Written evidence submitted by Dr Agnes Arnold-Forster and Dr Caitjan Gainty (DEL0103)
Executive Summary
The COVID-19 pandemic has newly exposed deep fault lines in British healthcare.These include but are not limited to:
Findings:
- The NHS is a healthcare system that is ill-equipped to deal with a health crisis of this type and magnitude and internally unsustainable, especially if current labour crises are not met.
- In many ways, the current crises of the NHS are, however, not unique to Britain, so that looking to international efforts to reform health care will be instructive
- We advise a multi-pronged, historically-informed approach to health care reform focused around
Introduction
Written evidence submitted by Dr Agnes Arnold-Forster, University of Roehampton, and Dr Caitjan Gainty, King’s College London. We are historians of healthcare with expertise in public health, the clinical workforce, and hospital management in twentieth- and twenty-first-century Britain. This written evidence articulates some of the critical findings of an ongoing study of healthcare in a pandemic, noting both well-known and new fault lines. It suggests the need to capitalize both on positive changes that have taken place in health and social care as a result of the pandemic as well as on the new visibility and transparency of health care concern and public buy-in so that momentum is not lost as services normalize.
Background
The COVID-19 pandemic has newly exposed deep and painful fault lines in British healthcare. It has dramatically manifested a pre-existing crisis of health inequality and its reliance on underpaid and under-resourced health and social care professionals has brought into focus an enormous and in some ways quite unique labour crisis. It has emphasised the current crisis of “evidence” in the constitution of best medical practices, and it has also laid bare the oversimplified nature of public understandings and conversations about healthcare.
The intense scrutiny on healthcare at this moment has created an unusually high level of interest and awareness of its shortcomings as well as increased interest in its improvement. This evidence looks at familiar issues with fresh eyes and asks the Committee to consider these challenges in their historical context and think creatively about how to reform Britain’s healthcare system for the better.
Key Issues
(1) Health Inequality
Observations:
COVID-19 has exposed and exacerbated profound social and health inequalities. People from BAME backgrounds, the poor, the disabled, the old, and the disenfranchised are dying at a much higher rate.
The report of a 1980 government investigation into the state of the nation’s health provided evidence of these inequalities. The ‘Black Report’ demonstrated that inequalities had not only seen no reduction since the 1948 institution of the NHS, but had in fact deepened, with death rates between social tiers widening over the decades. Now, thirty years after the Black Report, we can readily see in the daily death toll how our national health remains moored to our historical inequities. Then as now, it should be abundantly clear that extending free, comprehensive healthcare to all does not cure our social ills.
COVID-19 has also revealed inequalities within the NHS, where doctors and nurses form BAME backgrounds disproportionately lead the death rates. Indeed, while people of colour account for approximately 21% of NHS staff, 63% of those who have died from coronavirus have been from BAME backgrounds. Perhaps most starkly, 95% of the doctors who have died have been people of colour.
The reasons for this are complex and as yet under examined. But one cause is the class system found in the NHS’s internal structure. At the bottom of the pecking order are the non-clinical workers – men and mainly women who tend to be employed on less secure, temporary, and precarious contracts with limited union protection, and who come from already disadvantaged groups with far less social, economic, and political capital than doctors or even nurses. At no time is this ideal. In this current pandemic, it has meant that they are also at the bottom of the list – the least well protected - when it comes to things like the distribution of PPE.
Racism is also a factor here that must be contended with: it cannot be elided with class inequalities or with bullying or harassment in the workplace. The inquiry set up to investigate the stark BAME fatality statistics coming from the frontlines of the health service must take this into account.
Conclusions:
(2) Healthcare Labour
Observations:
The COVID-19 pandemic has exposed the challenges associated with safeguarding the emotional health and wellbeing of hospital staff. The NHS, already under chronic strain, has been put under additional pressure as its staff responds to an unprecedented global public health crisis. They are managing increased demand from anxious patients, whether dangerously sick or worried well, and they are likely working long hours in unpredictable situations. They are also managing fears about their own health and infecting loved ones. Evidence about the impact of COVID-19 on British healthcare workers has yet to be published, but a British Medical Association survey found that nearly half of UK doctors are suffering from burnout, depression or anxiety amidst continuing shortage of protective supplies.
The labour crisis has revealed itself particularly in the context of PPE. It has been widely reported that frontline staff did not have the PPE they required to deal with the crisis, a lawsuit has been filed alleging that guidance about PPE was lacking, and there have been widespread reports of physicians being warned against speaking out about the PPE crisis.
While new in their specifics, the notion that something is wrong with ‘work’ in healthcare is not. Indeed, that healthcare practitioners’ emotional health is compromised by the jobs they do and the environments they work in is a long-standing issue in the history of the NHS. Since at least the 1970s, there have been complaints about the welfare of hospital workers, anxiety about declining morale, and suggestions for reforms to improve staff wellbeing. have occurred with increasing frequency and fervor and over the past five years, attracting new attention from healthcare practitioners, professional organisations, and policymakers. There is now a consensus that the NHS is suffering a crisis of emotional ill-health and depleted wellbeing. Recent studies have revealed a high level of burnout about doctors and medical students in the United Kingdom and new and persistent pressures have led to a supposed ‘epidemic’ in serious psychological and emotional conditions.
On the positive side, COVID-19 has demonstrated the potential of simple, low-tech solutions to emotional ill-health among healthcare workers. Many of the things identified as crucial for staff wellbeing but hitherto lacking from hospitals – sustaining food, well-equipped places to relax, a sense of comradery – have appeared within weeks.
Though these have increased morale, failures to provide adequate personal protective equipment in particular have refocused attention on the unique nature of medical labour, with its conflicting demands of “professionalism” on the one hand, with which comes the persistent responsibility to sacrifice one’s self for one’s patients, and basic worker rights on the other, which ought to include basic safety in the workplace, fair and transparent working conditions, and the right to complain when these conditions have not been met.
Conclusions:
(3) The NHS and Public Health
Observations:
The NHS has shown itself to be underprepared and undersupplied for the pressures of a global health event. We are suffering the consequences of a system that privileges acute, hospital-based care over public health investment and provision. The mismatch of health resources to the health crisis that we are currently witnessing stems from the slow carving out of acute, hospital-based health services as the only and singular services that healthcare practitioners can perform and the concurrent slippage of public health into an arm of national security instead.
Well into the 1930s, one of the goals of medicine was to eradicate disease, so that the acute care that hospital medicine offered in the treatment of disease would become obsolete. Though this may well have been an implausible aim, it underscores just how much things have changed, such that healthcare now is only about acute care. It struggles to accommodate those in need of chronic care, and it seems to have almost no use for prevention.
The case of cancer is illustrative. In the nineteenth and early twentieth centuries, it was a disease of public health. Money flowed into preventive research, with investigation primarily into its distribution and its relationship with environment, pollutants, diets, and lifestyles. But in the 1930s, during change that touched all of healthcare, it became marketed as a matter of “personal care”, with individualised treatments that typified, as one physician put in 1934, the new emphasis on “private not public health”.
But when four in 10 cancers are shown to be preventable, advances in treatment alone will never be enough to reduce the rising cancer caseload. As cancer also becomes a lifelong, chronic disease, pouring money into acute care does not make sense. It is matter of the uneven distribution of resources and attention between prevention and treatment that specifically concerns us here. For even more in evidence now, when celebrated arsenal of acute medical care undergirding our systems can offer little more than support for those bodies struggling with COVID-19 or, in the failure of this, palliation, the unevenness of our healthcare system is quite evident. The need for a better integrated system that attends to prevention, housing, infrastructure even as it also continues to attend to acute disease is increasingly pressing at the best of times. It is absolutely vital in a pandemic.
Conclusions:
(4) Rhetoric Matters
A final point concerns the problematic nature of rhetoric around healthcare and the way in which this can obstruct and obscure critical analysis of its successes and failures. A frequent experience in teaching medicine’s history is the extent to which the NHS - ‘our NHS’ – has become a creation of various political rhetorical exercises more than it is a substantive entity worthy of our thoughtful consideration. This tendency to oversimplify has followed us through the pandemic. The notion that our health care workers are ‘heroes’ helps to forestall responsibility for the criticisms they themselves have made, while the notion that the NHS has become more ‘flexible’ as a result of the pandemic mistakes the efficiency of emergency for the reality of bureaucracy.
A more transparent, honest accounting of the NHS is needed. One that both acknowledges the profound social good a free-at-the-point-of-access health service can offer as well as its shortcomings and reckons with the clouding effects of that potential social good on many people’s critical judgment.
Recommendations
Inequality
- Health policymakers must contend with racism within the NHS.
- Further research is required to understand its permutations and effects and interventions must be designed to address its prevalence.
- These interventions must appreciate the peculiarity of race-based discrimination and abuse, rather than eliding the problem through generalised discussions of ‘bullying and harassment’.
- Healthcare workplaces must be restructured so that everyone within them is treated with equal respect and entitled to equivalent benefits.
- Policymaking that attempts to address health inequalities must recognise the limited capacity of free medical care to deliver equal health.
- Equal access to health care is not equivalent to equal health.
Healthcare Labour
- Interventions to ameliorate NHS workforce wellbeing must recognise the emotional benefits of being well-rested, well-fed, and feeling valued by your colleagues, your employer, and the public.
- Interventions designed to improve ‘resilience’ that focus on individualistic ‘solutions’ such as exercise classes and attitudinal change must be avoided as there is no evidence supporting their efficacy.
- Policymakers should instead focus on interventions that remain alert to the autonomy and individuality of hospital staff and the supportive nature of workplace communities; and that emphasise communication and the patient experience.
- With local food businesses providing free catering for hospital staff and homewares companies furnishing on-call rooms and dedicated rest-spaces, government and individual hospital trusts must step in to fill gaps currently addressed by local businesses and charitable giving after the current crisis abates.
Under-Investment in Public Health
- Historical analysis reveals that acute hospital based care and public health need to be better integrated. Early twentieth century examples of healthcare give us some indication as to how this might be accomplished.
- The outcomes of health care might be measured more in terms of prevention: not what are the results of being in the hospital, but how many people have we kept out?