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

Matt Hancock offered to auction his football shirt for the NHS – we need proper funding, not charity gimmicks

Doctors in Unite would like to remind the Secretary of State for Health and Social Care that the NHS is not a charity but a government funded health service, set up in 1948 with the specific intention to remove health care from the precarious state of reliance on income or beneficence.

Matt Hancock has his hands on the levers of government, he should be using his time and influence to bring investment in the NHS and Social Care up to the levels needed to redress the years of systematic underfunding, fragmentation and privatisation which have contributed hugely to the failures we now see in the government’s ability to cope with the challenges of COVID-19, not trivialising matters by suggesting that all of the problems can be solved with the sale of a football shirt.

Dr Jackie Applebee is the chair of Doctors in Unite

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

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

Taking over CCGs

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

Taking over the private sector?

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

Abolishing debt?

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

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

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

Xenophobia is alive and well

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

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

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

What next?

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

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

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

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

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

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

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

The private sector needs radical reform for patients to be kept safe

Michael Walsh, a shoulder surgeon, has been sacked by Spire Healthcare and accused of subjecting scores of patients to unnecessary operations that left many in pain, traumatised and unable to work. This is a depressingly familiar story, with echoes of the case of Ian Paterson, the rogue breast surgeon who also worked for Spire. Paterson subjected more than 1,000 patients to unnecessary and damaging operations over 14 years in both private and NHS hospitals. He is serving a 20-year jail sentence imposed in 2017 for wounding with intent and unlawfully wounding nine women and one man whom he treated between 1997 and 2011.

Walsh is the latest PR disaster for Spire and has exposed it to accusations of systemic shortcomings in its 39 private UK hospitals with 7,000 doctors and surgeons on their books. Most of Walsh’s patients were in the private sector with fees paid by insurers or out of their own pocket, but others were NHS patients under the choose and book scheme which diverts patients to the independent sector for speedier operations. Given pressure on the NHS and delay or cancellation of surgery, such diversions are becoming ever more common. While the NHS Long Term Plan promotes a consumer choice agenda, it is unlikely that patients of Paterson and Walsh would agree this leads to improved patient care as claimed:

“The ability of patients to choose where they have their treatment remains a powerful tool for delivering improved waiting times and patient experiences of care. The NHS will continue to provide patients with a wide choice of options for quick elective care, including making use of available independent sector capacity… Patients will continue to have choice at point of referral and anyone who has been waiting for six months will be reviewed and given the option of faster treatment at an alternative provider, with money following the patient to fund their care.”

The recent Paterson Inquiry, lead by Bishop Graham James, should have been an opportunity to highlight failings in the private sector that consistently put patients at risk. There was however an obvious omission – a failure to tackle the hugely problematic nature of the relationship between the private sector and the NHS. This includes the sharing of consultants, the need to make profit, and the inevitable conflicts of interest that these create. As pointed out by David Rowlands (director of the Centre for Health in the Public Interest), investors in UK private hospitals must have breathed a huge sigh of relief on reading the bishop’s recommendations:

“At stake for the investors was the possibility that the Right Reverend Graham James would deem their business model so incompatible with the safety of patients that it would require fundamental reform. Yet rather than tackle the private hospital industry head-on, the bishop put forward a series of low-impact recommendations which will do nothing to prevent another Paterson, but instead leaves intact the archaic and dangerous form of medical practice that abetted him.”

And lo and behold, we now have Walsh to demonstrate the prescience of this observation.

The independent sector is lavish with payments aimed at bringing in consultant work. Just seven private hospital firms paid about £1.5 million in gifts and hospitality to consultants who referred patients to them in 2017/18. Rowlands points out that consultants, by bringing in patients, are the main source of income to a private hospital and sometimes each worth millions of pounds. There is not only a financial disincentive to challenge their practises (killing the golden goose), but more operations mean more money, and since consultants are not employees of the private hospital it can deny responsibility when things go wrong. This is even more worrying when an increasing volume of NHS work is being sent to the private sector (including one third of hip operations) under the NHS England banner of “improved patient experiences of care”.

By November 2019, over a ten year period the number of NHS patients having surgery in private hospitals nearly trebled:

“NHS figures obtained by the Guardian showed that it paid for 214,967 people in England to have an operation in a private hospital in 2009-10, Labour’s last year in power. The figure soared to 613,833 last year, a 185% rise in nine years.”

It should now be obvious that the care model in private hospitals can have long term and even tragic consequences for NHS patients, such as Peter O’Donnell who tragically died after hip replacement. The Department of Health and Social Care should also come clean, and rather than disguising it on their balance sheets as NHS spending, accept that the cost of all these operations constitutes a form of privatisation. Rowlands demands logically that:

“private hospitals should take on full legal liability for what happens in private hospitals by employing the consultants directly… and private hospitals should fundamentally reform their post-operative care arrangements and bear the full cost of any transfers to NHS hospitals.”

An analysis of Care Quality Commission reports from private providers has identified a plethora of risks. These include consultant surgeons without indemnity insurance, clinical outcomes not being monitored by the hospital, not all clinical incidents being properly reported, and inadequate pre-operative assessments (important for excluding high risk patients, since most private hospitals do not have intensive care facilities or back-up specialist teams).

It is time for the independent sector to focus on patient care rather than profit, and for its parasitic relationship with the NHS to be brought to an end. The government must realise that so-called ‘patient choice’ has its limitations, and commit to proper investment in our public health services so that there is no need for patients to take the risk of going elsewhere.

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

An unequal society is an unhealthy society

Life expectancy is falling for the first time in over a century, driven by growing social inequality and a decade of ideological Conservative austerity.

Sir Michael Marmot, the director of University College London’s Health Equity Institute, specifically cited government policy as a driver of worsening health and shorter lives for people in the UK.

“England is faltering,” says Marmot. “From the beginning of the 20th century, England experienced continuous improvements in life expectancy but from 2011 these improvements slowed dramatically, almost grinding to a halt.”

His report, Health Equity In England: The Marmot Review 10 Years On, lays out in excoriating detail how the government’s failure to address social injustice has led to a less healthy society.

“When a society is flourishing health tends to flourish. When a society has large social and economic inequalities there are large inequalities in health.”

This is not just about the NHS, says Marmot. It’s about every part of society.

“The health of the population is not just a matter of how well the health service is funded and functions, important as that is: health is closely linked to the conditions in which people are born, grow, live, work and age and inequities in power, money and resources – the social determinants of health.”

There is apathy from the government, inaction on addressing a social care crisis for the last ten years, and an NHS straining under the weight of a decade of neglect. But there is also a vicious zealotry in their policies that make the lives of working people harder.

Doctors in Unite Chair Dr Jackie Applebee rightly condemns the findings of the report. “Yet again the evidence shows that austerity is bad for your health,” she says. “It is shocking that in one of the richest countries in the world, life expectancy is decreasing. It is an indictment of this government’s policies that it is the poor and vulnerable who are disproportionately affected.”

In the lead up to budget day, health workers across the NHS are coming together to put wellbeing at the centre of the country’s finances. Nothing is worth more than good health.

Doctors in Unite urges all members, all doctors, and anyone who cares about our society becoming less just and less healthy to sign the Health and Wellbeing Budget pledge, organised by medical justice charity Medact.

Join with us and sign the pledge now.

Coronavirus: how will an overstretched NHS cope?

Wuhan Novel Coronavirus (CoVid-19) has claimed over 1,300 lives and infected 60,000 worldwide so far, with no sign of slowing down. The NHS has become an increasingly fragmented service supplied by multiple providers, which is at risk of failing to deliver the co-ordinated, effective response that Coronavirus requires.

The last potential pandemic the NHS responded to was swine flu in 2009. Since then, the NHS has altered significantly – although privatisation was well under way, there were some notable differences that meant it was in a better position to respond to pandemic flu.

At the time there was a clear hierarchy from the top table decision makers: the Chief Medical Officer, Department of Health and the Health Secretary, down to the Primary Care Trusts and GPs. The Strategic Health Authorities operating above the PCTs had power to realign funding priorities between PCTs as needed.

An excellent report from the Centre for Health and Public Interest in 2014 reviewed the response in 2009 and found this hierarchy had a “clear line of sight,” allowing the co-ordinated response that swine flu required. There were flaws, such as a lack of evidence base for the widespread delivery, and the unnecessary stockpiling of anti-influenza medication, but in terms of interdepartmental communication and a joined up response, things worked well.

None of the organisations that existed then remain today, due to the top-down reorganisation that followed the Health and Social Care Act in 2012. We are now undergoing another costly reorganisation with the creation of Sustainability and Transformation Plans and Accountable Care Organisations. £79.9 billion of the NHS budget is controlled by Clinical Commissioning Groups, who purchase services from local providers. There is a fragmented landscape of different providers and disparate service provision across different regions. According to NHS England there are 150 independent providers of health services in England on top of the 233 NHS providers.

The Secretary of State for Health retains emergency powers to demand co-ordinated action, but these are yet to be exercised. It remains to be seen how these disparate services, with different contracts and arrangements, can be centrally directed to deal with a possible pandemic. We have lost the organisational memory that the swine flu response developed. With so many different providers with varying contractual arrangements offering widely differing health care services, an effective response to Coronavirus may be far more challenging.

Monitoring of the contracts with private providers is often poorly done, so it is conceivable that these arrangements might not be conducive to scaling up service provision in the event of a global health emergency. The chaotic healthcare architecture is exacerbated by the continuing cuts to local government public health services, as much as 8% from 2013 to 2018, and by our already overwhelmed emergency departments.

Coronavirus may well spread in large numbers. The neglect and fragmentation of our health service by the last 10 years of Conservative government could make a difficult situation catastrophically worse.

Dr Sammy Luney is a junior doctor and member of Doctors in Unite. A longer version of this article can be found on his Medium page.