NHSE/I consultation on Integrating care: a response from Professor Allyson Pollock and Peter Roderick, Population Health Sciences Institute, Newcastle University; and David Price, independent researcher

NHSE/I recently published a consultation document on the “Next steps to building strong and effective integrated care systems across England”. This response exposes the fundamental problems of a market based health care system in trying to deliver integrated care.

1. Overview

Publication of the next steps document during the covid-19 pandemic comes at a remarkable moment. Significant shortcomings have been exposed in the NHS1, in the systems for communicable disease control and public health,2 in the procurement system3 and in the social care system.4 The lack of hospital and ICU capacity have been major drivers of national lockdowns in March 2020 and January 2021 and the causes of severe winter pressures in previous years.

At the same time, the pandemic has demonstrated the obstacles created by market bureaucracy and heavy-handed and centralised market regulation which have developed over decades in the NHS.

The document hints at positive effects of the pandemic (paragraph 2.1) and refers in general terms to some of them (e.g., 2.72), which have played a part in “increas[ing] the appetite for statutory ‘clarity’ for ICSs and the organisations within them.” (3.8). It also recognises “the persistent complexity and fragmentation” which is rightly complained about (1.3).

This is largely the product of reforms premised on competitive relations and contracting among health bodies. Finally a new anti-competition consensus appears to have emerged in NHS reform5 which has found its way, though problematically, into the document.

But as David Lock QC has said in 2019: “The big picture is that you have a market system. If you do not want a market system and you want to run a public service, you need a different form of legal structure.” And this obvious truth raises fundamental questions, which the document seems to glimpse, but which it is unwilling to grasp.

Why, for example, continue to insist on running health organisations as businesses if the aim is collaboration instead of competition? How should needs-assessment and population planning be undertaken if the aim is to secure comprehensive health and social care for geographic areas? Where should they be located and on which bodies does the statutory duty of universality fall? How can major political questions surrounding resource distribution be undertaken consensually outside established political processes? Equitable access and solidarity require risk-pooling and a community response.

Rather than rising to the challenge of these questions in ways which could reliably “provide[] the right foundation for the NHS over the next decade” (page 31), the document puts forward substantial de-regulatory proposals which continue to ‘work-around’ the current statutory market-based framework and undermine risk-pooling, even when proposing legislative change; much essential detail is omitted.

As they stand, the proposals seek to achieve integration by focussing on increasing freedoms of the various bodies involved in commissioning and contracting. They rely on general exhortations to counter deregulation. Laudable “fundamental purposes” inform an “aim” of “a progressively deepening relationship between the NHS and local authorities”. Three “important observations” which may or may not be aims relate to more local decision-making, more collaboration and economies of scale. A “triple aim” duty of unspecified strength relates to “better health for the whole population, better quality care for all patients and financially sustainable services for the taxpayer” (1.3, 1.8, 1.9, 3.3).

The approach however leaves substantially unchanged the legal powers of the many incorporated bodies active in the health care market among which collaboration is expected but from which disintegration has spread. If the aim is “rebalancing the focus on competition” (3.3) a concrete.

administrative alternative is required. None is offered. Seeking to promote greater integration whilst retaining commercial autonomy will not work.

In summary, the proposals:

  • leave in place the purchaser-provider split and commercial contracting;
  • continue the ability to give further contracts to private companies, including, it seems, integrated care provider contracts;
  • provide no response to the finding of the National Audit Office in 2017 that “The Departments have not yet established a robust evidence base to show that integration leads
  • to better outcomes for patients”;
  • favour no controls on ICS membership;
  • give immense and barely-regulated power to monopoly providers and clinical networks
  • contain no controls on the composition of “provider collaboratives”, which could include, for example, large private hospitals;
  • are silent on public accountability mechanisms at a system level, and at the non-statutory “place” level;
  • repeal section 75 of the 2012 Act, revoke some of the ‘section 75 regulations’ and remove commissioning of NHS healthcare services from the Public Contracts Regulations 2015 – which are welcome – but are silent on the safeguards against corruption and conflicts of
  • interest, and some of the section 75 regulations would seemingly be retained;
  • emphasise the importance of strategic needs assessment – which is also welcome – but do not require the assessment to frame provision or to qualify the power of providers and clinical networks;
  • do not appear to make ICSs responsible for all people in an area, and there are unresolved difficulties for integrating health and social care because of different funding bases for different populations;
  • are silent on whether individuals on GP lists will transfer to an ICS body, a provider or a provider collaborative;
  • are unclear on the fate of CCGs in Option 2;
  • contain no explanation of how capital investment strategies will operate, and whether charges on capital, including PFI charges, will change;
  • do not address the powers of NHS foundation trusts;
  • are unclear on how local authority public health funding will be protected;
  • are unclear on how social care funding will be protected, and how the currently different funding bases for health and social services will be addressed;  
  • are silent about workforce planning;
  • envisage, but are unclear about, moving staff between organisations, and their terms and conditions.

We discuss the details in the following two sections.

2. ICSs during 2021/22 and before legislation

The document seems to have two purposes: to further progress ICSs and the merger of CCGs ahead of legislation; and to explain changes to the NHSE/I’s legislative proposals published in September 2019.

Our understanding of what an ICS will be and do, before legislation, is set out in the below.

What will an ICS be and do before legislation – as far as we can make out?

An ICS will not have legal form and will consist of:

  • provider organisations as part of one or more undefined and self-determined “provider collaboratives” operating within and beyond the ICS playing “an active and strongleadership role” and being “a principal engine of transformation”(2.4, 2.31, 2.63); and
  • place-based partnerships”, defined by each ICS but seemingly comprising providers of primary care, community health and mental health services, social care and support, community diagnostics and urgent and emergency care – i.e., excluding secondary care, but including local authorities, Directors of Public Health and Healthwatch, and “may” include acute providers, ambulance trusts, the voluntary sector and other – undefined – partners (2.31, 1.16).
  • It will receive a “single pot budget” which would comprise “current CCG commissioning budgets, primary care budgets, the majority of specialised commissioning spend, the budgets for certain other directly commissioned services, central support or sustainability funding and nationally-held transformation funding that is allocated to systems” (2.40), and will decide how that budget should be delegated to local “places” within the ICS.
  • Providers will “agree proposals developed by [undefined and self-determined] clinical and operational networks” and will “implement resulting changes” including “implementing standardoperating procedures to support agreed practice; designating services to ensure their sustainability; or wider service reconfiguration”; and will “shape the strategic health and care priorities for the populations they serve, and new opportunities – whether through lead provider models at place level or through fully-fledged integrated care provider contractual models – to determine how services are funded and delivered, and how different bodies involved in providing joined-up care work together” (2.11, 1.44).
  • The ICS will undertake more strategic needs assessment and planning than CCGs can do, resulting in “the organisational form of CCGs…evolv[ing]” (2.62-2.63).
  • The ICS will be subject to governance and public accountability arrangements that are said to be “clear but flexible”, but will not be statutory. (2.28-28, 2.19)

We make a number of key points under the following headings:

(1) Strategic needs assessment

The emphasis on strategic needs-based assessment and planning is welcome, yet there will be no single body which has the responsibility to carry it out and no legal mandating of it. This is likely to lead to buck-passing. Perhaps more importantly, it is also likely to lead to needs-based planning being overridden by increasingly powerful monopoly providers having pivotal influence over a single budget, and over its allocation both for non-secondary care services to undefined “places” with no statutory identity, and for secondary (and tertiary) care.

Moreover, it seems highly unlikely that services provided would be based on the needs assessment, because clinical networks are expected to carry out “clinical service strategy reviews on behalf of the ICS” and “develop proposals and recommendations” which providers will agree. Indeed, “[c]linical networks and provider collaborations will drive…service change” (2.26, 2.11, 2.72). No tie-in to the strategic needs assessment is proposed, let alone a requirement for it to frame provision.

Public health experts have traditionally performed the functions of needs assessment, facilitating service development and service planning. However, public health sits outside of health services and is further fragmented between local authorities and the Secretary of State (Public Health England, to be replaced by another non-statutory body, the National Institute for Health Protection) as a result of the 2012 Act.

Clinical Support Units provide information and support for commercial contracting. They are not substitutes for public health, are not integrated into CCGs or local public health departments, and do not inform strategic needs assessment and service planning.

(2) The single pot budget

It appears – certainly before, and perhaps after, legislation – that ICSs will not be responsible for all people within an ICS area. That term – an ICS area – is conspicuously absent from the proposals. The CCG membership model (‘persons for whom they are responsible’) cannot be changed without legislation and so will presumably be ‘scaled-up’ to cover all the CCGs involved.

We have previously expressed6 concern about how Accountable Care Organisations would have been able to integrate health and social care services because their funding would have been for a different population (GP lists versus local authority), and would not have health service funding allocated for unregistered CCG residents who might be eligible for local authority social services. This concern still applies in relation to ICSs, including provider collaboratives and place-based partnerships, both with and without legislation, and with and without integrated provider care contracts.

In addition, the bases upon which resources will be allocated to secondary (and tertiary) care and to place-based partnerships, and within those partnerships are entirely unclear. This is presumably deliberate. Already there has been a marked decrease in administrative accountability for spending, and multiple contracts and subcontracts – which will continue – make it increasingly impossible to ‘follow the money’, let alone to assess the costs of contract administration. Detailed financial reporting to NHSE/I is obviously essential and may be provided for, but public transparency in funding as between primary care, community and mental health services, and acute, secondary and specialist care, including sub-contracting, is also essential.

(3) Provider collaboratives

No control is proposed over the composition of these collaboratives. They could and presumably will consist of private as well as public providers, e.g., of mental health services, residential and nursing care, acute hospital care and pathology services. The potential inclusion, for example, of large private hospitals, which have been contracted during the pandemic, needs to be clarified immediately. No control is proposed over the granting of contracts to providers within thesecollaboratives, who may in fact be distant from and have no connection with the local community and be subject to commercially-driven mergers, acquisitions and closures that threaten patient care.7

Full integrated care provider contracts can be awarded, though there is no reference to the House of Commons Health and Social Care Committee in June 2019 having “strongly recommend[ed] that legislation should rule out the option of non-statutory providers holding an ICP contract [in order to] allay fears that ICP contracts provide a vehicle for extending the scope of privatisation in the English NHS”. In September 2019, NHSE/I acknowledged this and stated that it supported the recommendation. If private companies are not likely to be awarded such contracts, then what is lost by legislating to that effect? And what prevented a clear statement to that effect being made in this document?

Neither is there any reference to the HSC Committee’s recommendation that “ICP contracts should be piloted only in a small number of local areas and subject to careful evaluation”.

(4) ICS membership

There are two potential aspects in this regard.

The document proposes for legislative change Option 2 that the ICS body should be able to appoint such members to the ICS body as it deems appropriate “allowing for maximum flexibility for systems to shape their membership to suit the needs of their populations” (3.19). It seems that this will be possible de facto before legislation, e.g., via the unspecified provider collaboratives. This risks giving private companies influence over the allocation of NHS funding: “they are there to make money from the NHS” in the words of Dr Graham Winyard – and should not be admitted as members. Yet the document is silent on this point.

As for patients, the document is silent on whether individuals on GP lists will transfer to any provider (e.g. under an integrated care provider contract), or even to a provider collaborative – or, after legislation based on Option 2, to an ICS body; and, if so, how that would be achieved and whether individuals would have any choice in the matter. In addition, will individuals be able to move from one ICS to another? And what happens, for example, if an individual is on the list of a GP (or provider or provider collaborative) within the ICS, but lives in a local authority area within another ICS and requires social care?

NHSE/I should clarify these issues as soon as possible.

(5) Public accountability

ICSs will be making major resource allocation decisions, which will often be controversial. Transparency and scrutiny will be critical. However, the document says nothing about how current public accountability requirements and mechanisms will work in an ICS context. These mechanisms are based mainly around CCGs and local authorities, but in reality these bodies will no longer be the decision-makers. Actual decision-making will be de-coupled from legal functions and the effectiveness of public accountability will be diminished in the process.

(6) Competition and contracting

Proposals to remove market competition, compulsory contracting and the commissioning of NHS healthcare services (only) from the Public Contracts Regulations 2015 – which are welcome – cannot happen without statutory change; the rights of private providers and the purchaser-provider split remain in place. The work-arounds continue.

(7) Social care

Adult social services are means-tested. Health services are not. Providers of social care and support are said to be included in place-based partnerships, but the allocation of resources to and within the partnerships is entirely unclear. There is no mention of any safeguards to prevent services which are currently free from being re-designated as social care and so subject to means-testing and possible charges.

(8) Public health

Local authority public health will fall within place-based partnerships. As for other services covered by these non-statutory partnerships, there is no mention of how protecting public health funding will be achieved in the face of the power of provider collaboratives and clinical networks operating at the level of the ICS and beyond. Representation by DPHs and other local authorities is unlikely to be enough.

(9) Workforce planning

The next steps document is silent about work force planning. Lack of doctors and staff is already a serious issue after years of fragmentation, lack of investment and, appallingly, absence of a strategy: the Kings Fund described it recently as “a workforce crisis”. NHSE/I need to be clear about how attempts to improve this critical function would operate in the ICS context.

(10) Moving staff and their terms and conditions

It is proposed that there should be “frictionless movement of staff across organisational boundaries” (bizarrely in the context of data and digital technology, page 20). This is capable of different meanings across a spectrum, but nothing more is said about this, nor on the terms and conditions of staff in the ICS context. Much more information should be provided.

3. ICSs after legislation

There is much less information on legislative changes in the next steps document than was contained in NHSE/I’s September 2019 document entitled The NHS’s recommendations to Government and Parliament for an NHS Bill. The next steps document lists some of thoserecommendations and states, oddly, “We believe these proposals still stand” (3.3, 3.4). This statement makes it unclear whether they continue to be proposals.

The next steps document proposes two options for legislation.

Option 1 would establish the ICS as a mandatory statutory ICS Board in the form of a jointcommittee of NHS commissioners, providers and local authorities with an Accountable Officer, and with one CCG only per ICS footprint which would be able to delegate “many of its population health functions to providers” (page 29).

Option 2 would set up a new statutory ICS body asan NHS body by “repurposing” CCGs, taking ontheir commissioning functions, plus additional duties and powers, and having “the primary duty…to secure the effective provision of health services to meet the needs of the system population, working in collaboration with partner organisations”. It would have “flexibility to make arrangements with providers through contracts or by delegating responsibility for arranging specified services to one or more providers”. It would have a board of representatives of system partners (NHS providers, primary care and local government alongside a Chair, a Chief Executive and a Chief Financial Officer as a minimum) with the ability to appoint such other members as the ICS deems appropriate “for maximum flexibility for systems to shape their membership to suit the needs of their populations” (page 30).

NHSE/I prefer Option 2.

Most of the points we have made pre-legislation continue to apply. We expand on some of those and add to them as follows:

(1) Major reorganisation

It is striking that despite the apparent opportunity for primary legislation following the Queen’s Speech neither Option grapples with the fundamental questions posed in the Overview above, which flow from the anti-competitive consensus (if such there be). This might be because NHSE/I wish to avoid being seen to be proposing a major reorganisation. But this is exactly what is happening, even without legislation.

In September 2019, NHSE/I stated:

“The Select Committee [in July 2019] agreed that NHS commissioners and providers should be newly allowed to form joint decision-making committees on a voluntary basis, rather than the alternative of creating Integrated Care Systems (ICS) as new statutory bodies, which would necessitate a major NHS reorganisation.” (emphasis added)

(2) Competition and contracting

No legislative changes are proposed to the purchaser-provider split. Whilst repeal of procurement rules under section 75 of the 2012 Act and removal of commissioning of NHS healthcare services (only) from the Public Contracts Regulations 2015 are welcome, the document is silent on safeguards against corruption and conflicts of interest.

It is also important to recall that in September 2019 NHSE/I stated that it would retain a number of the provisions of the NHS (Procurement, Patient Choice and Competition) (No.2) Regulations 2013 – commonly referred to as the ‘section 75 regulations’. Of particular worry, exacerbated by the covid-19 pandemic, is retention of “the requirement to put in place arrangements to ensure that patients are offered a choice of alternative providers in certain circumstances where they will not receive treatment within maximum waiting times”. The possibility of the use of private providers in these circumstances, rather than increasing NHS capacity, is obvious.

(3) Fate of CCGs

NHSE/I still seem undecided about the fate of CCGs in Option 2. Under both Options, the document states that “current CCG functions would subsequently be absorbed to become core ICS business” (2.64). Yet the document only proposes, in relation to Option 2, to replace the CCG governing body and GP membership, but for some unknown reason does not state that CCGs will be abolished, which presumably they must be, under Option 2, with no replacement.

(4) ICS membership

The document proposes in Option 2 – though we are not clear why this is not a possibility in Option 1 nor de facto from now onwards (see section 2(4) above) – that the ICS body should be able to appoint such members as it deems appropriate. This would be a blatant undermining of the ICS as an NHS body.

In addition, as stated above (section 2(4)), it is unclear whether individuals on GP lists would be transferred to the ICS body.

(5) Missing proposals

  • Even though both Options propose primary legislation, the document contains no proposal for ICS-specific public accountability mechanisms, for abolishing the purchaser-provider split, or to give place-based partnerships a legal identity.
  • A fundamental omission is how capital investment strategies will operate and whether charges on capital will change. NHS Property Services is now charging market rent for property occupied by Trusts, CCGs and some GP premises. Foundation trusts have autonomy over the property they hold and investment decisions. However, the Private Finance Initiative has left a legacy of major debt in health services and in local authorities. There has been no public scrutiny of the impact of the covid-19 pandemic on PFI contracts, on debt repayments and on renegotiation of the exorbitant rates of interest being paid out as part of the annual payments.
  • The powers of FTs are not addressed not least the ability to generate up to half their income from outside the NHS, at a time when public capacity is reducing and waiting lists, e.g., for surgery and cancer care, are growing. Nor is it made clear whether current contracts with large private hospital chains (SPIRE et al.) are long-term and whether they will be involved in provider collaboratives.
  • In September 2019, NHSE/I recommended abolishing the prospective repeal of the power to designate NHS trusts that was enacted in the 2012 Act but never brought into force, to support the creation of integrated care providers. The next steps document only mentions this in passing (3.3). It remains unclear if this still being proposed and, if it is, the circumstances in which it could be exercised.

4. Conclusion

These proposals are incoherent, de-regulatory and unclear, and are not equal to the existential threat that is posed by the current government to the NHS as a universal, comprehensive, publicly-provided service free at the point of delivery. This has been amply demonstrated by the government’s response to the covid-19 pandemic which has directed billions of pounds to private companies to provide services that should have been provided by the NHS, Public Health England and local authorities. The proposals allow this to continue and increase.

Neither can the ambition of providing a sound foundation for the next decade be sensibly addressed without considering the inevitable but uncertain changes that will be necessary post-pandemic to the public health and social care systems, and to the functions of local authorities.

The challenge now is much greater than it was in 2019, when the difficulties of getting major NHS legislation through the House of Commons was used as a reason/excuse for not proposing legislation equal to the task of taking the market out of NHS once and for all. We urge MPs who are committed to the NHS as a public service to support scrapping the 2012 Health and Social Care Act in its entirety and to support the NHS Reinstatement Bill which would put back the government’s duty to provide key services, delegated to Strategic Integrated Health Boards and Local Integrated Health Boards.

Footnotes

  1. E.g., lack staff, beds and other capacity following inadequate investment and the absence of a workforce planning strategy over many years; inadequate planning and personal protective equipment (PPE); marginalising GPs..
  2. E.g., devaluing local authorities and the NHS by centralising and privatising tracking, tracing and testing; spending hundreds of millions of pounds on inaccurate lateral flow tests; by-passing the established system for notifying suspected cases.
  3. E.g., spending billions of pounds on untendered contracts, including to companies with no track record.
  4. E.g., shortages of staff and PPE; high excess deaths; inappropriate discharge of hospital patients to care homes.
  5. “These developments [of STPs and ICSs] represent an important shift in direction for NHS policy. The 2012 Act aimed to strengthen the role of competition in the NHS, consolidating a market-based approach to reform that has been in place since the establishment of the internal market in 1991. By 2019, however, competition rarely gets mentioned in NHS policy. Instead, the Five Year Forward View, STPs, and ICSs are based on the idea that collaboration – not competition – is essential to improve care and manage resources, including between commissioners and providers”. Health Foundation submission to the Health and Social Care Select Committee inquiry into legislative proposals in response to the NHS Long Term Plan, April 2019.
  6. Pollock AM, Roderick P. Why we should be concerned about accountable care organisations in England’s NHS. BMJ 2018; 360: k343. https://allysonpollock.com/?page_id=11
  7. Care Home Professional, Terra Firma close to £160m care home sale to Barchester Healthcare, 15 November 2019, https://www.carehomeprofessional.com/terra-firma-close-to-160m-care-home-sale-to-barchester-healthcare-report/

Statement on urgent need to update Public Health England (PHE) and Infection Prevention and Control (IPC) guidance on coronavirus infection prevention and control to reflect what has been learned about the importance of aerosol transmission

At the start of the pandemic it was thought that spread of coronavirus was through large droplets travelling over a relatively short distance or by fomites contaminating hands and mucous membranes. The danger of aerosol spread was recognised, but thought to be limited to ‘aerosol generating procedures’ (AGP) such as intubation. For this reason, high grade face masks (FFP3 or N95) were only recommended for staff exposed to AGP (1).

The denial of aerosol transmission of virus  (2) always sat uncomfortably with the acceptance that so called AGP represented a risk. It is now known that aerosols are generated by talking, shouting, singing, coughing and sneezing and are an important form of viral transmission.  Official Infection Prevention and Control (IPC) guidance [3] is now seriously lacking on the issue of AGPs: several studies [4] [5] [6] indicate that many of the “classic” AGPs (like intubation) produce little in the way of aerosols and that an actively coughing patient may be much more infectious than those undergoing various AGPs.  Moreover, patients with Covid-19 requiring AGPs are likely to be sicker and later on in their illness course, and will therefore produce much less aerosolised virus than patients who have just become symptomatic, when infectiousness is known to be at its greatest.

In fact, coronavirus can be spread over large distances, for example in food processing plants (7) or in restaurant settings. Studies in health workers of SARS-CoV-2 antibody status (signifying past infection) (8) strongly suggest that high level PPE (including high grade masks) is effective in preventing infection, and that use of surgical type fluid resistant masks is inadequate in situations where staff are in close contact with symptomatic patients such as on hospital wards.  

In addition, ventilation in enclosed and crowded workspaces is clearly an important risk factor in spread, yet there is little specific advice to manage this risk other than keeping windows open. This is a particular concern in workplaces and schools where maintaining social distancing is difficult; currently the highest rate of new infection is among secondary school children.  The fact that a recent update of official IPC guidance does not mention aerosol spread at all (outside of AGPs) is inexplicable, given that this was after Public Health England recognised this route of transmission over two month ago.  This puts tens of thousands of health and social care workers at potential risk in hospitals, primary care settings and in care homes, as well as the patients they care for.

The pandemic is far from over, with more than 600 health and care workers already having died, and an overall death toll in the UK equivalent to one international airplane crash killing all passengers every day for nine months. Although vaccine development gives some cause for hope, important unknowns remain how many people will receive/accept vaccination and how long this process will take, whether vaccination will prevent transmission and therefore achieve herd immunity, and how long protection might last. There is therefore every reason to hone non-pharmacological interventions in order to reduce further loss of life. We therefore call upon PHE and the Department of Health and Social Care to recognise an urgent need to update guidelines on COVID-19 prevention and control in the light of what is now known about aerosol transmission. This should include upgrading type of masks worn (9) and advice on how to maintain and monitor effective ventilation.

References

  1. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control
  2. https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations
  3. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/910885/COVID-19_Infection_prevention_and_control_guidance_FINAL_PDF_20082020.pdf

Doctors in Unite statement on Covid-19 vaccines

“Doctors in Unite are supportive of vaccination as part of a broader strategy to end the COVID 19 pandemic. In general we believe that any risks from the vaccines will be outweighed by the benefits.

However, it is difficult to say this categorically when the trial data and protocols have not been made available. We call for these to be published in full. Complete transparency should be a given and is vital in the current climate of mistrust.

We note that under usual circumstances Phase 3 trial participants are intensively followed up for six months followed by a lower level of surveillance for up to two years. We appreciate that these are unprecedented times but at the time of writing vaccines are being rolled out for mass administration within four months of the commencement of phase 3 trials with little opportunity to document medium or long term effects.

If debilitating side-effects emerge, there should be full compensation for anyone affected – including loss of pay, care and any other needs – for as long as necessary and without having to fight lengthy battles

Johnson and his government’s handling of the pandemic has been one of shocking mismanagement bordering on criminal negligence. They have lurched from one bad decision to another, have handed contracts worth billions of pounds to their friends without proper scrutiny and failed to listen to the experts. This has led to an understandable deep level of distrust amongst the public and a worrying reluctance among some sections of the community to agree to be vaccinated. This is concerning, as the very people who are at most risk of poor outcomes from COVID 19 are those who are least likely to come forward for vaccination.

We believe that until more is known about the efficacy of the vaccine in suppressing COVID 19 that vaccination can only be part of a broader strategy to combat the virus.

Robust, community based Find, Test, Trace, Isolate and Support, organised through local Public Health and Primary Care is still essential, though sadly lacking. Messaging about staying safe with frequent hand washing, mask wearing and social distancing must continue and proper attention must be paid to ventilation and indoor airborne spread.”

Mitigation of risk of COVID 19 in occupational settings, with a focus on ethnic minority groups: Consensus Statement from PHE/HSE and FOM *

* Summary response from Doctors in Unite to the recent statement by Public Health England, the Health and Safety Executive and the Faculty of Occupational Medicine.  A more detailed review of the consensus statement can be found here.

With thanks to the TUC: Dying on the Job.  A report into Racism and Risk at Work


Doctors in Unite feel that the recommendations are nowhere near enough to mitigate the risks of COVID 19 in ethnic minority groups.

Employers cannot be trusted to be left to their own devices to ensure that workplaces are safe. We are aware that this is an extreme example, but in the largest meat packing factory in the US, managers coerced staff to continue working when they were clearly symptomatic of COVID 19 and took bets on who would become unwell. Five of the staff died.

It is of course welcome to have culturally sensitive information in many languages to alert people of ethnic minorities to important measures that they can take themselves to mitigate their risk, but the consensus statement does not touch on the much greater impact that factors beyond the control of the individual has on their risk.

A disproportionate number of people from ethnic minority backgrounds are employed in low paid sectors such as cleaning and caring roles, where they cannot work from home. They often have inadequate PPE. Studies have shown that cleaners in hospitals are more likely to catch COVID 19 at work than clinical staff who work with COVID patients. The latter have greatly superior PPE.

To make matters worse people from ethnic minority backgrounds often live in overcrowded, multigenerational households meaning that spread of infection within communities is likely to be disproportionately high.

Neither does your statement mention the increasing evidence of the importance of indoor airborne spread in the transmission of COVID 19 and the necessity of proper ventilation in the workplace.  A detailed study of the outbreak in the Tönnies meat packing plant in Germany in June showed the importance of ventilation in such plants

Only last year the UN Special Rapporteur, Philip Aston said during a visit to the UK that:

“Policies of austerity introduced in 2010 continue largely unabated, despite the tragic social consequences.” 

We believe that the consensus statement would be much stronger if the emphasis was not focused on health education messages which put the onus on the individual to avoid catching COVID 19 but on the legal duty of employers to ensure a safe working environment and on Government to tackle the long recognised social determinants of health which lead to stark health inequalities.

A whitewash and another missed opportunity: the Consensus Statement from PHE, HSE and FOM on how best to mitigate risk of COVID 19 in occupational settings, with a focus on ethnic minority groups. *

* Detailed response from Doctors in Unite. A summary response can be found here.

With thanks to the TUC: Dying on the Job.  A report into Racism and Risk at Work

Doctors in Unite are disappointed with the recent consensus statement by Public Health England, the Health and Safety Executive and the Faculty of Occupational Medicine.  It is yet another missed opportunity to address the underlying causes of the high rates of infection and death from Covid-19 among ethnic minority workers in the UK.  The recommendations contained in the statement do not go anywhere near far enough to mitigate the risks they face from COVID 19 in the workplace.

The statement makes numerous self-evident statements like “existing workplace guidance and legislation should be reinforced across the whole workforce”, and “all individuals, including those from ethnic minority groups, should have the same approach to risk management in the workplace”, and “the approach to controlling risk should be equitable”.  While it says “employers have a legal duty to protect all workers from harm” it focusses almost entirely on individual responsibility and individual risk factors of workers, like age, sex, deprivation, obesity and diabetes.  Much of the statement concerns itself with “culturally competent” communication as though this were some new breakthrough in occupational risk mitigation, when it is simply the basic requirement to communicate clearly and respectfully with all people whatever their backgrounds.  The implication is that the disparities in infections and deaths of BME workers is down to their not understanding risks and risk mitigation, and better, “culturally competent” communication will solve the problem.

It is of course welcome to have culturally sensitive information in many languages to alert people of ethnic minorities to important measures that they can take themselves to mitigate their risk, but the consensus statement does not touch on the much greater impact that factors beyond the control of the individual has on their risk.

No mention of structural racism in society or racism in the workplace

The consensus statement opens by saying: “a wide range of research has explored the pathways that cause ethnic inequalities and have shown that this is a complex relationship, and the relative importance of different pathways in COVID-19 ethnic inequalities is not well understood”.  It references the paper by SAGE, Drivers of the higher COVID-19 incidence, morbidity and mortality among minority ethnic groups.

While the relative importance of different pathways or mechanisms may not yet be clear, the central theme of the SAGE paper is that structural racism determines these pathways, and their combined effect leads to the much greater impact of Covid-19 on BME people. (see diagram from the SAGE document in the appendix) The SAGE paper says, “All of these mechanisms arise from the wider social context that drive ethnic and other social inequalities, such as power relations and structural racism.”  Yet the consensus statement simply ignores this and does not mention the word “racism” once in the entire statement.  The consensus statement in fact misrepresents the SAGE paper in this regard, implying the usual “It’s very complicated and we need to do more research” response which is trotted out whenever action and real change is demanded over racial discrimination.  The statement is also extraordinarily myopic given the times we are living through, i.e. the Black Lives Matter movement, and the wider debate and reckoning with racism that BLM has engendered across UK society as a whole. 

The recent Channel 4 documentary “Is Covid-19 racist”, involved a number of high profile BME doctors, including Professor Tollulah Oni, Epidemiologist at the University of Cambridge, and member of Independent SAGE, and Dr Chand Nagpaul, Chair of the Council of the British Medical Association, who were unequivocal that discrimination at work was a direct contributor to the highly disproportionate deaths from Covid-19 suffered by ethnic minority doctors.

The consensus statement does mention “historically oppressed groups”, but only in relation to it explaining “understandable mistrust towards members of the majority culture in cross cultural interactions.”  Where is mention of current day racism and discrimination?

In an article in the New Statesman in 2018, Dr Zubaida Haque, also a member of Independent SAGE, and Deputy Director of the Runneymede Trust, wrote: “BME people are already affected by substantial structural inequalities: they are more likely to live in poorer households, more likely to face multiple disadvantages in the labour market (race, gender and religious discrimination) and more likely to have higher rates of child poverty in their households than white groups. Recent analysis by the Runnymede Trust and the Women’s Budget Group on the impact of budget and austerity cuts also shows that BME people, and BME women in particular, are the worse hit by the cuts.” 

Only last year the UN Special Rapporteur, Philip Aston said during a visit to the UK that: “Policies of austerity introduced in 2010 continue largely unabated, despite the tragic social consequences.”

To make matters worse people from ethnic minority backgrounds often live in overcrowded, multigenerational households meaning that spread of infection within communities is likely to be disproportionately high.

Where is the voice of BME workers?

The day-to-day experience, and the voice of BME workers is not reflected anywhere in the consensus statement.  There are countless reports documenting this, like the TUC’s report “Dying On The Job”, which has this to say:

“BME workers experience systemic inequalities across the labour market that mean they are overrepresented in lower paid, insecure jobs. These inequalities are compounded by the discrimination BME people face within workplaces. Our research carried out just before the outbreak of Covid-19 revealed that BME people’s experiences at work are blighted by discrimination: almost half of BME workers (45 per cent) have been given harder or more difficult tasks to do, over one third (36 per cent) had heard racist comments or jokes at work, around a quarter (24%) had been singled out for redundancy and one in seven (15%) of those that had been harassed said they left their job because of the racist treatment they received.

Yet very few had felt able to raise these issues.

As the disproportionate impact of Covid-19 on BME workers became clear, a range of individuals and organisations debated why this was the case, with a variety of explanations being put forward. Nowhere in these debates were the voices of BME workers heard. We set out to rectify this, launching a call for evidence to properly understand the issues workers were facing and what their preferred solutions were.

What people told us was shocking but not surprising as it directly reflected our research conducted before the pandemic and the experience of BME workers over the years. One in five of those who responded to our call for evidence said they had been treated unfairly because of their ethnicity at work during the pandemic and around one in six said they had been put at more risk at work because of their ethnicity. BME workers told us about being singled out for higher risk work, denied access to PPE and appropriate risk assessments, unfairly selected for redundancy and furlough and hostility from managers if they raised concerns. Workers repeatedly said that the fact that they were agency workers or did not have permanent contracts was exploited through threats to cancel work or reduce hours, both to silence them and force them to work in higher risk situations.”

Are these issues not relevant to the much greater rates of infections and deaths of BME workers?

Grossly inadequate health and safety monitoring and enforcement in the workplace

Employers cannot be trusted to be left to their own devices to ensure that workplaces are safe or to report occupational exposure to Covid-19.  For example, employers in the Leicester garment factories failed to protect Asian workers against Covid-19, while exploiting workers and paying illegal wages well below the minimum wage.  Widespread under-reporting of infections in the food processing industry goes on; one study found there were at least 30 times the number of cases as those reported by employers under the RIDOR regulations.  In the US an extreme example of employers acting with impunity over workers’ safety, occurred in one plant run by Tyson, the largest meat packing company in the US, when managers coerced staff to continue working when they were clearly symptomatic with COVID 19 and took bets on who would become unwell. Five of the staff died.

It is perhaps not surprising that practices like this occur, when the ability to regulate the workplace, the responsibility of HSE and Local Authorities, has been so severely weakened by cuts over the last decade, as well as a culture of “health and safety being a burden to business” encouraged by the government.  In 2015 the government issued a press release which said: “Boosting business by easing health and safety burden – 84% of rules scrapped or improved”.  The TUC estimates that in the past decade HSE inspections have fallen by 70%, and prosecutions for breaches by 82%.   The situation is so dire that statistically, each workplace can expect to be inspected by the HSE once every 275 years.  Local Authority enforcement of health and safety law and practices has been “eviscerated……Local authorities issued 80 per cent fewer health and safety enforcement notices in 2018-19 than they did in 2010-11.”  

Lack of regulation negatively impacts all workers, but more so BME workers as they are more likely to be in insecure work, and less likely to have the protection of trade unions

The impact on workers of a severely weakened regulatory framework is also not mentioned anywhere in the consensus statement.

BME workers face greater workplace exposure to Covid-19

A disproportionate number of people from ethnic minority backgrounds are employed in low paid sectors such as cleaning and caring roles, where they cannot work from home. They are often in public facing roles and often have inadequate PPE.  Earlier this month the High Court found the UK has failed to grant workers in the gig economy the rights they are entitled to under EU Health and Safety law. This includes the right to be provided with Personal Protective Equipment (PPE) by the business they are working for, and the right to stop work in response to serious and imminent danger.  The case was brought by the International Workers of Great Britain (IWGB) a union representing mostly Black, Asian and Latino workers, who are twice as likely to be on these zero-hour contracts compared to their white peers.

A study at the University Hospital Birmingham showed that cleaners in the hospital were more likely to catch COVID 19 at work as front-line medical staff who work with COVID patients.  ICU and theatre staff had less than half the seropositivity rates, and they have greatly superior PPE.  The study also showed that BME health care workers had twice the seropositivity rate of their white colleagues, and that this difference persisted after the results were corrected for deprivation, indicating that greater workplace exposure was the reason.

The TUC report “Dying on the job” spells out how racism in the workplace results in this greater exposure.  Where are any of these practices mentioned in the consensus statement or any recommendations made how to tackle them?

Inadequacies in existing workplace guidance also not addressed

The consensus statement also does not mention the importance of indoor airborne spread in the transmission of COVID 19 in the workplace, and the necessity of proper ventilation.  Existing government guidance was until recently very poor on this issue (it essentially said “open windows and doors where possible”); it now refers to the newly updated HSE guidance on ventilation, which is much better. However, without additional resources to improve ventilation and without a regulator to monitor and enforce the new ventilation guidance, it is difficult to see how things will improve for many workers currently working in risky environments. Workplace guidance has also not caught up with the scientific evidence on aerosol transmission in other respects, even though official PHE guidance recognised this 2 months ago.  The fact of aerosol spread makes a mockery of the “1m plus rule”, i.e. workers should wear a mask or increase ventilation only if they cannot socially distance by 2m.  The consensus statement simply endorses existing guidance; indeed it says it should be reinforced.  We would ask, why do there continue to be hundreds of workplace acute respiratory infection  incidents of Covid-19 every week if the current guidance is effective? 

Large outbreaks of Covid-19 have occurred in workplaces, many involving large numbers of BME workers, where inadequate ventilation is thought to play an important role.  A detailed study of the outbreak in the Tönnies meat packing plant in Germany in June showed the importance of ventilation in such plants, and demonstrated it was factory working conditions and not individual worker behaviour which was responsible for this large superspreading event.

It is the responsibility of employers to address issues like ventilation in the workplace, and to provide all workers with face coverings of appropriate specification to reduce risk of spread.  The consensus statement says nothing of these issues either, and while employers continue not to implement them, further outbreaks will continue to occur to the detriment of all workers.

Conclusion

The consensus statement offers nothing new and in fact is retrogressive.  None of the major determinants of occupational risk are discussed and the emphasis is focused on health education messages which put the onus on the individual to avoid catching COVID 19, and any individual risk factors workers may have.  Workplace guidance is seriously flawed in important respects, and the regulatory framework is barely functional.  Hundreds of Covid-19 infection incidents occur each week in the workplace.  All workers suffer the consequences.  There is also studious avoidance of the issues of racism both in the workplace and structural racism in society at large.  The voice of BME workers is yet again not heard.  The statement can safely be called a whitewash; it does nothing to draw attention to these issues or the failure of employers to ensure a safe working environment, or the failure of Government to tackle the long recognised social determinants of health which lead to stark health inequalities.

29 November 2020

Appendix

Structural racism in ethnic minority Covid-19 infection and mortality

If image is indistinct please see page 4 here.

From: Drivers of the higher COVID-19 incidence, morbidity and mortality among minority ethnic groups, 23 September 2020.  Paper by the ethnicity sub-group of the Scientific Advisory Group for Emergencies (SAGE).

We must stop being polite about Test and Trace— there comes a point where it becomes culpable *

Source: https://covid.i-sense.org.uk/

Test and Trace is a disaster and doctors should voice outrage, not remain silent.

We must stop being polite about the national Test and Trace service. Its privatised design by politicians is a lethal mistake. Yet the media is awash with statements implying that we should “allow” time for it to be improved. It cannot improve in its present state. Both the media and our profession appear complicit in allowing systematic misinformation, egregious miscalculation, delay, and diversion of public funds, to benefit private companies. We all want to pull together in a collective effort and we are wary of rocking the boat. But there comes a point when being silent (and being polite is a kind of silence) becomes part of the problem. 

A year ago Richard Horton of The Lancet urged doctors to consider non-violent direct action over our collective failure to address the environmental crisis. The government is failing to manage both the environmental crisis and the pandemic. This means that the covid-19 crisis is a likely precursor of environmental collapse. Horton’s exasperation is caused by the profession’s acquiescence. Our silence at the ineptitude of our government’s handling of covid-19 is as serious as our silence over the environment. 

The national Test and Trace is a disaster. Its design means that it cannot possibly contain outbreaks of covid-19. It is obsessed with testing at the expense of all the other necessary links in the chain of actions needed to control outbreaks. It fails to detect asymptomatic people and those who are unwilling or unable to be tested and it ignores false negatives. This means that before it starts, it has potentially missed up to 80% of those who are infectious. It then loses cases at each of the stages of informing the index case, collecting information on contacts, reaching those contacts, and then persuading them to self-isolate. Probably less than 20% of those advised will effectively self-isolate. The national Test and Trace fails dismally to find cases at the start of the process and then fails dismally at the other end of the process in supporting people through the difficulties encountered in trying to effectively self-isolate. It is likely that less than 5% of the contacts of those who are currently infectious with covid-19 self-isolate effectively. We as tax payers are paying billions of pounds for this failure.

During this second lockdown the country is paying a massive economic price, people are enduring enormous social disruption, and more lives are being lost. When the numbers of cases are reduced again by this second lockdown, unless there are root and branch changes, the national Test and Trace is likely to fail to prevent a third or even a fourth lockdown. Yet the government continues to expand the single link of testing while neglecting the other links in the long chain of find, test, trace, isolate, and support as described by Independent Sage. Surely, doctors should be standing up at every opportunity and on every platform to object vociferously to a massive failure of public health management? Instead, we are embarrassed to watch senior doctors be bullied by politicians who are out of their depth.

The mistakes the government has made in managing the pandemic are legion, but the national Test and Trace service is the single biggest and most persistent mistake. Plans for massive expansion of testing have some merit, but will be ineffective without each of the other links in the chain being properly organised. A big testing programme will not identify people who are unwilling to be tested because they just cannot afford to be found positive.

We have learnt many things about covid-19 this year. For example, it is spread more by aerosol than by touch, masks are helpful in decreasing spread and treatment with dexamethasone is effective for seriously ill patients. Most important of all however, is that track and trace services that are properly organised, generously funded, and locally run, can control and eliminate the virus from a population, as has happened in New Zealand and other countries.

Should we not listen to our own emotional responses? Societal problems are not caused only by bad people, but by good people remaining silent. It’s time for the medical profession to pull together and show nothing less than moral outrage. The privatised national Test and Trace system must be brought back under the control of the NHS and local public health experts with support from general practice as outlined by Independent Sage. Assessment of patients prior to and after testing by professionals, must be put in place. Primary care is best placed to provide this. There must also be meaningful financial and social support for those self-isolating, some of whom will need hostel or hotel accommodation to be able to do this. Full independent audit of every stage of this chain of interventions is required. We must show our outrage now to enable effective isolation of cases and contacts during November and December. Without this we will be stuck in a cycle of repeated lockdowns.

Bing Jones, former Associate Specialist in Haematology, Sheffield. 

Jack Czauderna, former GP Sheffield.

Paul Redgrave, former Director of Public Health, Sheffield.

On behalf of Sheffield Community Contact Tracers

*This is a reprint of an article that appeared in the British Medical Journal. Dr Jack Czauderna is a member of Doctors in Unite.