Prime Minister Boris Johnson has described the coronavirus pandemic as “the biggest public health crisis for a generation.” So it seems like a prescient time to ask the question, what remains of public health under the Tories?
A key plank of the Tory-Liberal Democrat Health and Social Care Act 2012 was to move public health out of the NHS and make local authorities responsible for it. Public health prevention services such as smoking cessation and weight management became the responsibility of local authorities, who at the same time were having their budgets slashed as a result of austerity. These reduced resources for prevention and public health in turn increase people’s risk of illnesses and put more pressure on the NHS.
One of the most important ideas in public health is the McKeown thesis attributed to the British physician Thomas McKeown. He showed that there was a dramatic reduction in death rates from respiratory tuberculosis since the nineteenth century, long before the bacteria causing the disease (tubercle bacillus) was identified, the first effective antibiotic was produced in 1947 or a vaccine was discovered in 1954. McKeown attributed the reduced deaths to effective isolation and public health measures including overall improved standards of living, especially from diet and nutritional status, improved housing and clean sanitation.
If the McKeown thesis was important in understanding the broader social implications to public health then austerity policies have been the antithesis of best practice. Contrary to good nutrition and secure housing, families have been plunged into poverty, increasing food bank use and homelessness. McKeown’s work and the socially patterned prevalence of disease and mortality shows that the rising number of vulnerable people in our communities makes us more susceptible to Covid-19 and its effects.
Another public health measure is isolation, or the containment of the virus, as recommended by the World Health Organisation (WHO). It is estimated that each person infected with Covid-19 can infect on average 2.5 people. This means Covid-19 can spread very rapidly, as we have seen. Europe is now the epicentre of the outbreak, but the government has consistently delayed reasonable social distancing methods. In contrast to other countries in Europe, UK schools remain open and details about an upcoming ban on mass gatherings are yet to be announced.
Against the advice of the WHO, we appear to have moved to a mitigation phase – with the government making high-profile references to herd immunity. Herd immunity is when vulnerable people in communities, who are more likely to suffer the life-threatening consequences of an infection, get a degree of indirect protection because healthy people around them have built up immunity. These healthy people break the chain of transmission of the virus to vulnerable people. A national vaccination programme is the safest way to build herd immunity without developing the disease.
But with no vaccine, the government is relying on 60% of the UK population becoming infected with Covid-19. Yesterday, it leaked plans to quarantine the elderly for up to four months during this process – but with few details of how that would be carried out. The WHO and other scientific voices have questioned the UK approach. At present we know little about Covid-19. Therefore, it is uncertain if we can even develop strong herd immunity or if the virus will mutate and develop new strains.
A Decade of Mismanagement
This is the backdrop against which already pressured NHS services are trying to cope. Public health is also concerned health service’s capacity and coordination to ensure delivery of care – but this too has also been undermined by the way our NHS services have been organised and mobilised to manage the crisis. There is an NHS staff shortage of 100,000. In the run-up to the general election nine out of ten NHS bosses believed these were putting patient care at risk.
Staff shortages and the drive to reduce costs have meant that call handlers at NHS 111 are largely not medically trained and follow algorithms to give advice. This has led to inconsistencies in advice and errors which have led to some people with symptoms of Covid-19 being asked to attend A&E and GP surgeries exposing staff and often already vulnerable patients to the virus.
There have also been delays and supply shortages in personal protective equipment (PPE) for staff. The British Medical Association warned against complacency as GP practices flagged a lack of PPE. Dentists have not been supplied with PPE and there are surgical mask shortages in practice. Despite this, they have been asked to continue to provide high-risk, non-urgent aerosol generating procedures such as scaling teeth to ensure targets are achieved by the end of the financial year.
The government’s obsession with targets has also meant GPs to continue to fulfil their QOF (Quality Outcomes Frameworks) metrics. At a time when committed NHS staff should be given the appropriate protection and support to use their valuable skills to mitigate the impacts of the virus, staff are using precious time ticking boxes and delivering non-urgent treatments which not only put their health at risk but the health of their patients and all our loved ones.
With the government’s laissez faire approach, more people are likely to need beds and critical care, and staff shortages may rise. The most recent NHS winter crises was the worst since records began. The annual crisis is increasingly not limited to the winter months. Since 2010, there are 17,000 fewer hospital beds which means some hospitals use overflow beds all-year-round. In the Tory NHS, it is always winter.
Overflow beds, or surge capacity, is a critical buffer for an expected rise in demand for hospital beds when a crisis hits. Hospitals have started to cancel planned, non-urgent procedures to increase their capacity for intensive care for people whose lives are at risk from Covid-19. The concern remains that it may not be enough. Boris Johnson has already said, “many more families are going to lose loved ones before their time.”
The UK has one of the lowest rates of critical care beds in Europe. Lower than Italy, which is struggling to cope, and far lower than countries like Austria and Germany who have put in place more robust social distancing measures. Germany and Italy are ordering thousands of ventilators to increase their capacity for intensive respiratory care. The UK, as yet, has made no such preparations. With a shortage of 43,000 nurses, it is unlikely we have the trained nursing staff or the beds to use the much-needed specialist equipment.
The crisis in social care which has left 1.5 million elderly people without the care they need will add to the pressure on beds, particularly since elderly people exposed to Covid-19 are more likely to need intensive care. Cuts in public health, local authority budgets and the NHS have created a perfect storm to place unprecedented pressure. Sadly, it is not improbable that as well as non-urgent care, some urgent treatments may need to be postponed.
Social distancing, isolation, prolonged stays in hospitals and losing loved ones is also likely to take its toll on people’s mental health. But the Tories have consistently failed to invest in mental health services – with many people left waiting years for the support they need.
Despite the scale of the public health crisis and claims that medical professionals will get the support that is needed, there was a conspicuous absence of public health from the chancellor’s budget. There was little transparency about how much of the £5bn Covid-19 response fund would be available to local authorities and could be used for public health prevention.
Intense prevention and public health efforts to reduce the numbers of affected people and ensure NHS services are appropriately organised to respond to the challenge is the only viable strategy. If a vaccine becomes available, local authorities must be given the resources to support vulnerable groups to access it. Public health resources must be used to help communities reduce the risk of Covid-19 for vulnerable groups such as the homeless or those living in care homes or supported accommodation.
A one-off Covid-19 cash injection is not enough to plug the gaping hole left in public health, mental health, social care, and the NHS by a decade of Tory cuts. Covid-19 has exposed the failures of their pro-market ideology. The case for socialism in a time of crisis has never been stronger.