Andy Cowper on the government’s response towards healthcare in care homes at the time of the pandemic

DKMH

I had hoped to be able to avoid the subject of M*tt H*nc*ck in this column.

Yes, really.

It is not edifying watching and reflecting on the human embodiment of the Dunning-Kruger effect going about … whatever it is. Alas, Mr H*nc*ck’s performance at the Friday briefing was sufficiently shoddy as to be worthy of comment.

Mr H*nc*ck’s assertion that “right from the start, we’ve tried to throw a protective ring around our care homes … we’ve made sure that care homes have the resources they need to slow the spread of infections” is striking, as is his re-emphasis later that “we’ve worked incredibly hard to throw that protective ring around our care homes”.

Tried. Worked incredibly hard. The government’s Colt Seevers figure (“The Fall Guy”) is casting around for a “school report for the dim child” defence.

It is not easy to swallow.

Look at the latest ONS data on deaths in care homes.

Look at the justifiably outraged response of Martin Green of Care England speaking to the Financial Times, asking to “see the evidence of what exactly the protective ring consists. Ask [Mr Hancock’s] office when exactly they instituted this protective ring.

“Ask them why, if in February the government was prioritising care homes, we did not see the statistics on deaths? Why we had our PPE distribution networks disrupted to send things to the NHS [and] why we had our primary care support withdrawn from many care homes?”

“Ask them why they did not prioritise care homes for testing. If there was a protective ring initiated by the government, it did not feel like that for the people who were living and working in care homes”. Mr H*nc*ck’s answer to a later question on the dating of government recommendations and instructions to the care home sector was also highly unconvincing.

Yet Mr H*nc*ck told the briefing that the government was following a “principle of maximum transparency”. Ahem. It’s an unfortunate statement in a week when the UK Statistics Authority has had to write to Mr H*nc*ck about the testing data. The poverty of the response in the care home sector is even being picked up by normally very pro-Conservative papers such as The Mail.

This flailing around is also in evidence on the Department For Health But Social Care’s Twitter presence, which has begun a trend of disputing unfavourable media stories without offering any explanation of the alleged errors. This approach is also being mirrored by other major government departments. The hand of the prime minister’s chief advisor Dominic Cummings in this social media strategy (of sorts) is not hard to detect, as I noted in previous columns.

The problem here is that the “War On Reality” gets lost if the endless distortions and lies don’t get catalogued and fought. It isn’t charming or fun having to do this, or to pay attention to this, but it is important. The existence of objective reality matters: this is a deeply depressing line to have to write, but we are where we are.

(Oh yes, and the government’s new covid-19 “five levels of threat” system graphic has been copied from the Nandos “Peri-ometer”, hasn’t it?).

Enough – more than enough – of Mr H*nc*ck.

I can’t improve on a friend’s comment about the current state of affairs with covid-19 in the NHS: “we’re not out of the woods yet, but at least the trees aren’t on fire”. This feels like an appropriate time to take some stock, and think about some issues coming towards us as the NHS and care system move towards some re-opening.

One of the first things we need to think about is how the experience of this pandemic, and the fear that it has generated, will change people. To start on the demand side of the equation, one part of the re-opening of the NHS to a more normal level of service will have to address this huge challenge. A system that already had a huge problem with late presentation for cancer diagnosis now has an even bigger one. There are those who did not attend during the pandemic’s first wave, who will now need treatment that will have sub-optimal outcomes.

And of course, there will be ongoing demand from those who had to be admitted and ventilated for covid-19. It seems plausible that as well as short-term physio and respiratory follow-up, they will need support for cardiac, kidney and long-term lung problems.

Supply-side

Then there is the supply-side. While the NHS’s successful adaptation to provide sufficient ICU-ish capacity to meet demand may drive more people to interest in careers in medicine, we have to look out for other things.

The first is the very real risk of burnout. The last few months have been massively stressful for many NHS staff at all levels. Smart managers will have been on top of this issue, and it isn’t going away. And no, mindfulness apps won’t do much.

The level of deaths that ICU staff (and other staff who transferred into the sector) have seen is likely to have traumatic effects. There is undoubtedly rich learning to be done from colleagues in the military, police and emergency services about dealing with post-traumatic stress disorders. Anecdotally, doctors in particular may tend to underplay the severity of their own physical health issues, or try to self-treat: the same risks are true of mental health.

Then there will be a cohort of staff for whom the desire is to leave the NHS. Whether the driver is “my life is too short to keep coming to the box on the bypass” syndrome; or righteous indignation at poor PPE provision and what it says about how their lives are valued; or just trauma from what has been witnessed, there is likely to be quite a significant problem coming here.

This will require sensitive and smart responses. Again, the best managers are probably already on this, but your team leads should be starting to have light, preliminary conversations to check how their colleagues are doing. The background context is, of course, that very few of the problems about which I wrote my last column of Season One of “Cut”, one of the biggest of which was workforce, have been even partly solved, and we now have the unwelcome legacy of this pandemic to add to the pile.

Another area is the ever-growing backlog of cases, whether RTT or non-RTT. Rob Findlay’s latest column is, as always, worth reading. There are a lot of people waiting for care. NHS staff who have not been able or required to be working on the covid-19 work should hopefully have been validating and re-prioritising these lists. If they haven’t, the question “why not?” is going to be coming their way very, very soon.

Social care requires serious thought. It will take only a very small number of financial awards from court cases for negligence to push the sector into an unsustainable level of financial difficulty. We really do need to work out why it has been possible for dementia to be the one clinical condition for which the NHS simply does not provide care free at the point of need.

The issue of transfer of patient data to large overseas companies, which I touched on previously, keeps cropping up as an area of concern to many colleagues. I have a strong feeling that we are going to see some significant news stories coming out of this.

We will also need to consider how we run the regional and national management of the NHS in a post-covid-19 world. Is the waiting list backlog going to bring about what political advisor and commentator John McTernan calls a “war Communism” era for the NHS? If so, what does that mean for commissioning, and the Commissioning Board? And how do we rebalance between the local and the national? Initial signals of a city-wide system approach from London, reported by HSJ, have an interesting flavour. The whys and wherefores of this are a significant project on its own, as will be the risk assessment.

Then there are broader questions on how we will manage the national and economic impacts of covid-19, in what prime minister Boris Johnson wants to call a “common-sense” un-lock: I heartily recommend economist Jonathan Portes’ column for the Financial Times on this theme.

The Churchill fantasy

The NHS never gets to stray too far from the context of national politics: this is for good reasons, given our funding system. This is not an un-mixed blessing at the best of times, and this is not the best of times. We have a government that is proving itself to be impressively inadequate. As I have previously written, nothing reveals a leader’s character more than being found out, and the current leadership is being found out a very long way indeed.

Prime minister Boris Johnson clearly has a bit of a thing for the UK’s great 20th century wartime leader Winston Churchill, and would like to remind us of him; but is in practice reminding us rather more of Churchill the insurance advertising dog (albeit a slightly less animated and useful version).

It’s the political equivalent of finding out that you’ve got a good-time girl when you need a warrior queen. And even Mr Johnson’s admirers within his party are starting to notice. The public will notice, too, that Mr Johnson’s Churchill fantasy (Winston edition) is as distant as ever. The prime minister seems to think he’s Prince Hal, when in reality, he’s Falstaff: this confusion is not likely to end well for him.