In Lord Denning’s 1980 judgement preventing the Birmingham Six from suing the police for injuries while in custody, he stated:
“Just consider………if their action were to proceed to trial………If they won, it would mean that the police were guilty of perjury; that they were guilty of violence and threats; that the confessions were involuntary and improperly admitted in evidence; and that the convictions were erroneous…….That was such an appalling vista that every sensible person would say, ‘It cannot be right that these actions should go any further’.”
It is what happens when an institution is seen as more important than the purpose for which it was set up or the people it is intended to serve. Denning could not countenance his “appalling vista” so he turned away from the more important concept: “Let justice be done though the heavens fall.” If it was not quite Britain’s Dreyfus affair, it shared many of the same characteristics: honour and reputation were seen, especially by those most closely linked to the institution, as more important than its actual conduct; challenge was most unwelcome. It is a failing to which all institutions are vulnerable.
So to the NHS. It is worth saying at the outset that the work, dedication and sacrifices of those working in it during this pandemic are worthy of praise and gratitude. It is possible to criticise an institution or the decisions taken at a policy level without demeaning its employees’ work and professionalism. Indeed, this is necessary if employees’ efforts are to be really worthwhile. Ultimately, any system is there for the benefit of its users, to serve the purposes for which it exists, not for those who work in it, however heroic they may be.
“Protect the NHS” has been a key message. Ahead of, curiously, “Save Lives”. The reason is that, were the NHS to become overwhelmed, lives (whether of patients or health workers) would not be saved. To that extent, this policy appears to have been a success. But it has come at a cost – a cost which may well mean that the lives saved have not been as numerous as they might have been. Was this cost unavoidable or was it, in part, the result of policy decisions taken? There are three (out of the many needing thorough examination in due course) worth looking at now.
A Too Successful Message?
It’s not easy to calibrate people’s responses, even to the most carefully crafted message. People have stayed away from GP surgeries and hospitals. Out of fear or because their health issues were not that serious or health services were not available. Or because they took to heart the government’s message, because they thought they were helping. In some cases, this will not have mattered. But in others, the delay may well have meant people dying at home or not having symptoms treated and developing more serious conditions than otherwise or enduring pain or losing out on necessary treatment. In health, delay is not always a consequence-free option. This may have been inevitable and is now being remedied. But the consequences of delaying or removing treatment needs to be added into the balance at the the final reckoning.
Staying at home when ill
The explicit advice from the 111 helpline anyone with Covid-19 symptoms was to stay at home. Only when a person’s condition became serious did hospital admission happen. Was this right? The risks of such a policy decision are that the more seriously ill a person is when they come hospital, the poorer their chances of survival or the greater the risks of surviving with long-term health damage. There is also a greater chance of them passing on the virus to others while at home. Delaying admission until absolutely essential was not Germany’s approach which was to intervene, not necessarily always via hospital admission, at an earlier stage, a practice enormously helped by its much more effective and wide-ranging testing regime.
Both of these decisions by politicians and health officials were explicitly a rationing of health care because of a lack of capacity. Any state funded health system will, in some way or other, ration health care, a point often overlooked in discussions about structures, targets and monies spent. Covid-19 has made this explicit and in the most brutal way possible. When it arrived, the NHS did not have sufficient ICU capacity. There was also insufficient testing capacity – though this was only recently admitted. The decision was therefore taken to divert NHS resources to building up ICU capacity and limiting access to hospitals and GPs in the meantime. This certainly protected the NHS and patients from the distressing scenes seen in Italy but at the cost of hidden suffering and death elsewhere. Nowhere has this been more apparent than in care homes.
Why are social care and NHS not integrated?
You may well ask. Decisions by successive governments to do nothing effective about social care, other than bunging a bit more money at councils from time to time, commissioning reports from the eminent then ignoring them were made long before this virus was a twinkle in its bat mother’s eye. But the virus has cruelly exposed these failings. Policies – lockdown, shielding vulnerable groups, staying away from Granny so as not to infect her – designed to protect those most at risk have been undermined by a policy which has treated care for the elderly and sick at the end of their lives as somehow distinct from and less important than health, an unfortunate after-thought. It’s as if we labelled pregnancy, birth and a child’s early years nursery care and left it largely to parents to sort out. If babies die, too bad: easy enough to make another. As easy as dismissing the elderly “bed blockers”.
Care for the elderly is not an optional extra when a virus dangerous for them comes. Why did NHS England give specific guidance on March 7 to “urgently” make available 15,000 hospital beds nationally by discharging anyone who was medically fit to leave without thinking of the consequences for care homes? Were patients sent there without testing for the virus even if they had symptoms? Or even if they had them or were known to be infected? And what did the Department of Health think would happen when it said on April 2nd that negative virus tests were “not required” before discharging people into a care home? What did they think would be the consequences of not making provision for PPE for care home workers? Or of having no policy for managing the movement into and out of care homes of care workers? Or of reduced access to GPs? Or of not having family members able to visit and speak up for their relatives?
However laudable the desire to protect the NHS is, its failure is that the NHS’s patients are too often defined – unthinkingly perhaps – as excluding some of the most vulnerable, especially in a pandemic. It’s not as if the government was not warned, as the report into Exercise Cygnus in 2017 stated. Care homes, their need for staff, for a plan, the dangers of discharging patients to them were all expressly raised as serious risks – but little was done.
So when a crisis came and health care had to be rationed, hospitals were given priority. Patients in hospitals over those in care homes. Hospital workers over care home workers. Social care took its accustomed second place in our priorities. And that is, in part, why there has been an epidemic of the virus among the most vulnerable group, the group which government policies were ostensibly designed to protect. Rather than cocoon the most vulnerable, they were left horribly exposed.
Perhaps in reality this is no different from what has always the case. This time we have noticed. This time, as Boris has said, we “bitterly regret” what is happening. Perhaps it could not have been otherwise. Other countries have suffered similarly high rates of care home deaths.
There is little good likely to come from this virus. Maybe one thing which might is that we – finally – do something serious about how we care for the old, the disabled, the vulnerable rather than simply talk about it.