Jeremy Hunt – Skat's Chat

Coronavirus week 13 – The best and worst of the NHS – the old normal is back…

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As it is nearly 40 years since I was awarded a BA(Hons) in Chemistry, I think I can be forgiven for not being able to give the modern name for dexamethasone. This is the drug announced this week used to treat patients with Covid-19 resulting in reduced deaths for those receiving oxygen or on mechanical ventilators.

Nomenclature has changed since I taught chemistry for five years in the mid-80s. Looking back at the literature of the time it was called 9α-fluoro-16α-methylprednisolone or 6α-methyl-9α-fluoroprednisolone, but either way even having done a biochemistry module I am not sure I would have known it was a steroid derivative of the well-known drug hydrocortisone. One of the main topics I enjoyed was organic chemistry, that of carbon compounds. Looking through the 1,280 pages of Hendrickson, Cram and Hammond’s textbook from 1977 there is no mention of it, despite being used in a clinical way since 1961. To complete the confusion that people often express when I tell them I used to teach chemistry, it is always good to have a chemical structure to describe the compound. Here are two for this drug.

The slightly more modern version on the right shows the different elements hydrogen, oxygen and fluorine as different colours and the methyl (CH3-) structures as a dark triangle. My pharmacy consultant (and wife) Alyson tells me that I was on dexamethasone for a short time in 2012. I was in hospital for 12 weeks (the time we have been locked down now) with a brain abscess, and was given it to reduce the resultant swelling of my brain.

The research on dexamethasone done in British hospitals, with volunteer patients involved in the clinical trials, has been hailed as ground-breaking. The drug has potential to save tens of thousands of lives worldwide. It must be devastating for those who have lost loved ones who may have benefited from it. This and the amazing dedication of the care staff, cleaners, physios, pharmacists, therapists, doctors, nurses, and administrators demonstrate the best of our NHS. As a country and tax payers we need to fund them to the level required. We will have a thorough review and ‘learn the lessons’, but I fear that once ‘real life’ takes over and self-interest resumes its ‘normal life’, we will forget those weeks early on when as one voice we said ‘this can’t be allowed to happen again’.

The whole system needs a thorough rethink. There have been many reviews and reorganisations over the years, and it would be natural for those who work in it to think ‘oh no not again’. The NHS needs rebuilding from the ground up, and possibly renaming. Before Covid-19 I think most people thought of the NHS mainly as the hospitals and local surgeries. In latter years, and certainly during the crisis, there have been concerns that care homes, mental health services, and some social care is linked to the NHS. Many people comment on ‘private business’ not getting involved in our health system as a bad thing. Well I have news for them, much of what we think of are ‘private businesses’. Community pharmacies which I worked in for over 20 years and Alyson has worked in for 40 now, are private limited companies owned mostly by pharmacists but some by medical wholesalers. The same is true of almost every doctor’s surgery who are businesses of doctors setup as a partnership of lead GPs who employ other GPs to help them. These private businesses operate as ‘contractors’ and are paid by Department for Health and Social Care (DHSC), itself only renamed in January 2018. They are paid a rate for their services, whether that’s seeing patients, running clinics or dispensing prescription or carrying out medicine use reviews that is negotiated by their professional bodies with DHSC. It should not be a surprise that negotiating with what is in effect a ‘monopoly’ supplier is not one that leads to mass riches. What does surprise those doctors who visit pharmacies or chat to owners is unlike their partnerships, DHSC pays nothing towards premises or staffing costs of pharmacy businesses, or pay for the holding of large amounts of drug stocks. And don’t even get me on the subject of Dispensing Doctor practices – people who can write a prescription if they have too much stock of a particular drug, or choose the one that’s best for their business rather than the patient.

‘Business’ and the idea of accountability and competition has been part of the health service for many years, and now we have ‘Trusts’ who are independent organisations running services at a local or regional level. They contract to suppliers and surgeries, pharmacies and ‘buy in’ other services from blood and organ donation services, laboratory services and a host of other clinical ones. There are companies who contract for IT projects, finance, property building and maintenance, catering, cleaning etc. This started when I was still in pharmacy 20 years ago and even then I could see the problems of having local GPs on trusts. As with teachers and risk assessments I wrote about in an earlier blog, most GPs are not businesspeople and they can’t be blamed for conflicts of interest between their business and that of patients and other contractors.

Many governments have presided over reforms but the last major one by the coalition government in 2010 and overseen by Andrew Lansley has proven to be disastrous. Even before starting it drew criticism from a lot of areas. The idea of giving even more power to GPs and frontline staff and increased ‘competition’ on one level might seem like a good one, but in reality it led to a mix of systems and lack of any central accountability. The devolving of the social care and public health issues to local government foundered as the secretary of state for health, Jeremy Hunt, cut the budgets under the guise of ‘austerity measures’. The well-publicised ‘scandals’ with Mid Staffordshire NHS Trust and others in care homes can be laid at the lack of oversight on patient safety. The organisation Public Health England (PHE) was formed as a result of abolishing Strategic Health Authorities (SHAs), and at the time several directors warned that this would compromise our ability to ‘fight any future pandemic’. SHA’s would have been able to lead on organising the local response and would have people on the ground able to conduct a ‘track and trace’ system. Andrew Lansley stepped down from government in 2015 and was rewarded for his efforts with a seat in the House of Lords.

Jeremy Hunt was the secretary of health who ignored the results of ‘Operation Cygnus’ in October 2016 used to check the resilience of the NHS to respond to a pandemic (albeit one of influenza). As widely reported at the start of this pandemic, this led to a failure to replenish our stockpiles of PPE, antiviral drugs and ventilators. It is shocking to see him in recent weeks, as the now chair of the parliamentary health and social care select committee, taking the government to task over their failure on issues he was responsible for. When he was elected by MPs to this role in January there was a feeling that this conflict of interest might stop him questioning too much. It’s extraordinary to see the exact opposite happening, but his ability to wipe clean his own responsibility is equally unbelievable.

Andrew Lansley promised a ‘bottom up’ review but ended up with more ‘top down’ structures in place and setting up a whole series of ‘independent bodies’ to monitor things.

Several people have expressed surprise that hospices receive so little funding from DHSC and other government bodies that they have to rely on local fundraising and charitable status to continue. This was put in the spotlight early in the current crisis when fundraising stopped and no provision was forthcoming to help with PPE. If a national health service is supposed to cater for us from ‘cradle to grave’, what has gone so wrong that patients and their families who are facing the real end of the health system are left to donations and sales from charity shops for the provision of care to their loved ones. Another part of the health service that I have experience of, and which has been neglected are rehabilitation units. It seems Covid-19 is an illness that takes a terrible toll on survivors, with months of aftercare needed to even walk again. Many weeks on a ventilator in a medically-induced coma leads to mental health issues as well as physical weakness.

NHS IT provision, which I had some experience of when trying to implement the Electronic Prescription Service (EPS) in our pharmacy branches in 2005/6 was one riven with problems. With the help of our wholesalers and investment in NHS broadband we got all 50 branches setup just as we were sold to the Co-op. Alyson continued working in branch and even now, 14 years on, the system is not fully implemented and looks unlikely to be any time soon. Only recently can pharmacists see a very small amount of information held nationally on any patient who comes into their branchwhen they are away from the place they live. I know from personal experience that my local hospital, 15 miles from the one in another county and a separate trust where I was treated for my brain injury, can’t access any of my scans or records. This is why I have a lever arch folder with all my records and several CDs of my scans/x-rays that I can take in should it happen again.

As predicted by my sons in a blog six weeks ago NHS IT, or NHSX as it is now called, was criticised this week for the failure to deliver the NHS Test & Trace app, and are considering reverting to the Google/Apple model. As my chair of district tweeted;

In all the ‘clap for carers’ and accolades given to those in the health and care systems, we shouldn’t fall into the trap of thinking everyone is working for the common good. In an organisation of about 1.5 million people there will be some ‘bad apples’ and strong management and administration supported by decent pay and training is needed.

Our National Health service should be as much about prevention and encouragement to live a healthy lifestyle as it is about treating us when we fall ill. The effects of obesity, diabetes, heart disease and respiratory conditions on the death rate from coronavirus demonstrates this need. The savings made from prevention should outweigh the costs of later treatment. Education, as in many things, is vital for health outcomes as is reducing poverty.

Let’s hope the next review takes all of the factors into account and, as I wrote last week, as a country we can fund the necessary changes. Our National Health Service has become a ‘Reactive Illness Programme’ (RIP), and needs to change, and quickly.

Other news this week

The ‘old normal’ resurfaced in our area this week when 6,000 people attended raves in two separate areas of Manchester on Monday. Several people were stabbed, one girl allegedly raped and local people had to clear up the mess after everyone had left.
Crime seems to be on the increase (or at least being more reported) and terror is back on our streets with the stabbings in Reading this weekend.
There is more talk of reducing the social distancing requirements to one metre to get hospitality and self-catering holiday accommodation open.
Dame Vera Lynn died this week at the age of 103. She was called the ‘forces sweetheart’ during World War Two and had shared her thoughts during the current crisis and her song was echoed in the address to the nation by our Queen when she said ‘we will meet again’.
The Labour Party review on the reasons for disastrous results in December’s general election was published. It didn’t make comfortable reading for members of the party like me. We must work for Labour to produce policies which chime with the need to do things differently in relation to funding the new health and social care system, tackling poverty, improving education and closing the gap between the wealthy and poorer in society.
The daily death announced totals continue to fall with the Monday-Friday total this week being 853 down from 1,065 last week (a fall of 20%). The total of deaths at the end of the week was 42,632.
With numbers seemingly under control in European countries despite some local outbreaks in Germany, I looked again at the statistics on Johns Hopkins site and there are some awful looking graphs in other areas of the world. Here are the graphs for cases in Europe;

These show that we are over the (first?) peak of infections. The story in two countries with presidents who think it is nothing to worry about, and are trying to get their country’s open again is not so hopeful…

and note that the scales on these are tens of thousands rather than the thousands in Europe.
The middle and far east countries are also showing curves which are concerning, with a ‘double peak’ for Iran. The cases are in hundreds but show no signs of decreasing.
We need to start looking overseas again now that we are getting the UK cases down. There is concern from aid charities that helping less well-off countries will be harder now that the department for international development (DFID) and the UKAid agency has been subsumed into the Foreign Office. A move criticised by three recent former prime ministers from both Conservative and Labour.
The debate and protests around racism and the ‘Black Lives Matter’ movement continued across the world.
I was going to write that the demonstrations and actions of climate protestors, similar to the ones for Black Lives Matters with marches and ‘direct action’ had not resurfaced, when yesterday I saw an interview with Greta Thunberg saying that she was looking forward to going back to school in Sweden, and vowing to carry on campaigning.
Greta’s target for criticism president Donald J Trump was back on the campaign trail with a ‘huge rally’ in Tulsa, Oklahoma where only 6,000 of a possible 19,000 seats were occupied despite over a million applications for tickets. For those who did attend there was little sign of masks or social distancing, and six of the organisers caught the virus. At the time of writing there are reports that Mr Trumps rally had been ‘turned over’ by teens and young people responding to campaigns on the Tik-Tok and K-Pop social media platforms applying for tickets then not turning up. Mr Trump said earlier in the week that a million supporters would come.

How has week 13 been for us?

Unfortunately we have another example of the ‘worst of the NHS’ in our household. Five weeks after Alyson applied to help out NHS 111 with taking phone calls from people who need to speak to a pharmacist, and after three polite chasing emails and responses from the HR team doing the ‘on-boarding’ stating that she will hear ‘in a few days’, there is still no sign of her contract or training plans. She has played her part by taking two more calls on the SOS NHS volunteering app.

We haven’t ventured to ‘non-essential shops’ yet and the crush at the Nike store in London and the lady interviewed in the Primark queue in Manchester who stated that she ‘felt like I’ve won the lottery’ didn’t pursuade us. We did go for another walk in Delamere Forest and had a picnic which was pleasant. The weather meant another postponement of meeting with friends in our garden, but we have a walk planned in a park further afield this week.

I have watched a couple of the Premier League football matches now live on ‘free tv’ and have been surprised how realistic the ‘virtual crowd noise’ is to make them seem more ‘normal’ despite empty stadiums. The online radio commentary I heard for my team Middlesbrough was a sign of the ‘new normal’ being much like the old – we lost 3-0 and are looking at relegation again.

I had my first international Zoom with a call to our subcontractors’ office in India with the person who helps on the IT project I am doing. We have had training sessions with the team from our district who are attending the Methodist Conference in a week’s time. With over 300 representatives, Zoom will be in the form of a webinar where we can only see the person presenting and another speaker who wants to add to the debate. Voting will by the raising of a virtual hand or completing a poll on the screen, so the feedback on numbers should be much quicker than the usual manual count of raised hands in the conference hall. I will write more about this next week. The conference service on Sunday will be at my now ‘virtual home church’ of Methodist Central Hall, Westminster in London.

Keep safe and let’s hope there is a safe further easing of lockdown in the coming week.

Life & Death – Coronavirus week 6 – light at the end of the tunnel.

Two narratives, but which do you believe?

This week’s total deaths has risen quite sharply as it now includes all deaths in the community (including care homes) and not just hospitals. At the end of the week the UK total is 28,446.

As I have gone through the last few weeks in this series of blogs, I note down topics that interest me and jot them down on my computer with some initial thoughts. On the Saturday I just start to write my blog and usually an idea comes to the fore, sometimes I write too much or go off in a particular direction and have to scrap large sections or keep them for another time. Often I am up against my own ‘deadline’ of Sunday evening and end up ‘rushing’ the last part. As I sit here this Saturday I am conflicted.

I have one narrative of the week’s events and my thoughts which some would describe as the ‘mainstream view’ as reported by the BBC and some on-line articles or extracted from large circulation newspapers. This view is dubbed by users on social media as ‘MSM’ or Mainstream Media. MSM as a term is often used in a pejorative sense as either left- or right-wing bias, depending on the political view of the person passing comment. In that sense it could be described as ‘balanced’ given that some agree, and some disagree. Coronavirus has taken over from last year’s key word ‘Brexit’ as a topic that divides the nation. The division appears not to be the same extent, but there are plenty of people asking hard questions of the government, and much finger-pointing at individuals or institutions/organisations who they consider don’t represent their particular viewpoint or stance.

I am also preparing this weekend for our Bible study group on the sayings of Jesus from the Gospel of Luke, under the title ‘A New Society?’. One of the main reasons I value my faith is the way that Jesus offers a ‘counter-cultural’ challenge to the accepted norm, and is not afraid to take the issue to the ‘powerful’ in society. As it says in the introduction of the book we are using:

Roman, Greek and Hebrew societies were heavily stratified. Fine, if you were a healthy wealthy, educated, well-mannered, pure-blooded male of noble descent and free citizenship; beneath that you were second class or worse all the way down to worthless slaves at the bottom…Samaritans and Gentiles were scum, the poor, the sick and the deformed, the tormented, well, they must have offended God so you avoided them; prostitutes and tax collectors were beneath contempt.

Jesus not only ignores these divisions but takes special delight in raising the status of the poor…..all may come irrespective of their status. The parable of the great banquet reveals that the self-satisfied will be excluded while the poor needy, the rejects of society, will be welcomed in.

Jesus came to abolish the man-made divisions of race, sex and class.

My second version of the review of the week takes is an alternative more ‘radical’, some would say political angle.

The ‘accepted/acceptable’ view…

The week started with Boris Johnson giving a speech on the steps of Downing Street, addressing the nation on his health and the possible steps that would be taken. Apart from being a little breathless he was full of his usual optimism and stressing words and phrases like ‘good’, ‘amazing’, ‘can-do’, heroes and ‘pressing on’. He said that the government were working ‘full-tilt’ to protect the NHS and save lives. He mentioned that it had been 50-50 at one point but that he was back to lead. The analogy he used was of having been in an alpine tunnel to avoid the peak and we could see the bright sunshine and the green pastures at the end of the tunnel.

Lots of people said he was the best communicator that the government have, and it was good to see him back. Things would get better and later in the week he would announce the next steps.

On Tuesday we had a special one minute’s silence to remember the heroes who had died at work in the NHS and care sectors.

Boris didn’t appear at Prime Ministers Questions on Wednesday when Keir Starmer asked searching questions of Dominic Raab. The press and social media were full of posts stating it was good that ‘the other lot’ hadn’t won the December election, and imagined the chaos that a Labour party, led by Jeremy Corbyn, would have made of the current crisis. We learned that Boris and Carrie had a baby boy and Boris had been by their side all the way through. Again, there was great rejoicing and congratulations and many political opponents wished them well. MPs across the spectrum suggested this joyous occasion would give a lift to the country.

Meanwhile Captain Tom, the war hero, managed to raise over £30 million for NHS charities in time for his 100th birthday. He got an honorary promotion to Colonel along with his card from the Queen and 120,000 from members of the public. Boris recorded a special message. Keeping the war theme going he had a flyover from the RAF of two WW2 fighter planes. Tom was even number one in the music chart. Tom has inspired many other people to raise funds for the NHS and Virgin Radio DJ Chris Evans held a ‘garage sale’ of a huge amount of expensive memorabilia and items from his self-admitted ‘excess times’ over the last 25 years. This raised just short of £500,000. The money will be going directly to the ‘Scrubs Glorious Scrubs’ who are coordinating the voluntary efforts from seamstresses making much-needed scrubs for NHS frontline staff or, the ‘heroes’.

The daily briefings continued and there was focus on the promised 100,000 daily test target which, by a huge effort and extending the range of people who could get the test, was met when 122,000 were done on Thursday 30th.

That evening Alyson and I joined in the weekly ‘clap for carers’ with most of the people on our street. Drums, pots and wooden spoons, hooters, whistles were used. We talked in slightly derogatory terms about those who have not been out for any of the five times we have done it.

The daily briefings feature a new section whereby members of the public could write or record a question to be put to the briefing. This was welcomed as often these questions cut through the ‘gotcha’ questions often put by the press to try and catch ministers out or show up errors or misjudgements. The first one from Lynne in Skipton simply asked, ‘When will I be able to cuddle my grandchildren, who I am missing terribly’. The minister said he understood the question but reinforced the need to ‘continue with the measures in place’.

When the journalists tried to ask about PPE and a BBC Panorama programme that exposed a shortage in the national stockpile, and an emergency exercise from 2016, the minister said he didn’t believe any of that and that we just needed to carry on. The press wanted to know more about the R-number and what value it needed to be for lockdown to be released. Professor Whitty was asked when we would learn the lessons of what had gone wrong. He said that would happen, but you don’t start in the middle of trying to focus on fighting the current crisis. When asked why our death total seems to be so much higher than the other European countries and second in the world, he pointed to what he described as a brilliant article in The Guardian by a professor of statistics on the difficulty of comparing countries.

Jeremy Hunt, former Health Secretary was very defensive when asked about the lack of PPE and ventilators. He said that President Macron had apologised for the lack of preparations but that he didn’t think Matt Hancock should and ‘now is not the time for the blame game’.

Rishi Sunak, Chancellor of the Exchequer was praised for putting in place a compensation scheme for the families of NHS and other frontline staff who had died as part of their duties dealing with Covid-19 patients. He also increased the guarantee for business loans from 80% to 100%. The week before he announced help for charities including foodbanks. On Saturday, a package of £76million to support vulnerable children, victims of domestic violence and modern slavery who were ‘trapped’ at home during lockdown. Pharmacies, who had previously been given £300Million to help with extra stock and deliveries, were to use consultation rooms as save havens for victims of domestic violence.

The ‘alternative/critical view’…

I can only imagine the Daily Mail headlines if Boris was the head of a taxpayer funded project managing an emergency caused by not taking the advice of experts from a few years before. Finding out that he had now fathered at least six children during two marriages and one extra marital affair, was not married to his current partner and had to deny several other similar allegations. He wrote a piece for The Spectator in 1995 where he attacked single mothers saying it was “outrageous” that married couples “should pay for ‘the single mothers’ desire to procreate independently of men”. Not only that but in two months he had taken several weeks paid sick leave from his £150,000 a year job, and now was going on paid paternity leave. He went to his paid for country mansion set in 1,000 acres of Buckinghamshire countryside for a couple of weeks. His bluff and bluster of a ‘Churchillian’ speech with its talk of light at the end of a tunnel might have been turned on him, and the question asked, ‘are you sure it’s not just an express train coming towards us…’?

The NHS is not a charity and should be fully funded by the government, the clue is in the name. It shouldn’t need Captain Tom or celebrities to get the general public to raise money for it during a ‘special season’. Of course there may well be a need to have a few ‘extras’ like toys/video games for the children’s wards or special luxury equipment for people in rehab or entertainment packages, but not vital equipment or PPE. Well done Captain Tom – only another £320million to go in order to fulfil the Brexit bus promise of £350million for the NHS for a week. It needs long-term guaranteed funding.

The NHS staff aren’t ‘heroes’ they are professional trained people who are willing to treat people in a system that has been underfunded and cut during 10 years of austerity. Some of the work they do is extremely stressful.

Some people are asking the question whether, once this is all over will the government be willing to continue to give the funding needed, and will those people who gave their donation to Captain Tom still be happy if they have to pay an equivalent amount of increased National Insurance every year? Will celebrities who earn tens or even hundreds times more than a nurse or senior doctor be willing to buy less ‘trinkets’ and support their heroes?

Certainly the pharmacy contractors, something I know a little about, will have their £300Million ‘gift’ (actually a loan) clawed back out of future payments. The sunk cost of all the PPE and extra staff they have had to take on and the small profit lost from reduced counter sales, will not be recovered. No doubt they will have to go back to providing unfunded services for quite some time yet.

The minute’s silence last Tuesday was on the annual International Workers Memorial Day. An initiative setup by trades unions worldwide to fight for safe working for people whose employers make them work in dangerous conditions or with hazardous substances. The 28th of April is officially recognised by the UK government as a day of remembrance around the world. So should we have an official act of remembrance on the 28th of April every year, not just 2020?

Now is the time to be challenging the government on how it was that emergency supplies of PPE were not replenished after Exercise Cygnus in 2016. Now is the time to make sure the government sets up a suitable commission to investigate and learn the lessons. A good question to the daily briefing might be;

If now is not the time to start learning the lessons of this crisis, is now the time to commit to setting up a wide-ranging independent group to look at it and report 6 months after the crisis is declared by the WHO to have ended. And is now the time to commit to ‘getting done’ all the recommendations and to fund them ‘whatever it takes‘?

Those ‘Masters of the Universe’ the bankers, who don’t appear to have changed much since they were supported after the 2008 market crash, will continue to control the supply of much needed loans. Some managed to bring forward their bonuses paid early, despite the Bank of England asking them to delay. Despite being given huge guarantees by the government (again) they will charge huge fees and take a lot of security from the owners of small businesses.

Returning briefly to Jesus, there was a time when people wore badges emblazoned WWJD, meaning ‘What would Jesus do?’ I think the first thing Jesus might have done was to ask the question ‘who are the people that will suffer most from this crisis and the long-term aftereffects?’ He might have decided the following priority list;

Take the homeless off the streets and put them all in hotels not currently being used for tourists, give them health screening and mental health support.
Before panic buying, make sure the supermarket stocks of food and necessary essential supplies go to foodbanks. Or better still, miss out the food banks and give £5,000 to every person or family with less than £1,000 of savings in the bank, along with guaranteed delivery of essential food and other items for the duration of the crisis.
Guarantee a payment of the average weekly wage to anyone on a zero hours or part-time flexible contract.
Provide support to the people who care for our most vulnerable people in care homes or their own homes.
Make sure every child living in a poor household is taken to school every day, given a full education, access to technology and two free meals.
Pay for all the care needed to support children or adults with a range of special needs for the duration.

Only after that has been done and ‘maximum effort’ has been given to them, and others identified as in danger of potential harm, can civil servants start to plan and implement the type of support package given by the treasury early in this crisis.

So, which narrative would you choose to believe…?

Thoughts at the end of week 6.

The relatively wet weather has confined us indoors. Alyson has been reading Terry Waite’s book Taken on Trust, sewing masks for us all and going for long walks every day.

I have had many more Zoom meetings and took part in an online quiz for Christian Aid. I have two quizzes to write in the coming week. I attended my weekly streamed service from Methodist Central Hall.

We had a family Zoom with 15 of us who should have been at a large house in Ross on Wye for the weekend.

Alyson practiced her skills as a home hairdresser on me with clippers and special scissors I had bought from Amazon.

I managed to put another shelf in my shed and am confident I can now do the last one in under an hour!

Stay safe everyone.