The only future for the NHS after COVID-19 is a return to its founding principles

The COVID-19 pandemic illustrates the vital importance of a comprehensive, publicly funded and universal health service. The choices we make during this crisis will shape the future of the NHS and our wider society.

We are already limited by poor decisions made before the virus struck. The Conservative’s ‘hostile environment’ policy, where people with a precarious immigration status risk deportation or destitution if they seek NHS services, means there may now be considerable apprehension to access necessary care. Though coronavirus treatment is exempt from charging for those without documentation, this message is likely to be lost.

When more beds were needed, rather than requisition private hospitals the government struck a deal where beds are rented for £300 each, per day. This amounts to a public sector bail out of private hospitals that the NHS should never have to pay. These beds could be utilised in the public interest; instead they are rented at public expense.

The government then wrote off £13.4bn of NHS debt. It is disingenuous to call this debt. It represents money that has been rightly spent on patient care, and the government’s actions acknowledge this with a trick of accounting. It is also only a fraction of the shortfall in NHS funding over the last ten years of austerity.

A sincere approach to the NHS’ debt would be to cancel Private Finance Initiative payments. £2bn was paid in 2016/17 in PFI debts, and repayments will continue every year until 2050. This lost wealth represents around 2% of the annual NHS budget. It could be reinvested to improve the nation’s health but instead vanishes into private hands. The same is true for private buildings used for NHS services. There is an opportunity to return these to the ownership of the public they serve.

Fragmentation, cuts and creeping privatisation have all contributed to the difficulties in our response the pandemic. More than 17,000 beds have been cut from the 144,455 that existed in 2010. The UK has a lower number of critical care beds per person than Italy, France, Spain, Germany, the USA, Japan, or South Korea. Years of underfunding led us to this moment. The PPE distribution fiasco shows the inability of the private sector to provide the service needed. Cutting warehouse capacity in order to prioritise profit means private distribution companies cannot now supply health and social care workers with the person protective equipment they need.

The hundreds of billions of pounds made instantaneously available in response to coronavirus shows the transformative power of the state to provide a crucial safety net for all of us. We can afford a far fairer society than the one we became accustomed to. Rapid changes to manufacturing capacity to produce ventilators, dialysis machines, PPE and other socially useful products demonstrates that an economy based on public ownership, planning and democratic control could meet the needs of people across the world, unlike the chaotic response of the free market.When this crisis eventually subsides, the public must not be made to pay. We must not return to more austerity.

We also cannot emerge from this pandemic and continue to ignore the harm caused by environmental destruction. The delayed, incomplete initial response to coronavirus echoes our apprehension to face the challenge presented by climate change. We should confront the runaway economic expansion that created the conditions for previous, current, and perhaps future outbreaks. We have an opportunity to live within our planetary means.

We could recreate our health and social care systems based on need not profit. We could choose to reduce inequality permanently. The reset button on society has been pushed – what happens next is up to all of us.

‘Laid-off cabin crew with resuscitation skills’ – what is the answer to the NHS staffing crisis?

Faced with an NHS and social care system ill prepared for the coronavirus pandemic, a call went out for 250,000 volunteer community support workers to help up to 1.5 million people who have been asked to shield themselves from infection because of underlying health conditions.

The response has been staggering, with more than 400,000 coming forward. The recruitment target has now been raised to 750,000. They will deliver medicines from pharmacies, drive patients to appointments and bring them home from hospital, and make regular phone calls to check on people isolating at home.

Quite how vetting, safeguarding, training and safety issues will be addressed is unclear, but that this is tapping into a strong desire on the part of many people to be helpful to their fellow humans cannot be doubted. There have also been large numbers of retired NHS workers offering to return to work and help their struggling colleagues. 

The Tories have been obsessed with getting unpaid labour to support the failing health and care systems, now wrecked by years of their austerity and underinvestment. In the process, they have also given volunteering a bad name. After Cameron’s ‘big society’ initiative sank without trace, 2018 saw the launch of a charity called helpforce. This planned to massively boost the numbers of NHS volunteers from 74,000 to “millions” and was the (as yet unrealised) ambition of merchant banker Sir Thomas Hughes-Hallet, better known to his friends as ‘Huge-Wallet’. The aim appeared to be for volunteers to do the work that hard-pressed doctors and nurses (through staff vacancies) did not have the time for. With 40,000 empty nurse posts, and bursaries that had been axed, NHS England managed to find £2.3m for helpforce in the Long Term Plan.

Currently, the NHS Nightingale nursing workforce is to be supplemented by recently laid-off air cabin crew with resuscitation skills, and first aiders from St John’s Ambulance. This unit has more than 80 wards each with 42 beds; around 16,000 members of staff could be needed should it reach full capacity. 

An unresolved question is just where the trained NHS medical and nursing staff will come from to add to the small numbers of military personnel and staff promised from the private sector. Chief nurses around the country have been asked to state their numbers of spare critical care staff – the replies are not difficult to imagine. One suggestion has been to send staff from distant parts of the country relatively behind London in the course of the pandemic and give them crucial experience before sending them back to their own hospitals. One of the objections to this is that the average length of stay for a critically ill patient is two weeks, and the surge in patient numbers likely to be maintained much longer than this. Staff sent to London would probably be kept there, greatly reducing NHS capacity in the regions just as the caseload rocketed. However, if we had a properly coordinated national response to the crisis, the possibility of NHS workers moving temporarily to hot spots might be a valuable strategy.

Of course many people still have a sense of social solidarity and want to find ways to help others. Such altruism should be both lauded and facilitated. It stands in stark contrast to the neoliberal ideology of Conservative governments – it appears there is such a thing as society after all. 

In response to the pandemic support for medical and care staff, as well as vulnerable neighbours, has been provided by members of the public all over the world, independently of the state.  This is indeed evidence of the thrilling and transformative force of mutual aid. In this context there is plenty of room for volunteers, and an energy that needs to be harnessed in the fight for universal health care in the post-covid era.

However, volunteers recruited by the government or their agencies should never be used as a substitute for trained staff. They should only ever be in supporting roles. Look to supermarkets: now in urgent need of extra hands, they have created new jobs and hired people to work. In the first instance community support staff could be recruited from those workers who have lost their jobs and livelihoods. They could be given a contract, a wage and some training. While I would prefer an experienced ICU nurse to look after me if I become ill in hospital with COVID-19, since they will be at a premium and caring for six patients rather than the usual one, I will not object to them being assisted by redeployed cabin crew with some medical skills and experience of keeping cool in emergencies. There may well also need to be willing volunteers in non-clinical support roles to keep the show on the road. 

Volunteers are not the solution to the crisis in staffing that existed pre-pandemic, and is now exacerbated by illness. But together with additional paid redeployed staff recruited with some level of skills, given basic training and afforded the usual protections of employees, they will be part of the solution until the crisis is over. Some of them may then even join the fight for restoration of a truly public, universal NHS.

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

Living together, staying apart: self-isolating in a shared house

Like many people in the UK, I live in a house of multiple occupation (HMO). We make an improvised family of five. Three of us work in the NHS: one junior doctor on a geriatric ward, one junior doctor on a psychiatric dementia ward (me) and one working in administration. The other two are finishing off their studies as mature students.

Last week, we went into self-isolation as my housemate in admin had developed a fever and cough the week before. It was a strange time, none of us became ill as a result but we had to make big adjustments quickly at a time when the country was still getting its head around the emerging pandemic.

Now that we are going back to work, I am actually more anxious about how this will affect the health of our patients and of each other. While my other doctor housemate will likely be working with patients who have COVID-19, my patients in psychiatry are highly vulnerable if they contract the virus. If one of them does, it will be hard to contain the spread, as we cannot force patients to stay in their rooms if they wish to wander. The last thing I want now is to pick up the virus at home and bring it to my patients.

There are around 500,000 HMOs in England and Wales. People who live here tend to be young single adults choosing HMO living because it is a more economically viable and social option.

HMOs present a challenge in controlling the spread of disease. Apart from the fact that people are living closer together and sharing communal spaces, there is also housemate etiquette that can make it challenging to use the space in a harmonious way. Social distancing is understandable when going to the shops, park or to visit friends, but to change behaviour within the home is a change in behaviour that asks much more of us. When you share a bed and eating spaces with other people, where do you draw the line in this time of social distancing?

To answer this, I have tried to compile some simple tips for minimising the spread of disease in the home:

Wash your hands as soon as you come in. The alternative to this is rigorous washing of front/back door handles and keys. I think it is more achievable to make sure that hands are washed after this, especially if you have just been shopping.

If you have been working in a clinical environment, try to change your clothes at work or as soon as you get home. I am also going to leave a change of clothes at work to make this easier. If you will be working in areas with covid-19 then ask for scrubs to help protect yourself and others.

Have your own mug/glass/bowl/cutlery and wash them well after use. This minimises on washing up and means there won’t be any accidental cross contamination.

Have your own assigned tea towel/towel in the kitchen and bathroom. Slightly more tricky as it can result in there being also of fabric everywhere. Hand washing is all very well, but drying hands on a contaminated cloth will only re-contaminate them. If you don’t have endless supplies of paper towels (which we definitely don’t) then an individual towel will help.

Shared meals mean less people in the kitchen at once and it’s great not to have to cook every night. Practice hand hygiene in preparing meals. Communal living can still be isolating at times and shared meals are the perfect opportunity to check in on everyone.

Daily clean of: cupboard, door and appliance handles, light switches and taps. Any surface that is going to be used by multiple people could be a source of spread. The number of times a day to clean is not evidence-based, just realistic!

Physical distancing not social distancing: enjoy each other’s company from a safe distance and combat loneliness! Ultimately, if unwell people in your house are well looked after, this will allow them to stay isolated and make them feel cared for.

Rachel Hallam is a junior doctor and member of Doctors in Unite

COVID-19: Response from Doctors in Unite

The threat posed by COVID-19 demands a united national response across the UK. As well as protecting individual and public health, the burden of maintaining public resilience must be shared equally, on a pooled basis across society.

In response to COVID-19, Doctors in Unite urges the government to:

  • Extend day-one sick pay to those on zero hours contracts, in the ‘gig-economy’ and to the self-employed.
  • Ensure that workers are not under pressure to attend work while they are unwell and may inadvertently pass on the disease, both financially and in regards to staffing.
  • Allow the NHS to requisite private health care facilities to accommodate effective COVID-19 treatment and quarantine provision if needed.

Trades Union Congress General Secretary Frances O’Grady has said:

“Employers have a duty of care to support workers affected by coronavirus. No one should have to worry about making ends meet if they have to self-isolate or if they fall ill. They should be able to focus on getting better.”

The government issued a statement on 4th March, explaining that statutory sick pay (SSP) would be available from day one, and that “there is a range of support in place for those who do not receive Statutory Sick Pay, including Universal Credit and contributory Employment and Support Allowance (ESA).”

This solution is not sufficient for the three million people in the UK on self-employment contracts plus the two million workers who do not earn enough (£94.25 per week) to claim SSP. In order to claim, these workers would need to enrol for Universal Credit which can take up to five weeks for payment. The alternative is ESA which requires claimants to have built up two to three years of National Insurance contributions.

Doctors in Unite endorses the position adopted by the Socialist Health Association which strongly supports the TUC, and urges that this scheme is extended to those workers who currently do not qualify for SSP.

Employers should make up SSP to the average pay of workers to ensure they are under absolutely no financial pressure to attend work while they are unwell and may inadvertently pass on the disease. This must apply not only when patients are ill but also when people are laid off work for public health reasons, even if they themselves are not actually unwell. 

This is an area where the government must step in, as many sectors (e.g. retail, hospitality, or care providers) which interact most with the public may not have the financial resilience to weather the storm created by COVID-19.

Should the coronavirus outbreak spread significantly everyone will be expected to respond by putting the interests of the community first. Undoubtedly workers will volunteer long hours and take on exceptional responsibilities. This will increase the risk of errors, which will need to be balanced against the risk of failure to treat patients in a mass outbreak. We urge professional bodies to be aware of this.

Our NHS must be in a position to requisition private health care facilities where it will increase local health capacity or facilitate quarantine provision.

As the trade union for medical doctors, Doctors in Unite congratulates our colleague trade unions and Labour leaders for engaging with the government and employers, to ensure that these steps are taken as a matter of urgency in the national interest.