Pandemic truths 1: How Covid-19 shone a spotlight on the warped values of our current way of life
by Andrew Webster
‘Stupidity has a knack of getting its way; as we should see if we were not always so much wrapped up in ourselves.’
Albert Camus, The Plague
Barry Knight’s 2017 book Rethinking Poverty showed how many government policies are out of step with what people want and need for their lives in a good society. Examples include the obsession with economic growth; an ungenerous, often punitive social security system; and top-down regeneration programmes. In her 2018 book Radical Help, Hilary Cottam showed that most human services remain based on a mid-20th century model of standardised provision wholly unsuited to help us navigate the challenges we face in the 21st century. In this article, the first of four, Andrew Webster takes up this theme, applying it to how we organize our health care.
After 40 years working to improve public services I have spent two months of lockdown reflecting. I have drawn on a wide experience as a hospital manager, social services director, senior roles at the Audit Commission, in central government, for Turning Point and at the Local Government Association. I have distilled 12 tough truths that have always been known, but which have been thrown into sharp relief by the pandemic. These range from how we run our health system and grow our food to how we organize work, learn, reward people, and protect people from violence in their homes. This first of four articles looks at two harsh lessons about how our current society understands, experiences and organizes health and care.
Truth 1: Our health service focuses on hospitals, which are hazardous places for patients, staff and the public.
For at least three decades government policy, underpinned by clinical and professional analysis, has supposedly been to shift the balance of healthcare away from hospitals into homes and communities, away from illness to health, away from acute interventions to long-term health management. Despite this, during the same three decades spending on hospitals has increased as a proportion of health expenditure, and managerial and political attention has ruthlessly pursued higher efficiency in hospitals. The consequence is a system overwhelmed by predictable but unpredicted emergencies, which then, for example, labels vulnerable old people as ‘bed blockers’ as if they were voluntarily over occupying hospital beds out of some perverse malice.
There are many political, cultural and historical reasons for this unhealthy obsession with hospital services – but at its heart is a deep attachment to the fantasy that a centrally controlled, hierarchically managed, institutionally focused health system will be fair and ensure that the deep social contract of accessible healthcare for all remains intact.
We now know that while the government was promising to build 40 new hospitals, the public health infrastructure, testing laboratories and protective equipment that can protect a community during a pandemic were under-resourced and received a tiny proportion of the political and managerial attention devoted to sweating our existing hospitals to cope with ‘winter’. In fact, our hospitals had to re-invent themselves to respond to the new threat and largely did so without central control or hierarchical management, making up for the deficiencies in preparation with improvisation and creativity.
The hospital focus hampered the overall response to the crisis. Of course, all governments would be concerned that their hospitals were not overwhelmed and forced to turn people away, as appeared to be happening in northern Italy and eastern France. While the existing hospitals stretched their staff and equipment to the limit, we built new temporary hospitals that we could not staff and ultimately did not need. And people turned themselves away from hospitals: A&E attendances plummeted and there are serious anxieties that many people with serious illnesses have not been diagnosed or treated.
Why was the government worried that hospitals could be overwhelmed? Not because we had too few hospitals (admissions per 1,000 population in New Zealand, Kerala, Taiwan and Hong Kong – to name four contrasting experiences – have been a fraction of those in the UK), but rather because the government believed it had too few alternatives. It concluded that a test, trace and track strategy could not be delivered, and moved swiftly to contract new capacity for testing. Clearly, central government chose not to trust and deploy 152 public health departments in local authorities and their contractors in sexual health services and colleagues in environmental health departments who are experts in testing for infections, tracing contacts and tracking outbreaks of more deadly diseases than Covid-19. A local approach combined with high levels of public engagement has led to successful testing and tracking in South Korea (without the much-heralded apps that have generated such controversy). The truth is that had we invested in, and made full use of, local leadership in councils and their services, and trusted the skills and expertise of our community clinicians, we would have better protected the NHS and saved more lives.
Truth 2: We tolerate older and vulnerable people being poorly served by invisible care services that run on a shoestring.
Anyone who had participated in exercises to simulate an influenza pandemic (as I did when a director in a local authority) would have placed care homes second only to hospitals on their risk register. Indeed, the first cluster of deaths reported in the USA was in a care home in Seattle. Care homes themselves took early precautions by restricting visiting and isolating staff. Some care home staff moved into the homes to reduce risks of bringing in Covid-19. Meanwhile, in a bid to protect the NHS, larger than normal numbers of patients were discharged to care homes, often in a hurry and without adequate checks on their health and infection status. It is widely believed in the care sector that the infection was spread quickly through care homes by patients discharged from hospitals.
There have been care home scandals in other countries responses as well (Italy, France, Spain and Canada all report appalling neglect in some instances). Care homes in England do not stand accused of abandoning their residents or staff; rather they have silently borne about a third of the burden of death and loss. Extraordinarily, we did not even know this until several weeks into the pandemic because no one was collecting the data about infections and deaths in care homes. Apparently hospital deaths were a satisfactory proxy. We know too that the government rejected advice to completely isolate care homes in order to reduce infections and save lives.
If the NHS has spent the last decade on a restricted diet, publicly funded care is close to starvation. Half a million fewer people receive publicly funded care, fees for private providers have been frozen, and most staff are on minimum wages. Many care homes and their owners remain going concerns because of the value of their buildings rather than their income. Just before the pandemic the Department of Health and Social Care started yet another review by issuing an invitation for people to suggest ways of improving the quality and resilience of the care sector – as if it itself had not produced several white papers in the last 20 years, all of which foundered on the cost of creating a sustainable system.
The Care Act 2014 is exemplary legislation requiring local councils to support people’s wellbeing through effective stewardship of the whole community’s resources and the markets for care and support. It has proved toothless because citizens have no redress for lack of attention and resources. The truth is that remaining independent in your own home is a threadbare gift from the state, not the basic right, enforceable in the courts, that it should be. We don’t tolerate children’s lives being turned upside down without judicial scrutiny; why would we accept otherwise for adults?
In the next articles I will look at the tough truths about work and learning, about space and mobility, and finally about rights, responsibilities and leadership.
Andrew Webster is a Trustee of Centris and an advisor to health and care systems and businesses, having worked in the NHS, Local Government and Central Government for 35 years.
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