied having a full record of who has been attending the task force and steering group meetings.

Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, has criticised the government’s secretive approach as “the worst possible way to design a major reform.”

“Secrecy encourages groupthink. The government rightly stresses the importance of public and patient involvement and co-production with users when designing new models of care. It is bizarre to reject these ideas for the really big decisions.”

What today’s disclosures do show is that the task force’s civil service policy lead is Adrian Masters. An alumnus of the management consultancy McKinsey, Masters played a key role in shaping the last major piece of NHS legislation, the 2012 Health and Social Care Act.

McKinsey was reported to have drafted large parts of that bill, which was criticised as enabling increased fragmentation and private sector outsourcing of large parts of the NHS.

The task force also includes William Warr: Johnson’s health advisor and a former lobbyist at the firm of Lynton Crosby, who masterminded numerous Conservative Party election campaigns and Johnson’s successful 2008 London mayoral bid.

Warr described the NHS as “outdated” in a Telegraph article penned shortly before he and Johnson entered Downing Street last year, suggesting that the incoming prime minister should ask himself: “If I created the NHS today from scratch, what would it look like?” Warr answered: “Nothing like the monolith we have today.”

Boris Johnson’s first Queen’s Speech in December last year promised to “bring forward detailed proposals” and “draft legislation” to “accelerate the Long Term Plan for the NHS, transforming patient care and future-proofing our NHS.”

The British Medical Association (BMA) has characterised this Long Term Plan as a “plan for a market-driven healthcare system”.

Kailash Chand, the former BMA deputy chair, told openDemocracy he believed the purpose of the task force was part of a wider effort to drive forward more NHS privatisation: “These people are really clever at bringing these things in disguise. This is essentially about getting us towards… big pickings for private companies. It’s not going to happen overnight but this is the road map.”

Referring to McKinsey’s regular NHS recommendations that were implemented under the Cameron government, he said: “McKinsey were brought in previously to recommend financial savings. The easiest way for hospitals to achieve those targets was to cut beds, cut nurses and the salary bill. And we’re still suffering today.”

Political appointments

Boris Johnson has faced criticism for appointing political allies with no health experience to key roles in the COVID-19 response. Test and Trace head Dido Harding, another former McKinsey employee and Tory peer, is in the process of taking over a large portion of the soon-to-be-abolished Public Health England’s remit, the government announced in August. She has also been tipped as favourite to take over as chief executive of the English NHS from the current incumbent, Simon Stevens, next year.

Stevens’ own proposals for major NHS reform last year attempted to allay fears about further privatisation, though campaigners raised concerns that they could make outsourcing less transparent.

Both the Department of Health and the NHS now appear to be taking a back seat in policymaking. Stevens is not on the task force, and none of the four top senior servants in charge comes from the department.

Open Democracy approached Munira Mirza, Adrian Masters, Number 10 and the Treasury for comment, but all have declined to respond by the time of publication.

This is a reprint of an aricle in Open Democracy by Caroline Molloy 19.11.2020: https://www.opendemocracy.net/en/opendemocracyuk/revealed-boris-johnsons-controversial-policy-chief-leading-secretive-nhs-task-force/

Statement on Integrated Care Systems

Integrated care systems are part of the government’s plans for NHS organisations, in partnership with local councils and others, to take collective responsibility for managing resources, delivering NHS standards, and improving the health of the population they serve.  This seemingly laudable development has the potential to further undermine the NHS, particularly since the Covid-19 pandemic. 

The NHS in England is being rapidly and profoundly changed under the cover of COVID-19. There is no public consultation or the necessary legal Local Authority scrutiny on what are emergency measures being made permanent as part of Integrated Care Systems (ICS) development.

The changes include unproven innovation, privatisation and paid for care, and the developing systems present clear opportunities for commercialisation and private investment. The government’s procurement response to the COVID pandemic has been wholly unaccountable and riddled with corruption.

We call for full democratic Local Authority scrutiny and public consultation, as well as democratic representation (i.e. partnership) throughout the incipient ICS structures.  We demand a renationalised National Health Service in the longer term. 

We passed the following motion at a recent meeting of Doctors in Unite.

Integrated Care Systems:

ICS have been introduced and developed undemocratically, without consultation and with a lack of transparency.  Their aim is to impose ‘reduced per capita cost‘ control totals to force unproven and unsolicited  innovation, including elements of privatisation and paid for care, in each system’s struggle to meet local population need. This has been NHSE/I’s practice with individual Provider Trusts over recent years. Each ICS will form a new Integrated Care Provider (ICP) organisation. NHS England plans for ICP organisations to be managed through commercial contracts. We therefore call on government to ensure that:

 1.Local Authority Scrutiny Committees across England be allowed to fulfil their legal responsibilities to scrutinise fully the significant changes in NHS services that have been initiated without scrutiny under the COVID-19 emergency measures before they become any permanent part of ICS development. If the Committees decide that the changes require full Public Consultation then this must also happen before the changes are allowed to remain. These actions are well established legal process.

 2. Some democratic representation is created in the Governance structures of ICSs by: i) an increase in Local Authority Councillor representation on the Governing Bodies so as to match in numbers the NHS representation (Partnership) and ii) full public engagement and involvement for all significant changes and developments in the NHS, with full Consultation as well on the more major issues as decided by the Scrutiny Committees which have been set up in our democracy for this purpose.

 3. In the longer term there must be a return to universal risk pooling and funding with renewed efforts for National equity of care and National decisions about affordability. ICS must be replaced by Health Boards with the return to geographically based responsibility for the delivery of health to local populations. The apparatus of the market that divides the NHS must be dismantled. Health Boards as public, accountable bodies would plan and provide the full range of NHS services, with participation from elected councillors, community organisations, Neighbourhood Health Committees as advocated in our paper “Public Health and Primary Care” and trade unions. The quality of services would then be monitored by locally-based independent bodies involving local patients and community groups, with the powers once enjoyed by Community Health Councils.

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

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.