Medical activism

John Launer

This article is reproduced from the Postgraduate Medical Journal 25 August 2021.  Please click on link for references.

Medicine and politics are inseparable. This applies from the very beginning of medical training and throughout doctors’ careers. In most countries, the young people selected to go to medical school are predominantly drawn from a social elite. (The state-educated 94per cent of the school population in the United Kingdom, for example, were given fewer than half the offers for medical training in Oxford).1 They will generally share the experiences, assumptions and values of the privileged backgrounds from which most of them come. As they go through training, medical students almost everywhere will receive an intense grounding in the scientific and technological aspects of medicine but vastly less in the social and political determinants of health. They may be exposed to some of this information (such as the difference in life expectancy between the least and most deprived deciles in England of 9.5 years for males and 7.7 years for females.)2 However, the teachers who impart these facts are equally unlikely to have come from deprived backgrounds themselves, or to imbue them with the sense of outrage that such figures should evoke.

Once qualified, most doctors will begin to understand that some of the frustrations they encounter at work arise from political decisions rather than ones made by clinicians and service managers. These decisions may include limitations on budgets, and performance targets. Many will complain about politicians, but they may be unaware how far their own practice, including the use of hi-tech investigative technologies and expensive medicines, has been massively influenced by political lobbying. (In 2020, the pharmaceuticals and health products industry in the United States spent more than any other sector on lobbying efforts, totalling around 306.23 million US dollars)3 Few will campaign for government funds to be spent outside the health sector altogether—on social care, nutritional support and housing assistance—where these would demonstrably have more impact.4 They will probably not question the structural inequalities which lead to their earning incomes that may be ten times the median income of their patients.5 6

Campaigning doctors

To set against this, there is also a long and distinguished history of individual doctors (and nurses) who have chosen to be political campaigners. Such people have seen their vocation as not only treating patients but fighting on the political front for the welfare of under-privileged groups, communities or society as a whole. Famous activists from the past in the United Kingdom include Thomas Wakley, John Snow, Florence Nightingale and Elizabeth Garrett Anderson. More recently, the physician Sir Douglas Black and the socialist general practitioner Julian Tudor Hart had a considerable influence in orienting the profession towards population and community health as well as individual care.7 8 (For over 20 years I had the privilege of practising alongside Ron Singer, an ally of Tudor Hart, a fierce campaigner for the original values of the National Health Service, and a role model for combining clinical and political commitment).9 Across the world, notable activist doctors have included Franz Fanon, a guiding light of the Algerian independence movement, who wrote of how the medical profession were complicit in the oppression that colonialism brought about. Che Guevara became a revolutionary in Cuba after being profoundly affected by his experiences as a medical student. Sun Yat-Sen was instrumental in bringing down the last imperial dynasty in China and became first president of the republic.

While such activism is not new, there has been a notable upsurge recently in the number of influential voices from within the medical profession arguing that every doctor has a duty to move beyond their clinical work and challenge the current political realities. In an essay entitled ‘The moral determinants of health’, the leading US physician Don Berwick has pointed out: ‘No scientific doubt exists that, mostly, circumstances outside healthcare nurture or impair health.’10 He makes a passionate plea for doctors, nurses and their professional organisations to become involved in campaigning on issues such as racial discrimination, women’s equality, human rights, climate change, the criminal justice system, hunger and homelessness. Countering objections that this campaign list might seem out of character for many health professionals, he argues bluntly: ‘Healers are called to heal. When the fabric of communities on which health depends is torn, then healers are called to mend it. The moral law within insists so.’

In a similar vein, David Kopacz of the University of Washington writes of medical activism as ‘a foundation of professionalism.’11 He quotes Robert Jay Lifton, who studied how U.S. soldiers could participate in war atrocities and how German doctors participated in the Holocaust: ‘As citizens, and especially as professionals, we need to bear witness to malignant normality and expose it… That inevitably includes entering into social and political struggles against expressions of malignant normality.’12 Kopacz also cites educator Parker Palmer, who speaks of a new kind of professional: ‘a person who not only is competent in his or her discipline but also has the skill and the will to resist and help transform the institutional pathologies that threaten the profession’s highest standards.’13

Failings of governments

Doctors are also speaking out with growing urgency and frankness about the failings of governments to address the health and social needs of their citizens. Kamran Abbasi, executive editor of the BMJ, has written a blistering attack on the British government’s ‘politicisation, corruption and suppression of science’ during the COVID-19 pandemic.14 Rachel Clarke, a palliative care doctor, has become a bestselling writer and contributor to social media, drawing attention to government mismanagement of the pandemic, and the human consequences. While occasional voices are still raised in support of the notion that doctors should only treat patients and keep their noses out of everything else,15 such views are increasingly likely to seem blinkered and outdated.

As health and social inequalities widen, and we learn more about the power held over human lives by an ever-diminishing number of individuals and corporations,16 I predict that more doctors around the world will be drawn inescapably into political campaigning. Doctors who believe that medicine and politics are entirely separate will be seen as fundamentally out of touch with medicine or politics, or both.

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

Bring out the dead

let’s bring out the dead
the defeated
the destitute
the isolated mind

our bodies scarred
memorial on the high street
medals for the survivors
parties for the kind ones
no dancing by eros
we endured

knightly collusion
politicians begone
in the shadow of the slaughter

we had it within us
court friends knew better
call centre illusions
our best chance
oxbridge sage
modelling murder
follow the money
eat out to help out
double or quits

bloated self-confidence
free trade in virus
haig‘s walk-over 
no-man’s land
herding the old
graves to cry by
r numbered 
bullingdon barbarism

we knew by summer
winter would come
indi_sage zoomed out
zero the virus 

mum’s phone for two plus two
frightened to play childhood 
the rich relax
the powers protect
pox on your spare bedrooms
your lofty ceilings
sourdough smugness
bring out the dead

spurt of growth 
vaccine forgiveness
all forgotten
learn the pandemic
bring out the dead

our leader rides high
mussolini by his feet
bonfire the masks
politicians on top
of rolling heads
crucify conceit
bring out the dead

eruptions of anger at our children’s stunting
renew with love
rage contained

let’s flatten the curve of the footsie one hundred
lockdown the bentley
take their front room

scream at the sky
madness
we do it with love
look the sun in the face
the heat of the heart
look death in the face
and give it new life

breath deep
smell your friend
passionate kiss for the lonely
the frightened
the mad
smile on your smile
two metres of touching
the colour of love

reach out to the victims
of torment at home
batter on batter
you made me do
hear the pain
of privatised violence
name the deed
heal the wound

payback cayman islands
they tell us now
our stocks are high
your hopes low
defeated

long
poem
long
lives
lost

death haunts the land
fear for what’s next

refuse the future they have for us
bring out the dead

our genius create
pfizer be damned
the meekest show too
beauty unbound
learn from the children
let life break through

roll up our sleeves
it’s our time now
we see kindness abound
bring out the dead

let’s house the homeless
rip the damp songs
for the frightened
care for the old
talk of the past
repair the swings
work with dignity
laugh with laugh
colour by day
love by night

let’s build a country worthy of the dead
let’s make it a country

a joyful period
of warm hearts 
and bright living rooms
of peace for the overworked
the exhausted mother
three jobs juggling
sauna and sleep
debts denied

the pandemic will pass
the shadow grey
let’s paint it red
and blue and green

but bring the dead too
to bury in our hearts

Paul O’Brien

“Wo ich war, sollte es werden” [1]

[1] With apologies to Freud. ‘Wo es war, soll Ich werden’ – “Where it was, I should become” – is his version of the Enlightenment goal of knowledge that is in itself an act of liberation – the ego replaces id and so we develop. Here we have the reverse, ‘Where I was, it should become’ – an undoing. The Health and Care Bill 2021 is an act of destruction. Greed and indifference fuel these changes; a wish for continuous exploitation will undo our greatest achievements.

How the ICS will work in practice

The way ‘Accountable Care’ works is through its funding mechanism and the legal duty put on the ICS and all the individual Partners [2] not to overspend their and the system budgets. The sheer size of the ICS is important to allow this to be possible.

Alongside the budgetary control totals [3] , the structure will be built using Payment Incentives for ‘aligned’ services and required percentage spends on ‘integration’ development. With the ‘new models of care’ in place and the absence of any legal duty to provide secondary care services then referral avoidance and the whole range of other efficiency measures as described in McKinsey‘s 2009 paper ‘Achieving World Class Productivity’ [4] can be fully used to try to cut costs. The increased waits and lists of Procedures of Limited Clinical Value (PoLCVs) [5] will increase the number of people willing to pay for care either directly from Private providers or as ‘NHS paying patients’ utilising the NHS or the developing public-private partnerships’ services.

Clinical activity, costs and ‘outcomes’ will be monitored in real time – everything will be developed as a ‘currency’- and ‘best value’ for the system
(possibly decided using IT) will be used to explain away individual decisions not to provide care.

The majority of the limited community spend will be focused on those patients selected as ‘at risk’ of requiring elective secondary care by the predictive Artificial Intelligence algorithm. They must be kept away from any test ordering, hospital admitting doctors.

Squeeze the system control total and watch the system work.

Integrated Care Boards will be able to enter into financial agreements with external parties. They and their Partners will generate income streams; this is already evident at the Royal Marsden Trust, the HCA-UCLH Trust partnership and the Johnson and Johnson- St Thomas and Guys Trust partnership. There are also 65 NHS Trust subsidiaries (2018 figure) [6] currently trading as private companies which could also generate capital income streams, perhaps with private partners, once the ICSs are set up and current capital spending limits relaxed. Essentia, a St Thomas and Guys subsidiary in SE London, is currently a partner in Optimedis COBIC UK and is accredited on the Health System Support
Framework (HSSF).

NHS Trusts and major academic organisations will become ‘anchors’ of place and help with inequalities through preferred employment of local people within their organisations and preferred contracts for local Small and Medium Enterprises using subsidiaries to negotiate this. They could also use their financial resource to leverage finance for local community development and Public Health initiatives.

Community care will be ‘asset- based’ [7] (MacLeod & Emejulub 2014) and digitised, with all digital platform providers only accredited by NHSE if they can support Personal Health Budgets. ‘For profit’ and ‘Not for profit’ providers will be heavily involved and both will be able to receive financial assistance directly from the Secretary of State or bodies to which he has delegated this function. It also seems that many of the huge number of community healthcare apps carry adverts [8] – a new market – which will gain a huge boost described as ‘the rise of the consumer in healthcare’ when apps and devices are linked to Cerner Millenium or similar health information packages [9].

Not having private corporations on the board will not stop any of this.

It is the removal from the remit of PCR 2015 [10] and the CMA [11] that will deregulate the market with the loss of all its labour and environmental protections. PCR 2015 allows procurement without tendering but only within public services, so it seems they need deregulation if they wish to give contracts to private providers. The NHS Provider Selection regime also makes it easier for ‘Any Qualified Providers’ to get accredited and placed on Provider lists, and makes it more difficult to remove them- it will be mandatory for the Secretary of State to impose standing rules on NHS England and ICBs to enable people receiving certain treatments to exercise choice.

National pay scales and collective bargaining will become virtually impossible as each of the 42 ICSs will develop its own plan and outcomes, and will need to provide the services required to achieve them while bound to its own legally agreed budget/control total. There are expectations for ICSs to innovate to achieve sustainability. Also the People Plan requires a flexible, agile workforce that can move between disciplines and the Partners and can be ‘passported’ between NHS and social care and beyond the system. There is an ambition that technology will allow the deregulation of various groups of staff.

Notes

[2] The Provider organisations within an ICS will be called Partners. The ICBoard is a ‘body corporate’. So in North Central London we have ‘North London Partners’.

[3] IC Boards are required to keep revenue expenditure within an agreed range set by NHS England.

[4] See here for the McKinsey paper

[5] They used to be called Procedures of Limited Clinical Effectiveness (PoLCEs) but the immaterial nature of ‘value’ broadens the scope of what can be rationed and allows comparison with activities across the system when decisions are to be made about where to spend the limited budget.

[6] Jan Savage, Marion Macalpine and Carol Saunders ‘How come we didn’t know about SubCos? The growing use of NHS-owned private companies’. Pamphlet 2021

[7] a specific kind of neoliberal community care developed during the Reagan administration relying heavily on ‘assets’ e.g. volunteerism, families and friends, charities etc and the use of the market and marketing

[8] Healthcare apps are booming (53,979 registered on Google) and many/most carry adverts to pay developers, and once apps and health devices are linked to health records it will allow tailored adverts to help care and optimise markets.

[9] As Distie Profitt CEO Cerner UK reported in Digital Health- The challenges of leading Cerner UK during the Covid-19 pandemic 2020.

[10] Public Contracts Regulations

[11] Competition and Markets Authority


integrated care systems (ics) and the Health and Care Bill 2021-22

Statement by Doctors in Unite

The Health and Care Bill is now in Parliament, and a new Health Secretary in charge. Doctors in Unite branch of Unite the Union opposes the Bill, and calls for MPs and Lords of all parties to vote against it at every opportunity.

The Bill splinters the NHS into 42 separate ‘Integrated Care Systems’ (ICS), each with its own budget set at a level to promote ‘innovation’, and ‘new models of care’ from the US in pursuit of ‘financial sustainability’. This is also known as cuts and rationing, and where they chose to spend will be determined by what they call ‘best value care’ for the system. Local NHS services will be commissioned by, and finances portioned out by, a ‘streamlined’ IC Board, open to the private sector, and committing local authorities to a financial project without real democratic representation, accountability or control.

The Bill will bring the market and marketing, with profits for corporations and investors from ‘the rise of the consumer’ and the ‘certainties of capitated budgets’ in healthcare. Our future healthcare is to be impacted by transnational corporations and banks, and surely it is no accident that a former banker and Chancellor is now Health Secretary, while the Prime Minister’s NHS advisor for integration is the former CEO of Operose (the UK branch of Centene) Samantha Jones. Some 200 companies, at least 30 of them US-owned and prominent in the health
insurance market, are already accredited to help to develop and manage the Integrated Care Systems. They include Operose (which now controls dozens of GP surgeries and community services), Optum (owned by the largest US health insurance firm and previous employer of Simon Stevens- UnitedHealth), IBM, McKinsey, ATOS, Deloitte and Palantir.

Most importantly what will all this mean for patients and for NHS staff, whose wellbeing is essential to provide effective care?

For patients:
● more remote services resulting in fewer face-to face appointments creating a twotier health service, with access tied to an ability to use computers or smart phones

● less contact with GPs with more care given by less skilled and cheaper staff, and with less chance of seeing the same health worker

● growing expectation that patients will ‘self-care’, using phone apps or websites for advice or information

● more risk that services will be cut or rationed, and non-urgent referrals to hospital delayed or refused because of pressure on ICSs to make savings

● faster discharge from hospital without care assessments, and with family carers expected to take on more unpaid care due to lack of community services

● more confidential information being digitised and shared, with no clear protection for patient privacy.

For staff:
● a threat to national agreements on pay, terms and conditions as each IC Board will have their own limited budget and seek to cut costs

● flexible working, with staff redeployed across and even beyond the ICS area, undermining team working, union organisation, continuity of care, and thus creating more ‘work related stress’

● deskilling, as nursing and other jobs are advertised to candidates without the professional qualifications required, but asked to perform using standardised procedures and algorithms

● deregulation, as the Secretary of State will have the power to remove jobs from regulation with an apparent expectation that clinical decisions will be determined by new technology superseding the need for professional judgement and negating the need for staff development.

For democratic accountability and Local Authorities:
● The Secretary of State for Health will assume decision making power to impose local service reconfigurations weakening the power of scrutiny by local authorities

● the right of access by the public to board meetings and papers may also be threatened.

For legal protections:
● Exempting the NHS from the Public Contract Regulations 2015 will remove the associated environmental, social, and labour law protections (ILO conventions guaranteeing Freedom of Association and the Right to Strike). The government plans for the NHS will have reverberations throughout our society. The responsibility for budgetary constraint in our healthcare will be devolved from Government to each ICS, each of their provider Partners and every member of the public for whom they have core responsibility. The threats to staff should ring alarm bells for every trade union with members in the NHS, and the threats to patients should concern everyone.

Let’s stop this Bill now.

DOCTORS IN UNITE PROTEST OUTSIDE DEPT OF HEALTH 27 JULY 2021 AGAINST INADEQUATE PPE FOR HEALTH AND SOCIAL CARE WORKERS

DiU were joined by a number of organisations on our demonstration to demand protection from airborne transmission for all HCWs. We also received a number of messages of support, including from Diane Abbott MP, the Hazards Campaign, Every Doctor, Prof Trish Greenhalgh, Unite health branch in Nottinghamshire and Prof Raymond Agius. Photos of the protest appear below followed by the messages of support.

Statement from Janet Newsham, Chair of UK Hazards Campaign

The hazards campaign supports those organising and campaigning for justice and safety at work.

UK Hazards Campaign and all its supporters send solidarity greeting to the Doctors in Unite demonstration taking place outside the Dept of Health in London at the same time as our protest outside the HSE in Bootle in the North West England.  We agree that the HSE has a legal duty to ensure safe working conditions for all workers, in our hospitals and clinics and across businesses and industry. 

Throughout the pandemic, the HSE has failed to ensure that employers in all settings are controlling the infection risks to their staff through their duty to provide suitable and sufficient risk assessments. 

They have reacted too late leaving hundreds of thousands of workers infected, thousands left with long-covid and some have sadly died.  We know that PPE is the last resort in the defence from an airborne disease and that before it is considered all other safety measure must be put in place to remove the risks, however if PPE is necessary then we expect high quality respirator face masks at a precautionary standard are provided. 

We accuse the HSE of being complicit with Government in not ensuring that workers have been provided with these, including in high risk health and social care settings. 

Employers, enforcement authorities and the government are responsibility for thousands of needless deaths of workers all over the country by failing to ensure proper air quality in the workplace. 

The UK Hazards Campaign will remember all those who have died but we will continue to fight like hell for the living!

We wish you every success on Tuesday and look forward to continue working together in the future.  Airborne protection NOW for all workers!

Janet Newsham – Chair of UK Hazards Campaign

Statement by Dr Julia Grace-Patterson, Chief Executive, Every Doctor

16 months after the World Health Organisation declared COVID-19 a global pandemic, and where are we? Still trying to get NHS workers the protection they need to stay safe.

Those early months of the pandemic were chaotic. Some NHS staff were given out-of-date PPE, others had none at all. Thousands of health and social care workers were left at risk; and carried this risk to their patients and their families.

Over a year on, 1,500 health and social care workers have died from COVID-19. At least 122,000 more are suffering from long COVID. And yet NHS workers are still waiting.

This government claims to ‘follow the science’. Well the ‘science’ now is very clear. COVID-19 is an airborne virus. And FFP3 respirator masks are the safest PPE we can give healthcare workers. And by protecting NHS workers, we not only protect these individuals; we also protect their families and loved ones, and their patients too.

All health and social care staff should have access to them – no exceptions, no excuses. 

We heard horrifying stories from our community of frontline doctors last year about makeshift PPE. Of staff in GP surgeries and hospitals having to craft their own gowns and masks out of bin bags and sanitary towels, or having to rely on generous donations from local businesses.

Where was the government?

Awarding PPE contracts to companies that were completely unfit, without any transparency or competition, and some of whom had no experience at all in supplying medical equipment.

Alongside Good Law Project, we took the government to court over these shoddy PPE deals. We’re still waiting to hear the verdict, but for EveryDoctor these cases weren’t so much about the judicial outcome itself, but to recognise the sacrifices every one of our colleagues have made in the last year.

One legal victory is never going to solve everything. Our fight to Protect NHS workers is far from over. After 18 months fighting this virus, NHS workers still don’t have the protection they need.

We know that COVID-19 is an airborne virus. But right now the majority of frontline health and social workers are still not being given respirator masks. Government guidelines are still recommending basic surgical masks for the majority of workers.

No amount of clapping or empty words can take away the fears our NHS colleagues still feel when being forced to work in unsafe environments. No one should be forced to work like this, but especially not those who have given their all to care for us throughout this pandemic.

That’s why we’re proud to support this protest today.

Dr. Julia Patterson

Chief Executive, EveryDoctor

Statement from Diane Abbott MP

“I am sorry I cannot be here with you today. But I want to say firstly thank you for all you and your colleagues do and have done throughout this pandemic. 

But I am sorry you have been asked to do it. It is the government’s responsibility that you came into this pandemic completely understaffed and underpaid.  It was the government which didn’t provide PPE, including the saintly Jeremy Hunt as Health Secretary. It was also the government which has allowed so many of you to become ill and die as a result of this virus. 

It didn’t have to be this way.  In New Zealand and China currently have 40 cases between them, and have had no deaths in months.  ZeroCovid is possible. None of this needed to happen.

If £37bn can be wasted on a useless Test & Trace system, why can’t you get a 15% pay rise?  If money can be found for renewing Trident, why can’t you all have proper PPE? And if the government is hiring consultants on £1,000 a day, why can’t they hire more doctors and NHS workers? If the NHS vaccine programme is great, why are they intent on privatising the NHS?

Instead, they let Black and Asian people die in huge numbers, while demonising their communities and denying that racism exists. 

They must be challenged. They must be opposed, so I am glad that you are doing this today.”

Statement from Trish Greenhalgh, doctor and Professor of Primary Care Health Sciences, University of Oxford

This is a shortened version of a video statement by Prof Greenhalgh, which can be seen here https://www.dropbox.com/t/hutkC5mWxinVbx1b

“At the beginning of the pandemic we thought the virus was spread by large droplets and from surfaces.  We now know, beyond any real doubt, that the virus is airborne, and that makes it that much harder to protect against it.  But it also means that this old classification of aerosol generating procedures, for which you would be given higher grade protection, doesn’t really apply.  Because anybody who is look after somebody who has got Covid or might have Covid, really needs to be protected with a level of PPE which protects them against airborne infection, which means a higher grade respirator mask in particular, together with other precautions.

I’ve been working with the Royal College of Nursing, Unite the Union, and many other health and care unions and we’ve been trying to get the rules changed to protect health and care workers, many hundreds of whom have already died from Covid-19.  We shouldn’t be putting our front-line key health workers at this risk.

Please support the demonstration organised by Doctors in Unite outside the Dept of Health on 27th July, if you feel strongly about this issue, as I do.  Lets hope this is a successful protest and that it changes policy, so that front-line workers are better protected.

Thanks very much and good luck to all the protestors on the day.”

Statement from Jon Dale, Unite Nottinghamshire Health branch

Unite Nottinghamshire Health branch congratulates Doctors in Unite for organising this demonstration. We send our solidarity and full support in the campaign for safe workplaces for all.

NHS workers should decide what PPE is required – not government ministers or cash-strapped management. Safe workplaces need enough workers to do the job – not a skeleton staff working exhaustingly long hours.

The campaign for proper PPE is linked to the campaign for a fully funded 15% pay rise. With united trade union action and solidarity, NHS workers can win and inspire all workers to fight for workplace safety and decent pay.

Jon Dale

Secretary

Statement from Professor Raymond Agius, doctor and Emeritus Professor Occupational and Environmental Medicine

Prof Agius has worked tirelessly to publicise the failure of the government and the HSE to protect people in the workplace from Covid-19

“Sorry I can’t join you in London. Because of my age and gender, I don’t fancy travelling from Manchester by train and then on the tube, especially since the ex-mayor of London has decided to grant the ‘freedom’ of the city to the SARS-CoV-2 virus.

However, I have been looking after the health at work of health care workers since 1986 and have been campaigning since March 2020 for them to be provided with FFP3 and other protection against Covid, since #COVIDisAirborne.

So what you are doing today has my wholehearted support.

Best wishes,

Raymond”