The Thatcherite mantra that ‘there is no money’ is finished
The Lansley Re-organisation resulted in a fragmented public Health Medicine framework.
Major disconnects between various units with no over-arching machinery to swing into action.
A huge emphasis on “reducing waste” equating spare bed capacity and stock piling with waste, and paring to the bone so there was no slack in the system, regardless.
This would not just apply to an epidemic, but to major climate related disasters, major fires, (Braford- or Liverpool-type crises).
The fall-back mechanism could ONLY be that the whole health service shut down entirely, so that all resources including trained personnel, equipment and space be dedicated to the acute situation.
- Over 10, 000, skilled and trained public health workers were lost.
- Operational memoryand archival references were lost as professionals were geographically moved into new alien spaces including council offices;
- previously they worked cheek by jowl with health workers and crucially with the General practitioner coordinating groups.
- Speaking to colleagues in corridors, sharing titbits, picking brains, knowing someone has dealt with something before… these are all things which create the essence of a high-quality informed response to a crisis. That is what I think of as ‘memory’.
The British pandemic: anatomy of a disaster
In January 2011, following the Conservative victory at the 2010 election, the Andrew Lansley NHS re-structuring White Paper – despite repeated denial of any such plan throughout the Tory campaign – was presented to the Health Service.
It abolished primary care trusts (PCTs) and Strategic Health Authorities (SHAs), and transferred between £60 and £80billion of ‘commissioning’, or health care funds, from the abolished PCTs to several hundred “clinical commissioning groups“, a major point of access for private service providers. A new executive agency of the Department of Health, Public Health England, was established. Writing in the BMJ, Clive Peedell (NHS Consultants Association and a consultant clinical oncologist) compared the policies with academic analyses of privatisation and found “evidence that privatisation is an inevitable consequence of many of the policies contained in the Health and Social Care Bill”. In April 2011 the government announced a ‘listening exercise’, halting the Bill’s legislative progress until after the May local elections. The ‘listening exercise’ finished by the end of that month. The Bill received Royal Assent on 27 March 2012.
Major, and largely destructive, changes were wreaked on the UK system of delivery of Public Health and protection. The plans produced diffusion of responsibilities and roles, changes to geographical locations of professionals, and disruption of working links between critical areas of health provision. Senior academics and clinicians with years of experience did not survive the changes, several thousand skilled people were lost. Numerous bodies with opaque remits arose from the ashes of this bonfire of scientific and clinical expertise and experience.
In a pandemic there should be clear lines of communication and responsibility, with a capacity to direct personnel and healthcare resources towards areas of greatest need at speed and without excessive need for negotiation between parties. The more financial and business interests and parties within the system the less feasible any such expedient response.
Successful creation of rapid surge capacity and emergency responses depend on there being long-term planning and strategic built in slack within the acute health system for a major disaster. Intensive care beds both within and without quarantine facilities;
trained staffing at all levels tasked with step-up step-down roles;
seamless links with transport (including ambulance and paramedical services) and
These are all the essence of routine major emergency response for a local area. They should form the basis for a coordinated National response too
In the 2009 pandemic crisis, the team at the Department of Health could issue clear advice to the field – because Strategic Health authorities (SHAs) and local commissioning groups held by Primary Care Trusts could lead, police and adjust response and funding across the board. For example, PCTs were charged with ensuring that their local populations were able to get access to antiviral drugs – within 48 hours of the symptoms and were able to plan various methods to ensure compliance. (They were best placed to know sites most easily accessible to the most vulnerable and they were able to locate community centres and pharmacies with strategic spacing across conurbations and bus routes). The provision of PPE and planning for adequate hospital spaces was done at an early stage.
During the 2009 pandemic, the response was led by the Government Chief Scientific Advisor (GCSA) and the Chief Medical Officer (CMO) for England playing key roles. Politicians and civil servants had access to independent scientific and medical advice when taking crucial decisions, such as whether to recommend school closures and to whom to distribute anti-virals. At the time, the CMO was expected to be the cross-government lead for public health emergencies such as pandemic flu.
- The CMO is no longer responsible for medical advice to the NHS (but only to the Secretary of State)
- The CMO does not have Public Health England reporting directly to them
- The CMO no longer has the Department of Health Flu Policy Team reporting directly to them
- The CMO no longer has a budget.
So, it is uncertain how the CMO could play an independent, well informed and credible role in any planning for a pandemic. The frequent trope “we are following the science” and “we did the right thing at the right time” has no traction within this faux-advisory arrangement.
Fragmentation has caused a dangerous lack of clarity about responsibilities, independence, and governance.
An ideological bid to diversify health delivery through numerous private providers has taken precedence over the reconfiguration of services. This, together with years of austerity and a crude and misguided interpretation of ‘waste’ has resulted in an institutional inability to respond to crises even of a minor nature.
Laboratory services, acute beds, provisions of transport, cleaning, sterilisation and PPE services are fragmented within numerous bodies. Existing contractual commitments are impossible to rescind, urgent diversification in supply needs cannot be met by private companies.
So: the old order died and there is no new order.
There were no extra bed spaces, testing facilities and swabs, quarantining facilities, ventilators, masks, visors, gowns. Nowhere to isolate the infected infirm who could not be hospitalised.
No sage, fiercely independent clinicians and academics of stature to provide advice in good enough time, or who could access the public ear in good enough time.
The UK Government’s overarching plan (if it can be called that) for a catastrophic nation-wide health crisis was that the National Health Service, itself should shut down.
And so it has – adding untold deaths to the list of casualties.
The UK is in the shameful position of presiding over the highest death toll in Europe; surpassing even Italy who did not have the benefit of weeks of warning alerts.
And you might imagine, in face of this carnage that somewhere, basic human elements of sorrow and shame or embarrassment might trigger self-appraisal. Not a bit of it. Fragmentation, cronyism, nest-feathering, and profit remain widespread in the government’s responses to the crisis.
The Guardian 5 May 2020, reports
Serco was in pole position to win a deal to supply 15,000 call-handlers for the government’s tracking and tracing operation.
In recent weeks, ministers have used special powers to bypass normal tendering and award a string of contracts to private companies and management consultants without open competition.
Deloitte, KPMG, Serco, Sodexo, Mitie, Boots and the US data mining group Palantir have secured taxpayer-funded commissions to manage Covid-19 drive-in testing centres, the purchasing of personal protective equipment (PPE) and the building of Nightingale hospitals.
Now, the Guardian has seen a letter from the Department of Health to NHS trusts instructing them to stop buying any of their own PPEand ventilators.
From Monday, procurement of a list of 16 items must be handled centrally.
Many of the items on the list, such as PPE, are in high demand during the pandemic, while others, including CT scanners, mobile X-ray machines and ultrasounds, are high-value machines that are used more widely in hospitals.
Centralising purchasing is likely to hand more responsibility to Deloitte.
As well as co-ordinating Covid-19 test centres and logistics at three new ‘lighthouse’ laboratories created to process samples, the accounting and management consultancy giant secured a contract several weeks ago to advise central government on PPE purchases.
“The government must not allow the current crisis to be used as cover to extend the creeping privatisation of the NHS,” said Rachel Reeves, the shadow chancellor of the Duchy of Lancaster.
by Camille Mazarelo, retired medical consultant,
[i] In the writing of this document I have consulted the 2014 document from the Centre for Health and the Public Interest
Dr Hilary Pickles (Public Health) and David Rowland (health and social care policy research)
iii Other material worth reading:
How Market Reforms Made the NHS Vulnerable to Pandemics Colin Leys: Tribune Magazine 4.03.2020
Scientists fault UK’s pandemic strategy as deaths rise. Maria Cheng : Star Tribune May 2nd 2020[i]