100,000 Deaths and a White Paper: What we need instead in Britain
When Imperial College’s modeller Neil Ferguson told the British government in early March 2020 that it was on course to see 250,000 deaths from COVID-19, he was widely seen as scaremongering. Now his warning looks no more than sober. The government has already taken us past the grim milestone of 100,000 deaths, more deaths per capita than any other country in the world except Czechia, and is on course for 125,000 by the end of the winter. And the government’s plans for lifting the national lockdown that began in January look likely to cost between 32,000 and 55,000 further deaths between February and June this year.
The cost in lives has been matched by greater economic cost than almost anywhere else too: UK national income fell 9.9% in 2020, compared with 3.5% in the US, 4.8% in Japan and 5% in Germany, while China’s and Korea’s national incomes actually grew.
To cap these achievements, the government has now brought forward legislative proposals for changes in the National Health Service (NHS), to be implemented next year. It claims that its proposals “capture the learning from the pandemic and are driven by the context of a post-COVID world, which is now in reach.” In reality, they just aim to legalise the ramshackle arrangements cobbled together by Simon Stevens (Chief Executive of the NHS) in order to get around Lansley’s unworkable marketisation scheme; and they undo the one marginally benign consequence of that scheme – the formal independence of the NHS chief executive from the health secretary of the day. The real lessons of the pandemic are studiously ignored. As a response to the moral and social catastrophe we are living through, the white paper is grotesquely inept.
We need to remind ourselves of the nature of the crisis, and what a government genuinely committed to national security would have done. A pandemic was going to come – a flu pandemic was high on the government’s risk register – and the UK was exceptionally vulnerable. London, with six international airports, was the world’s largest aviation ‘hub’. In mid-2019, including all UK airports, two and a half million passengers were arriving from other countries every week. Once imported, a new virus would spread easily, thanks to the UK’s high level of inequality compared with every other comparable OECD country except the US. Neoliberal economic policies and deindustrialisation had created the classic conditions for transmission: areas of poor and overcrowded housing, concentrated in the midlands and north and parts of London, with high potential for transmission and lower levels of immunity among the residents. All this was well known by every public health professional in the country.
This vulnerability had also been exacerbated by ten years of austerity imposed on the poor: local authority spending on adult social care per capita was cut five times more in the poorest areas of the country than in the most affluent areas, and many other services critical for poor people’s health were closed.
On top of this the state’s capacity to respond to a pandemic was severely reduced. By 2020, the UK had fewer hospital beds, fewer doctors, and fewer nurses per thousand people than almost all comparable OECD countries. Ninety per cent occupancy of hospital beds came to be seen as normal, rising to a hundred per cent or more in the winter. Surplus hospital-bed capacity came to be seen as a waste of money, not a necessary reserve.
The drive to marketise healthcare from the mid-1990s onwards also downgraded public health. Creating a quasi-market in healthcare meant thinking in terms of quasi-profits from individual quasi-customers (‘money follows the patient’), and there were none to be made from protecting public health. So, the previously autonomous Health Protection Agency was merged into Public Health England, an organisation within the Department of Health, and its regional personnel were transferred to work in local government, where their funding could be – and was – cut, leaving local Directors of Public Health with just a handful of staff. And when, in 2016, Exercise Cygnus showed that there were serious gaps in the country’s readiness to deal with a pandemic flu outbreak – fragmentation of responsibility, lack of equipment, lack of coordinated information – no significant steps were taken to close them. Overall responsibility for responding to epidemics no longer rested with the Chief Medical Officer, and so it was not done.
These weaknesses were compounded by the kind of government that came to power in December 2019. For the next two months, it was deaf to anything but Brexit. The threat from the new virus was spelled out definitively in the Lancet in late January, but throughout February, little was done. On 11 March, the Director General of the WHO finally declared a pandemic:
“In the past two weeks, the number of cases of COVID-19 outside China has increased 13-fold, and the number of affected countries has tripled. There are now more than 118,000 cases in 114 countries, and 4,291 people have lost their lives. Thousands more are fighting for their lives in hospitals. In the days and weeks ahead, we expect to see the number of cases, the number of deaths, and the number of affected countries climb even higher.”
The same day, Chancellor of the Exchequer, Rishi Sunak, presented a triumphalist budget focussed on delivering Brexit and ‘levelling up’, with provision of about £12-billion for the economic costs of COVID-19. Six days later, this had to be raised to £330-billion. On 23 March, the country went into lockdown. By the end of March, 1,700 people had died of the new disease. By the end of June, 40,000 had died.
Behind this delay, and the even more lethal delays that followed in September and December, lay a mindset promoted by Dominic Cummings in the Brexit campaign in which magical thinking and falsehoods had proved extraordinarily successful. Disdain for expertise, celebration of ‘disruptors’, an inclination to think that dreams will come true if believed in fervently enough, blocked the recognition of reality for some time. Johnson’s keenest supporters, such as the backbenchers who later formed the so-called Covid Recovery Group, were strong on slogans and wasted little time on trying to understand the essential nature of the pandemic. When the emergence of new variants of the virus showed that vaccination would never be a complete solution, the CRG turned to bluster, demanding a complete end to restrictions and urging us to just accept that some people are always going to die from COVID-19.
Why this is so is perhaps a question for psychoanalysts, but there is also the embarrassment of £22-billion of sunk financial and ideological capital in the outsourced ‘NHS Test and Trace’ programme. The decision to outsource this work was, of course, driven by an ideological commitment to private enterprise, but the capacity of the state to plan and implement a national project on this scale had already been surrendered to outsourcing companies; there was no longer a pool of senior civil servants capable of mobilising the needed response. The result was a profitable failure: the companies involved, besides being grossly wasteful, never delivered on any of their targets and failed catastrophically to make ready for the huge second wave that scientists had been predicting from the late spring onwards.
But the project was also fundamentally misconceived, having no component for monitoring or enforcing the isolation of Covid-positive people and their contacts, and making no realistic provision for maintaining their incomes while not working. So on top of the late delivery of test results and the limitations of the ‘call-centre’ approach to tracing and providing contacts (only some 60% of the contacts of people who tested positive were reached in time to prevent them transmitting the virus if they had got it), compliance with isolation was minimal: in August 2020, five months after NHS Test and Trace was set up, fewer than a fifth of people who tested positive, and only 11 per cent of their identified contacts, were self-isolating. In short, the whole purpose of mass testing was defeated, yet nothing has been done to change this. Two weeks of isolation is unpleasant: two weeks without income is impossible for breadwinners on low incomes, many of whom decline to be tested for fear of being told to self-isolate and risk losing their income or even their jobs.
The government’s continued refusal to confront this question is interesting. To the extent that it comes from anxiety about the potential cost it looks irrational: the cost of providing full income support for two weeks to people in isolation would be much less than the estimated cost of keeping several million people on furlough (about £5.5-billion a month down to December 2020); and it would have a major impact on suppressing the virus, eventually making income support for everyone else unnecessary. Perhaps what blocks the government is the scale of the U-turn that would be involved in scrapping the ‘NHS’ Test and Trace Programme, hastily rebranded as a core component of the new National Institute for Health Protection announced by Hancock in August last year, with the ineffable Baroness Harding nominally in charge. Perhaps, too, there is a reluctance to look too closely at the living conditions of the people who are suffering most from the pandemic.
In March, the government’s chief scientific adviser, Patrick Vallance, shocked the public by saying that 20,000 deaths from COVID-19 would be ‘a good outcome’ of the measures the government was belatedly taking. Now we are close to 120,000. It might be unfair to say that the Johnson government is answerable for all the additional 100,000. But their responsibility for most of them – and for the other ‘excess deaths’ resulting from the NHS’s inability to maintain many non-Covid services – is inescapable. What is more, it is their reluctance to respond rationally to the pandemic, leading to successive lockdowns, that accounts in large part for the scale of the still unfolding economic disaster.
The New Policy Paper
Entitled “Integration and Innovation,” the white paper proposes two main changes as lessons learned from the pandemic. The first is to give a legal basis to the 44 ‘Integrated Care Systems’ (ICSs are called systems rather than Organisations to avoid sounding like America’s Health Maintenance Organisations) that have taken over decisions from Clinical Commissioning Groups (CCGs) on how both primary and most hospital care is organised. At the moment, the managers of ICSs have no legal authority for doing this – it has been authorised by Simon Stevens with government backing, meaning that the actual disbursement of funds continues to be by CCGs, but deciding how much should be spent on what services by which providers is decided by the ICS. The end result of legalising the ICSs will be 44 bodies that bear a superficial resemblance to the old Regional Health Authorities, but there is a crucial difference: whereas the health authorities were regional offices of the Department of Health, the leadership of ICSs consists of people mainly drawn from the hospital, from mental health and other trusts, and from general practices in their area. In other words, providers will be paying themselves (and each other, and their sub-contractors, in various mixes, under the rubric of ‘collaborative commissioning’). At the same time, the requirement to put all contracts out to tender is to be scrapped, and the centrally-determined ‘tariff’ for specific treatments will be able to be varied without reference to the centre.
All this is represented as reducing ‘bureaucracy’ in favour of ‘internal’ (i.e., within NHS) integration. But what will stop ICSs from becoming a welter of conflicts of interest, and an open door for cronyism is not clear. How the people in charge of ICSs will be appointed is not clear, and the white paper provides no proposals for making them accountable to Parliament or local communities. Being required, in principle at least, to commission work from the lowest bidder, under the competition rules was at least one way of trying to ensure accountability for public funds. What is to replace competitive tendering as a guarantee of accountability the white paper does not say. Apparently, funds will be allocated on the basis of ‘social value’. And to ensure that funds are allocated according to this remarkably flexible principle, the white paper suggests only that the notoriously underpowered Care Quality Commission may be asked to ‘review’ how the new system is working.
As for ‘external’ integration, especially between the NHS and social care, as the pandemic has painfully demonstrated, none currently exists, but this is not one of the lessons mentioned in the white paper. It is silent on the basic problem that, unlike NHS care, social care is means-tested, and that the public funds that do go into it for those who can’t afford it come from local authorities. Instead, the paper says that the government will yet again bring forward proposals to reform social care later this year, and while we wait for this constantly-receding prospect. it proposes to legislate for a ‘duty to collaborate’ to be laid on both NHS and local authorities. How this duty is expected to prevail over the conflicting legal obligations of ICSs and local councils is left undiscussed.
The second main change, which has attracted the most media concern, is the plan to give the health secretary extensive powers to direct the strategy of NHS, to intervene and decide on local service changes (hospital closures or mergers, etc.), and to issue guidance on what collaboration means in practice. It is difficult to know what to make of this. Campaigners were previously afraid that the chief executive of NHS England would use the independence given him by the Lansley bill to privatise the hospital system, and so, they called for the restoration of the health secretary’s power of control. But the chief executive was still appointed by the health secretary, and could be removed by him, and so, far from selling out to American health companies. Stevens replaced the market model with something closer to the old system. In light of the way the government has used its Covid emergency powers to favour its friends with lucrative contracts, it is perhaps Conservative health secretaries who now present the greater danger.
But what is really most striking about the white paper is what it omits. There is no reference to the need for far more substantial funding for the NHS: while it may not have ‘fallen over’, it was forced to abandon a large part of its services, building up a list of people waiting for treatment that will take several years to clear even if additional Covid-related funding continues. There are proposals to make it clearer who is responsible for training the workforce but nothing on the need to substantially expand it. There is no reference to the need to restore the centrality of public health, other than to allude to the National Institute for Health Protection, whose structure and functions have still to be spelled out. In the midst of a national catastrophe, the white paper contains not a glimmer of original or creative thinking about the future.
What We Need Instead
We must refuse to engage on this paltry terrain. The pandemic, and the government’s abject failure to respond to it, should prompt a radical set of popular demands. Not since 1948 has there been such overwhelming public support for the NHS, or for the medical scientists and public health experts without whose knowledge and warnings even more lives would have been lost. In this context, and in recognition of how close we have come to an even greater disaster, we must reject this tinkering with the status quo.
‘Integration’ has served as a useful cover for Simon Stevens’s dismantling of the Lansley competition-based model, but it is a perverse misnomer for what the white paper proposes to embody in law. True integration is incompatible with a system of in-built conflicts of interest. Decisions about service provision need to be clearly accountable both to Parliament, and locally, to the public, neither of which is the case in what is proposed. Integration of healthcare with social care is indeed also needed, but is only possible if social care also becomes a public service. And neither this, nor adequate funding for the NHS, is ‘unaffordable’, especially while real interest rates are negative. What is unaffordable is to face the next pandemic as unprotected as we were for COVID-19. •
This is a revised version of article published on the Tribune website.