Allyson Pollock and Louisa Harding-Edgar say there is also an opportunity to end the neoliberalism that got us to this point
There is no doubt that the Westminster government’s delay in implementing public health measures to prevent Covid-19 has cost thousands of lives and enormous hardship for the many millions of people plunged into unemployment and debt. For nearly two months following the first confirmed case of coronavirus in Britain on 30 January, the Westminster government allowed the virus to let rip throughout our communities with inadequate effort to control or contain it. This was despite the early warnings from China (via the World Health Organisation (WHO)) in January this year and when our newspapers and televisions were covering stories of hospitals in Wuhan being erected in nine days.
Perhaps the most surprising aspect of the British Covid crisis is that the Scottish Government has allowed its strategy and operations to be directed by Westminster, which has taken a London-centric approach to the epidemic and with respect to the lockdown. And yet the Covid pandemic is not just one big homogenous epidemic. It is made up of hundreds – if not thousands – of outbreaks, each at a different stage, ongoing throughout the country.
Structural changes to public health – loss of local capacity and fragmentation
The lack of capacity is down to budget cuts and structural changes that removed and fragmented local public services for communicable disease control in England. Lansley’s Health and Social Care Act 2012 in England carved out public health functions from local health bodies and then further fragmented them, splitting them between local authorities and Public Health England (PHE) – an agency of the Department of Health and Social Care.
PHE now controls the decimated workforce for communicable disease control, including the 300 or so field epidemiologists who, instead of being largely based in local authorities, have been centralised in regional hubs, thereby reducing their numbers and their effectiveness on the ground. Meanwhile, although there are said to be over 5,000 environmental officers in local authorities, some of whom had indicated that they were ready to go and start contact tracing if called upon, no one made contact with them. However, when COBRA made the fatal decision to stop contact tracing on 12 March, PHE had only contacted 3,500 people in Britain – of which just 3% were cases and had been told to self–isolate. Resumption of contact tracing has been beset by delay. Instead of immediately building up capacity in local public health and local contact tracing teams, the government wasted time and resources awarding contracts to the private sector to develop an NHS App, and on an unevaluated centralised privatised system for contact tracing – neither of which are operational.
And so, for 12 days after stopping contact tracing on 12 March until 23 March, the virus was left to tear through our communities. Not only that, but the governments north and south of the border had not put in place travel restrictions and quarantine at the ports of entry for people coming from abroad – it appears Scotland had no powers. But lessons from communicable diseases and previous epidemics have shown that it is vitally important to monitor the ports of entry – harbours and airports.
Contact tracing and travel restrictions not implemented
The governments had both advance warning of the epidemic and advance sight of the measures that China, Singapore, Hong Kong and Taiwan had put in place. By 24 February, WHO had published a most compelling and informative WHO China mission report – but as the WHO assistant director general, Bruce Aylward, commented: “Much of the global community is not yet ready, in mindset and materially, to implement the measures that have been employed to contain Covid-19 in China.” He went on to say: “These are the only measures that are currently proven to interrupt or minimise transmission chains in humans. Fundamental to these measures is extremely proactive surveillance to immediately detect cases, very rapid diagnosis and immediate case isolation, rigorous tracking and quarantine of close contacts, and an exceptionally high degree of population understanding and acceptance of these measures.”
In Wuhan, the national lockdown and travel restrictions were accompanied by local intelligence gathering and local, on-the-ground contact tracing and medical observation. Even without mass testing capacity – it appears there were only 10,000 RT-pcr tests conducted in that time in Wuhan with a population of 11m – the Chinese controlled the infection, combining contact tracing with house-to-house symptom checking and quarantining and isolation, travel restrictions, and lockdown. All these measures were necessary and had been ramped up. If anything, testing was of far less importance, though, of course, was a very useful support.
When the epidemic was spreading too fast in some areas in Britain for contact tracing capacity, then the next step should have been to keep disease out of areas which had no cases and to stop all mass gatherings.
As the epidemic was raging in Italy, the government allowed the transmission of the virus across the border as plane-loads of infected skiers from Austria and tourists and visitors from Italy made their way back to Britain. In April, plane-loads of Romanians were being flown in to pick fruit, despite the millions unemployed and in furlough and despite Brexit. And yet at the same time, people have been fined for making unnecessary journeys in their local areas.
The vulnerable were failed because social care is fragmented, privatised and underfunded
Now the grim news. More than 80% of the deaths are in those aged 70 years and over, with the majority of deaths occurring in those aged over 80 years. The appalling state of social care funding in the UK means that those at greatest risk – those living in social care and nursing homes – have been least able to effectively ‘self-isolate’ and most likely to contract the virus, and in consequence to die. We do not know the full extent of the Covid-19-related deaths of those within the social care system, but deaths in care home residents are very high. Moreover, in England by 1 May, 72% of residents dying from Covid died in a care home; in Scotland the figure was even higher at 91%, highlighting the lack of access to high quality treatment and hospital care.
Then there are the excess numbers of non-Covid deaths and disability that are still occurring due to the state of emergency in the health service. These deaths are the unintended consequence of the clearance of hospital wards (in anticipation of a flood of corona cases), the reduction in GP services, podiatry, speech therapy, mental health services and physiotherapy services and access to cancer diagnosis and treatment and heart and stroke services.
Social services in the UK are among the most privatised and fragmented in the western world. They have been underfunded for decades. Between 2010-11 and 2017-18, local authority spending on social care fell by 49% in real terms, reducing spending from £16.1bn in 2010 to £14.8bn in 2016-17. Reduced funding has been accompanied by privatisation and the shifting of responsibility for funding to individuals, as well as the tightening of NHS and local authority eligibility criteria. Often, there have been long delays in assessing eligibility, and inconsistent and inequitable application of criteria.
Although £48 billion is flowing into this sector from the state and individuals every year in the UK, the industry expects an 11% return on capital invested in the residential care sector. From US data, we can see that for-profit companies generally have the lowest staffing and poorest quality as they seek to maximise profits for investors.
Care services in England employ roughly 1.6 million care staff (1.1 million full time equivalent), of which 78% are employed by the independent sector. The sector was 120,000 workers short before Covid struck, which results in inadequate care, while the use of agency staff moving from one home to another increases the risk of disease transmission. Staff on zero-hour contracts do not receive sick pay, and often go to work when sick.
This is truly an appalling situation. On top of this has been the lack of PPE for social and health care workers and residents and relatives, despite the high mortality associated with Covid-19 among frail older adults, and high risks to staff.
Covid collateral damage
The impact of Covid-19 provides the most compelling case possible for a national care service free at the point of delivery with all the elements of sheltered housing, community and home support and residential care integrated. A national care service would require legislation but (as with the Beveridge plan 85 years ago) many of the private providers funded by the state are in significant financial difficulty and the net cost of bringing these directly under local authority control is likely to be small.
Of course, the costs of running a national care system that mirrored the principles of the NHS would be significant, but two important factors must be appreciated. Firstly, that we are already paying for social care in the UK. For those not eligible for state-funded care there is no way of knowing what their costs will be: no way of off-setting the risk. Some will use up their entire assets in paying for it and some (for instance, those who do not require long-term care home support) will avoid paying altogether.
A national care system would be that ‘risk off-setting’ system and will ensure that the costs of care are distributed equitably (just as the NHS does for the costs of healthcare). It would also recognise the needs of the 5.8 million unpaid, informal carers (10% of people in England reported providing unpaid care in the 2011 census).
Secondly, according to a 2019 IPPR paper, Social Care: Free at the Point of Need, the cost would be of the order of 1% of total government expenditure. This would not only do away with the debt and tax leverage and offshoring that characterises the current private social care system, but it would provide secure, properly equipped and remunerated employment for those who perform this vital work. In so doing it would go a long way to ensuring that we have a resilient and well-resourced system that not only frees up NHS resources for acute care but is also able to cope with the next epidemic.
The vast majority of the people who die as a result of Covid-19 will be people failed not by the NHS but by social care: elderly, chronically ill and disabled people. If this government is serious in its commitment to ‘never again’ allow a disaster of the Covid-19 variety, it needs a plan to transform our shameful social care system: a system that fails those in need, fails carers (paid and unpaid) and shames the UK.
Way forward
With some form of lockdown continuing, we need local action plans around easing restrictions locally. First, it needs to put public health and communicable disease control experts in the driving seat. Second, we need to have the humility to learn from our colleagues in China, Singapore, South Korea and Taiwan. Third, as well as tracking the epidemic nationally, we need to go local and understand the epidemic in each local area. This requires contact tracing.
We need to use local public health teams to work with local authorities on local Covid surveillance to see where cases are and where they are continuing to spread. We need to rebuild capacity for contact tracing using local volunteers, health workers, the army, teachers, students etc for tracking and tracing in each local authority and health board, and environmental health officers and public health and communicable disease consultants should be driving it in each local health board and local authority. GP practices must also be involved and given data on cases and contacts in their practices. Local laboratory facilities for testing must be restored and not outsourced.
Fourth, we need to put in place a radical plan for the NHS and social care.
The Chancellor’s budget announcement on 11 March that the NHS would receive £6bn over the course of five years suggested it would wipe out trust deficits, but this did not go far enough. The UK Governments should be reopening the PFI contracts and renegotiating the interest rates, just as large stores have been renegotiating their rental charges down with the property owners. Interest rates are at their lowest ever (0.11%) and yet PFI debt interest payments vary from 5% to 16%.
Services that have been part-privatised should be renationalised (social care; some public laboratories and testing and data facilities). Intellectual property and patent laws need to be urgently changed, in favour of the public, with the government issuing compulsory licenses to stop the exploitation of patents for medicines, vaccines, medical tests, and tests and reagents. In return for bailing out companies and businesses, the government should ensure it has a stake in them so that when the good times return the public sector sees those returns and not the shareholders who have done so well in recent years.
We still have the chance to take the road not yet travelled. A progressive government would see Covid-19 as an opportunity to plan and legislate for a National Health and Care service. To take the road not taken since the 2008 financial crisis is essential if we are to address and remedy the poverty, inequality, and injustices brought about by policies of the last three decades and the austerity of the last ten years.
This is an abridged version of an article that appeared in Scottish Left Review. April/May 2020