Session 1: Summary
How well prepared was the NHS?

Introduction

Tony O’Sullivan Co-Chair Keep Our NHS Public

Tony O' Sullivan opened by saying there are urgent lessons to be learned from the Corona virus pandemic. Deaths now exceed 121,000 and yet the Government have refused to hold an inquiry. Boris Johnson said only a month ago: ‘We have done everything we could and continue to do everything we can to minimise loss of life and to minimise suffering’ (January 2021).  This inquiry will hear evidence and the panel will draw conclusions which will be shared with the Government at the end of it.

 

Michael Mansfield QC

Michael Mansfield stated he was honoured to chair the inquiry on behalf of the public of the United Kingdom who have been wanting answers to a large number of immediate questions. A public inquiry of the usual kind will take years to set up and hear evidence. Witnesses have made statements and provided other evidence. Lorna Hackett, Counsel to the Panel will ask questions on these, followed by questions from the Panel. Public questions sent in will be included where possible.


 

Witness 1: Jo Goodman, co-founder, Covid-19 Bereaved Families for Justice, representing 2,600 families of the bereaved
Read witness statement

Jo’s father, aged 72 and a cancer patient died after he contracted Covid-19, very likely at a crowded outpatient clinic where there was no advice on or protection from coronavirus.

 

There are common patterns arising from accounts from families Jo has heard from:
 

  • 40% of families believe their family member had acquired the infection in hospital.

  • Severe PPE shortages affected both patients and NHS staff

  • Lockdown came too late and too little was done to protect vulnerable people.

  • Families had had difficulties accessing hospital care via the NHS 111 coronavirus service, where people clearly needing hospital treatment were told to stay at home.

  • Symptoms of Covid-19 were much broader than had been acknowledged – many families reported gastroenterological symptoms and intense fatigue which were not recognised by NHS 111 because family members did not have typical breathlessness.

  • At the outset of the pandemic the NHS 111 coronavirus service was outsourced to a number of companies and there was very limited training compared to the normal 111 service.
     


Witness 2: Professor Sir Michael Marmot, Director, UCL Institute of Health Equity, UCL Dept of Epidemiology and Public Health (author of ‘the Marmot reports’)

 

Michael Marmot’s evidence shows how the basis was created for the disastrous toll of the Covid epidemic in the UK prior to 2020. He spoke of a ‘lost decade’ in terms of the public’s health.
 

He spoke to the following article and reports:
'Health Equity in England: the Marmot Review 10 years on' BMJ February 2020 Read pdf here

Build Back Fairer - the COVID-19 Marmot review, The Health Foundation and Institute of Health Inequality. December 2020. (pp 4-10 is a recommended essential selection from the full report) 

Health Equity in England: The Marmot Review 10 years on, Institute of Health Inequality. February 2020 (pp 8-12 recommended)

 

  • Marmot’s 2010 report ‘Fair Society, Healthy Lives’, commissioned by the Gordon Brown Labour government, concluded that the key determinants of health lie outside the health system – such as early childhood, education, lifelong learning, employment, housing, etc

  • The report was initially welcomed by the Cameron/Coalition government [from May 2010] but they and successive Conservative governments failed to put the principles into practice. There was no interest in doing so.

  • Over that decade, public expenditure was rolled back from 42% of GDP to 35%.

  • The less well-off lost 20% of their income, while the better off lost a smaller percentage

  • Life expectancy which had been increasing by one year every four years since 1890, but that gain had almost ground to a halt by 2020.

  • Health inequities widened between the most and least advantaged during the decade, as did inequalities between regions, with the population in the North East and North West being among the hardest hit.

  • Systemic health inequalities – much could be put right as a matter of social justice ie racism had not been addressed.

  • Local authority spending in the least disadvantaged areas went down by 16% whereas spending in the most deprived areas fell by 32%.

  • After these 10 years, the causes of inequality in COVID-19 overlap considerably with the causes of inequality in health more generally.

  • There was a poor health record coming into the pandemic due to social and economic inequalities, disinvestment in the public sector; and disastrous management of the pandemic due to the (poor) quality of governance and political culture.
     


Witness 3: Holly Turner RN, an NHS nurse working with children with disabilities in Child & Adolescent Mental Health Service (CAMHS) for the past 10 years
Read witness statement

 

Holly Turner told the panel how her job had changed in the last 10 years: staffing and working conditions had worsened. People are living in extreme deprivation, housing accommodation is not big enough for disabled children and their families, respite services have got worse. 
 

Questioned about the pandemic Holly Turner described how:
 

  • All schools including special schools and respite care had been closed in her area, visits from carers stopped, leading to huge suffering for children and young people with disabilities, who need routine, continuity and predictability, and for their families.

  • Holly Turner spoke of children who have suffered long term injury through self-harm in their distress.

  • Referrals to CAMHS are also increasing rapidly, yet there continues to be no investment in services.

  • In terms of preparations for the pandemic she stated that she was not aware of any discussions building up to the start of this pandemic at the beginning of 2020.  She stated that just getting your day-to-day work done there was too much – with limited capacity to be thinking about anything else.

  • In her written evidence (see statement) Holly spoke of the personal effects of Covid-19 on her family. Holly and her husband, both nurses, had contracted Covid-19.

  • In her written evidence Holly spoke how whilst working within CAMHS inpatient services from 2012-2016, they were regularly faced with chronic understaffing and several times she finished a 12 hours shift, would stay all night as there was no one to take the nursing keys and then run the night shift.

 

Witness 4: Professor Gabriel Scally, President, Epidemiology and Public Health Section Royal Society of Medicine, Visiting Professor of Public Health, University of Bristol, member of Independent SAGE  
Read witness statement

 

Professor Scally was public health regional director in N Ireland and the South West of England for over 19 years: his testimony reviewed the 10-year decimation of the system.

Before 2010 there had been a complex system of preparedness for regional planning. But after 2010 there had been:

  • a systematic hollowing out of state provision for emergencies.

  • the abolition of strategic health authorities and primary care trusts

  • the NHS had moved to a purchaser-provider model, and existing structures were broken up

  • Directors of Public Health had a much-reduced role and resources.

  • The creation of Public Health England as a centralised body lost a very direct connection with local and regional organisations.

 

There had been plenty of opportunity to develop skills in emergency planning and response for example in relation to Foot and Mouth Disease and MERS outbreaks, but with the stripping out of resources, areas were left to make their own arrangements. If that hadn’t been the case, with a stronger public health system the UK would likely have coped much better with coronavirus.

Exercise Cygnus was a training exercise based on an influenza scenario. Up to 950 people took part and the report had important recommendations. The ability to follow these up had been clearly affected by the 'decimation of public health’.

Our public health has been in decline and inequalities increased purely because we have had governments that have no real interest in improving the health of the population.
After 2010 we lost our status as having eliminated measles in 2016 – vaccination rates have been falling; cancer screening rates are falling; rates of sexually transmitted diseases and drug-related death rates are increasing. 


During the pandemic, destruction of local organisations and lack of resources have made it impossible to address equity issues and build community resilience eg the failure to have a locally based ‘find, test, trace, isolate and support’ system involving the directors of public health, with the responsibility of helping the community and its organisations take control of the pandemic at a local level, is a really major failing.
 

In his written evidence Gabriel Scally also made the following points:
 

  • Countries that have successfully contained COVID-19 and reduced it to tiny numbers of cases have been able to protect their economies from substantial damage and provide their citizens with a near-normal life experience. On the other hand, failure to suppress COVID-19 successfully has forced countries to rely upon periodic imposition of severe social and economic restriction to limit the loss of life and prevent their health services from being overwhelmed.
     

  • The UK government’s performance in protecting its citizens from the deadliest pandemic in more than a century has been lamentable. The UK’s early response was examined in a published article See article 1 below. With well over 100,000 deaths from COVID-19, all potentially avoidable, and the worst economic performance of any country in the G20 group of nations,there is little to praise.
     

  • He also stated it was impossible to critique the UK’s strategy because there had never been an explicit strategy for responding to the pandemic.
     

Gabriel Scally stated that he had resigned from his post as a senior civil servant with the Department of Health in early 2012. In November of that year, he gave oral evidence to the House of Commons Communities and Local Government Committee. In that evidence, he warned of the very distinct possibility that the new structures would not work in the event of a serious national emergency. I also stated that “I do not want to be sitting and talking about this in the aftermath of something that goes wrong”.
See extract of the committee’s report, which contains my evidence (Questions 104 and 111).

Professor Scally submitted the following references in evidence.


1. Scally G, et al. The UK’s public health response to covid-19 May 2020.

BMJ 2020;369:m1932 https://www.bmj.com/content/369/bmj.m1932

2. https://www.oecd.org/newsroom/g20-gdp-growth-third-quarter-2020-oecd.htm#:~:text=2020%20%2D%20Gross%20domestic%20product%20(GDP,the%20final%20quarter%20of%202019
3. House of Commons. Communities and Local Government Committee. The role of local authorities in health issues. Eighth Report of Session 2012–13. 27 March 2013. https://publications.parliament.uk/pa/cm201213/cmselect/cmcomloc/694/694.pdf

4. Chapter 16 Collaboration and Co-operation between Local Resilience Forums in England: Revision to Emergency Preparedness. Cabinet Office. March 2012. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/61039/Chapter-16-final-post-consultCCS_amends_16042012.pdf

5. Scally, G., 2013. Chief medical officers: the need for public health at the heart of government. BMJ, 346. https://www.bmj.com/content/346/bmj.f688

6. Scally, G., 2020. The demise of Public Health England. BMJ 2020;370:m3263 https://www.bmj.com/content/370/bmj.m32

3.full
 

Witness 5: John Lister, health researcher, academic and journalist answered questions on the state of the NHS before and after the pandemic
Read witness statement
 

  • In the decade before 2010, the New Labour government recognised the need to invest very substantially in the NHS leading to a reduction in waiting times and performance, improved pay and conditions of staff, an increase in numbers of staff.
     

  • From 2010 the Cameron government committed immediately to a policy of austerity and there was a reversal of the years of increase in NHS funding in real terms. There was an increase per year of only 1.5-2% by year compared to a 3.8-9% average increase over the previous 40 years. This created deficits on a massive level in frontline trusts but also a real pressure on capital and maintenance.
     

  • The 95% target – emergency patients to be seen or treated in A&E within 4 hours – has not been met for five years; waiting lists prior to the Covid pandemic had risen to 4.5 million with 15% of those waiting for more than 18 weeks.
     

  • The problem is exacerbated by NHS staff shortages of up to 100,000 in total but including 40,000 vacant nursing posts plus a large number of doctor positions. There were repeated promises of recruitment of large numbers of extra GPs and 50,000 nurses These did not materialise.
     

  • Hospital beds:  In 2010 there were 144,000 hospital beds which came down to 128,000 100 by 2019. This includes 9000 fewer frontline general acute beds that treat waiting list and emergency patients, but also a reduction of 5245 mental health beds ie 22% lost from the total in 2010.
     

  • Models of mental health care change and continue to move away to some extent from hospital beds. However, many of these NHS hospital beds are being replaced by increased dependence on private hospital beds, quite often at a long distance away from where the people actually needing the treatment live.
     

  • Learning disability:  There was a 61% reduction in the already much-reduced level of beds for people with learning disabilities in 2010: again, some of this was due to changes in treatment and the transfer of responsibility to local government.  But at the same local government has been drastically cut, making it impossible to maintain a lot of the infrastructure outside of immediate healthcare provision that could enhance life and deliver the kind of care necessary for people with learning disabilities.
     

  • Social care:  From 1993 and the Thatcher reforms, social care was effectively privatised.  Private nursing homes took over that area of responsibility. As far as social care in the community is concerned, it's at the point now where unless you have the most extreme level of need you will not receive support from local authorities. Effectively people who had medium or low levels of need who could be kept happily in their homes and supported by a properly funded resource, are now getting nothing until they actually reach crisis point. 

    Waste of money on a marketised health system
     

  • Prior to greater marketisation in the NHS, 6-7% of spending was on administration and management overheads. If you look at fully marketised systems, the level of that spending on overheads is upwards of 20% – we're somewhere between these. We are not a fully marketised/privatised system but at the same time, we've obviously introduced a lot of the overheads and the complications that run along with them, without bringing the funding.
     

  • Comparison to other countries as we went into the pandemic:
    Countries such as France, Germany the Netherlands have spent much more per capita, over decades. Germany has put in much greater investment in intensive care beds, and have locally-controlled Test and Trace.