2 April 2020 — Politics & Insights
Written by Kitty S Jones
The National Health Service (NHS) was born on 5 July 1948. It was the first time anywhere in the world that completely free healthcare provision was made available on the basis of citizenship rather than the payment of fees or insurance.
The NHS was founded on the principle of universal healthcare. It upheld the most fundamental principles of human rights: that each life has equal worth, and that we all have a right to life.
In 1946, the new Labour government passed the National Health Service Act. The model they used was based on one used in Tredegar in the 1930s, which was like an early, local version of the NHS. However, the new Minister for Health, Aneurin Bevan, who was MP for Tredegar, had to overcome opposition to the NHS. For example:
- The British Medical Association (BMA), who feared that doctors employed by the NHS would lose income.
- Many local authorities and voluntary bodies, which ran hospitals, also objected as they feared they would lose control over them.
- Winston Churchill and many Conservative MPs thought that the cost of the NHS would be “too great.”
There are now four times fewer beds within the NHS than there were originally. That is despite increasing demand.
The Conservatives know the cost of everything and the value of absolutely nothing.
Tory governments have always been misers with public funds that are for funding public services. They prefer to hand our money out to millionaires.
However, the most fundamental role of government is to keep citizens safe. Without doing that, they have no legitimacy or authority. They have no point.
The role of public services is to protect and support the public who pay for them. As the coronavirus epidemic in the UK peaks over the coming weeks, many of our most vulnerable citizens face being cruelly let down by a government that has failed to ensure our public services are fit for purpose, particularly the NHS.
Chronic underfunding over the last decade has left us with treatment rationing and situations in medical settings where patients are left for hours on end on trolleys in corridors without adequate care. That was happening long before the coronavirus did the epizootic shuffle through a couple of species to settle, often catastrophically, in humans.
The government are transmitting irrational adverts asking the public to ‘protect the NHS.’ Yet it is the government that has failed in that endeavour. And systematically failed the British public. The NHS has ceased to be fit for purpose. Not because of its hard working frontline staff, but because of chronic underfunding.
This government have pathologised the notion of social safety nets, civilised support, and inverted the purpose of public services with an insidious neoliberal narrative.
It’s absurd, perverse and obscene.
This perverse rhetoric of ‘protecting’ a public service from ‘overuse’ has been with us for over a decade. It’s a way of normalising the dismantling of the services we have paid for.
Imagine the public needing to use a public service… makes you wonder what the Conservatives think they are actually for, if not serving the public.
Of course, within the neoliberal framework, perverse profit incentives overshadow quality of service and delivery. It’s all about ‘efficiency’ and not quality. Public services have become cash cows: privatisation and profit. Another effect of market fundamentalism is the increasing conditionality of services, and in healthcare settings, the progressive rationing of treatments and cost cutting.
However, that hasn’t worked out very well to date. It’s become a way of making individuals responsible for being ill and needing healthcare, and for the chronic lack of funding the government are responsible for; an inadequacy which is now being thrown into sharp relief.
The whole point of the NHS was to protect citizens, providing a universal healthcare service to all, ‘from the cradle to the grave’, regardless of someone’s circumstances. It was never intended to treat only the healthiest citizens, while leaving those who are elderly, frail or have expensive ‘underlying conditions’ to simply die.
Rationing treatment for covid-19
Rationing healthcare increased over the last few years, it has become the norm. Now, it has become very clear that treatment for covid-19 is going to be rationed. We have moved a long way from universal health care.
The National Institute for Health and Care Excellence (NICE) have already introduced guidelines for establishing treatment ‘ceilings’, based on who they think is likeliest to survive COVID-19. However, we have no way of knowing in advance of a treatment if someone actually will survive.
Formal guidance says GPs should “proactively complete DNAR forms, in advance of a worsening spread of coronavirus.”
People over 80 years old, and high risk groups are now being contacted about signing “do not attempt to resuscitate” forms. This approach is firmly embedded in coronavirus planning and provision amid concerns over a lack of intensive care beds during the worsening coronavirus crisis.
Multiple GPs have said they are talking to patients who are older or in very high risk groups about signing “do not attempt to resuscitate” forms in case these patients were to go on to contract the virus. Some practices have also sent out letters to patients requesting they complete the forms, it is understood.
One leader of a primary care network, who asked not to be named, said: “Those in the severe at-risk group and those over 80 are being told they won’t necessarily be admitted to hospital if they catch coronavirus.”
Guidance issued by the Royal College of General Practitioners last week also touched on the issue, saying: “Proactively complete ReSPECT/ DNAR forms and prescribe anticipatory medications in advance of a worsening spread of disease.”
End of life conversations cover prescribing palliative pain relief, so patients aren’t left without the ‘appropriate’ medicines.
It’s understood these conversations are also being had with people living in nursing and care homes.
Jonathan Leach, a practising GP who helped draft the guidance, told Health Service Journal (HSJ) “We have a huge role as a college [on this] as we see the volume and type of patients we should be sending into hospital and those we shouldn’t be.”
Type of patient? I wonder if I will be the type of patient that doctors will decide to treat? Or will I simply be left to die at home, because I have comorbid conditions?
Leach continued: “If covid-19 gets into a care home because residents are mostly vulnerable, we will see a significantly greater number over a shorter period who need this type of [palliative] care. So, part of coping with that is thinking ahead [about having these conversations].”
I always thought that covid-19 gets into any place simply because of its contagion quality, not because of a particular demographic – it doesn’t have any special preferences towards care home residents because they are vulnerable. Vulnerability doesn’t invite more coronavirus infections. That’s why the prime minister, the health and social care secretary and other no-vulnerable ‘clever’ people among the government have been also infected recently.
Dr Leach called discussing DNARs with people who are not at the end of life but are older or in a high-risk group a “grey area”. He added these decisions “need to be done on a case-by-case basis” but it was “more humane” to do it in advance.
How can leaving someone to die because of deliberately inflicted government funding cuts, based on an artificially constructed ‘type’, be “more humane”? Leach should have met my grandmother, who, in her 90s was probably fitter and more active than he is. Yet she would have conformed to his ‘type’ of patient to be considered for a eugenics by laissez faire approach, based on just her age alone.
Recent guidance issued to hospitals said palliative care conversations with a patient’s family may have to take place remotely, and skilled palliative care teams may not have the capacity to undertake all conversations themselves.
A spokeswoman for the British Medical Association, which also co-drafted the GP work prioritisation document, said: “Considering, and where possible making, specific anticipatory decisions about whether or not to attempt CPR is part of high-quality care for any person who might be approaching the end of life or who might be at risk of cardiorespiratory arrest.”
That decision – choosing who is and who is not going to be given CPR- isn’t ‘care’, high quality or otherwise.
The National Institute for Health and Care Excellence’s (NICE) role more generally is to improve outcomes for people using the NHS and other public health and social care services.
Yet the NICE guidelines concerning treatment provision for covid-19 are founded on a distinctly eugenic rationale: ensuring the ‘survival of the fittest’ only.
The guidance for the NHS on which coronavirus patients should receive intensive care treatment has heightened fears among disability campaigners that many disabled people will be refused life-saving treatment if they are admitted to hospital.
The guidance, which originates from NICE, says that all adult covid-19 patients should be assessed for “frailty” when admitted to hospital, and that “comorbidities and underlying health conditions should be ‘taken into account’.”
In other words, those who need it most will be the most likely to be denied treatment, based on a fundamentally discriminatory scoring system.
The guidance is in gross violation of the Equality Act, as it will result in discriminatory health care provision and violate the fundamental universal right to life, on the basis of protected characteristics; in particular, those of age and disability.
The guideline says: “the risks and benefits and likely outcomes should be discussed with patients, carers or advocates and families using decision support tools (where available) so that they can make informed decisions about their treatment wherever possible.
“For patients with confirmed COVID-19, the guideline says decisions about admission to critical care should be made on the basis of medical benefit, taking into account the likelihood that the person will recover to an outcome that is acceptable to them and within a period of time consistent with the diagnosis.”
The Clinical Frailty Scale: NICE’s cold, callous categories of ‘types’, ‘they’ and ‘these people’:
Profound discrimination and human rights violations are deeply embedded in the NICE covid-19 treatment guidelines. The NHS are offering a limited treatment plan, in advance, for those of us considered ‘frail’.
It’s worth noting that China didn’t leave elderly people or those with comorbid conditions to die without trying to save them. In fact some were saved through the sheer persistence of doctors.
Young and healthy people also die of covid-19. We have no way of knowing in advance if someone will respond to treatment, unless we try it. Ismail Mohamed Abdulwahab is the youngest person in the UK, to date, at just 13 years old, to die of covid-19, without his family around him in hospital. And Luca Di Nicola, who was just 19 was also healthy previously. Neither had underlying conditions.
Even when doctors are reasonably sure someone will die, sometimes they don’t
In 2017, I had flu. Within just four days of the start of my symptoms, I ended up with advanced pneumonia and was in septic shock when I arrived at A&E. My prognosis was very poor. At one point I was having chemicals pumped into me to try and raise my blood pressure from off the floor. In the end a doctor decided to try a ‘last resort’ vasopressor (to raise blood pressure and prevent organ failure) called methylene blue, which is injected very slowly (it’s called a ‘slow injection’), because the chemical is dangerous if it accumulates in one spot.
Septic shock happens when a person’s blood pressure drops so low that organs are starved of oxygen, leading to sequential organ failure. If it can’t be remedied quickly, people die because of injured organs. It’s one of the key causes of death in people who are critically ill with covid-19.
But in my case, it worked. OK, so it turned my urine green for days, but here I am, still.
However, if I become critically ill with covid-19, my comorbid conditions will mean I am most likely going to be among those who reach a ‘ceiling’ of treatment, if the NHS is overwhelmed. One of the key reasons people die of covid-19 is because it causes severe pneumonia and sepsis. Deciding who may survive those conditions is difficult in advance of treatment. Yet the NICE guidelines show those decisions have already been made.
Eugenics in practice
A GP practice in Wales sent out a letter which recommended patients with serious illnesses complete “do not resuscitate” forms in case their health deteriorated after contracting coronavirus. Llynfi surgery, in Maesteg near Port Talbot, wrote to a “small number” of patients on Friday to ask them to complete a “DNACPR” – do not attempt cardiopulmonary resuscitation – form to ensure that emergency services would not be called if they contracted covid-19 and their health deteriorated.
The letter says: “This is a very difficult letter for the practice to write to you,” stating that people with illnesses such as incurable cancer, motor neurone disease and pulmonary fibrosis were at a much greater risk from the virus.
I have pulmonary fibrosis. I have to say the letter is probably rather more difficult to receive and read than it was to write.
“We would therefore like to complete a DNACPR form for you which we can share … which will mean that in the event of a sudden deterioration in your condition because [of] Covid infection or disease progression the emergency services will not be called and resuscitation attempts to restart your heart or breathing will not be attempted,” it continued.
“Completing a DNACPR will have several benefits,” the letter continues.
“1/ your GP and more importantly your friends and family will know not to call 999.
2/ scarce ambulance resources can be targeted to the young and fit who have a greater chance.”
“The risk of transmitting the virus to friends, family and emergency responders from CPR … is very high. By having a DNACPR form in place you protect your family … [and] emergency responders from this additional risk.”
The letter said that in an “ideal situation” doctors would have had this conversation in person with vulnerable patients but had written to them instead “due to fears they are carrying the virus and were asymptomatic”.
“We will not abandon you,” it said. “But we need to be frank and realistic.”
But the letter makes it very clear that some people’s lives are valued rather more than others. Abandoning those people considered ‘frail’ is exactly what the guidance issued by the Royal College of General Practitioners and NICE outline and this GP surgery are intending to put that into practice.
The GP surgery said the letter originated from Cwm Taf Morgannwg University Health Board, which then clarified the recommendation that vulnerable patients complete DNACPR forms was “not a health board requirement.”
“A letter was recently sent out from Llynfi surgery to a small number of patients,” a spokesperson said. “This was not a health board communication.
“The surgery have been made aware that the letter has caused upset to some of the patients who received it. This was not their intent and they apologise for any distress caused. Staff at the surgery are speaking to those patients who received the letter to apologise directly and answer any concerns they may have.”
The letter went viral on social media and one person said a nurse practitioner had recently visited her father, who is receiving palliative care, to also request he sign a DNACPR form.
The NHS currently has 8,175 ventilators and has said it needs 30,000 more to deal with an expected peak of covid-19 patients, while the health service is reportedly attempting to increase its intensive care capacity sevenfold amid fears the full effect of the pandemic could be overwhelming.
There is a lack of personal protective equipment across the NHS despite renewed efforts to provide ambulance crews, GP surgeries and hospitals with the masks, visors, gloves and aprons that help prevent coronavirus transmission. At least three healthcare workers have already died from the virus.
Doctors in the UK must consult with patients or their families if they decide that resuscitation would not be effective or that complications would result in more pain. Families can seek a second opinion but apparently, the decision is ultimately a “medical judgment” to be made by a doctor.
Based on the damning guidelines issued by the Royal College of General Practitioners and NICE .
So the ‘collateral damage’ due to years of Tory governments systematically underfunding the NHS is an uncivilised denial of medical support for those who need it most, based on a distinctly eugenic logic.
It took just two months into a global pandemic to scrape away the thin veneer of civilised democracy, equality and universal human rights.
Once the coronavirus crisis subsides, we must never forget that those of us with ‘underlying’ medical conditions were considered expendable in order to ensure those who generally needed medical intervention the least got it at the expense of others, because of government priorities, which are never about ‘uniting and levelling up’.
Universal health care was destroyed by the Conservative governments of the last decade, and has been replaced by calculated, cost-cutting eugenic practices based on a deeply ingrained antipathy towards groups with protected characteristics, but in particular, towards those citizens with any degree of frailty.
A doctor in Spain breaks down, as he describes how people over 65 years old with Covid-19 are being sedated and left to die, so that younger people may have priority for treatments such as ventilators.
In the UK, NICE have drawn guidelines that set out who will get priority for treatment for the coronavirus. Not those most in need. Those most likely to survive anyway will have priority access to treatment. Elderly people and those who have underlying conditions will simply have isolation to protect them.
Universal health care and the universal right to life has become conditional. The universal human rights that were fought for and earned are now a distant memory.
The Conservatives have systematically eroded both human rights and universal health care provision. The latter because of deliberate and chronic underfunding.
Scratch the surface of right-wing neoliberal ‘libertarianism’ and there lies a deeply embedded eugenic ideology.
The NICE guidelines have introduced the notion that our society requires triage, not as a last resort, but as a preemptive measure. It seems some people are considered too expensive to save. The NICE document separates human life into blunt categories. In one small group of boxes, there are people deemed to be worth saving. In the others, there are groups of people who, it has been decided, ought to be just left to die. As cheaply as possible.
What is outlined in the NICE guidelines and clarified in the and letter from the GP practice is not quite mass murder, but it is a sort of pre-planned, homicide by lack of funding, indifference and laissez faire.
The arguments presented for triage on the basis of ‘frailty’ are arguments from the eugenicist right wing. The fact that those who designed the guidelines think the elderly and the ill are acceptable losses is something we should remember long after the pandemic is over. This tells us the neoliberal obsession with ‘market forces’ was not about human potential or a flourishing society, nor was it about, productivity and abundance, but about something else.
For the high priests of ‘small government’ and market fundamentalism, citizens are expensive, especially if they need regular medical care. And the NHS should provide that care, because WE pay for it. The real drain on our health care is the increasing number of private company ‘providers’ who are draining vital funds into piles of private profits.
The UK will emerge from pandemic with its hierarchy still intact, and its elite shielded from the grim realities and disadvantages that ordinary people face. Those citizens who need things such as public services (perish the thought), well, they will continue to be regarded by the powers that be as ‘life unworthy of life’.
This is a government, lets not forget, that decided initially to run a dangerous, pseudoscientifc experiment on ‘herd immunity’ and ‘behavioural change’. That didn’t work of course. No-one knows if having covid-19 leads to immunity after recovery. Or for how long. Some viruses simply mutate. A good example is H3N2 strains of influenza. My entire family had it over Christmas in 1968. I was very young, and remember my mother said we had “Hong kong ‘flu”.
H3N2 evolved from H2N2 by antigenic shift and caused the Hong Kong Flu pandemic of 1968 and 1969 that killed an estimated one million people worldwide. In 2017, I got it again. It’s a particularly nasty strain that the ‘flu vaccination can’t protect people from, and has become increasingly resistant to antivirals such as Tamiflu. In the years that H3N2 circulates, more people are hospitalised with ‘flu complications. Partly because this virus simply changes itself to dodge defeat. The second time I got it, I ended up with pneumonia and in septic shock, as outlined earlier.
You’d think parasites like viruses would have evolved to find ways of not killing their hosts off. It’s hardly in their best interests after all.
It’s almost the epitome of neoliberal commodificationism and consumerism.
My point is, we simply don’t know if people who have covid-19 are immune afterwards. No-one does.
The NICE guidelines have introduced the notion that our society requires triage, not as a last resort, but as a preemptive measure. It seems some people are considered of less worth than others, and too expensive to save.
Now we know that our current government, with it’s apparent ease in sliding towards eugenic solutions, are never going to be the cure for all of our ills.
On a global scale, covid-19 has thrown the evils of neoliberal economic systems – especially embedded inequality, the systematic erosion of fundamental human rights and the fragility of democracy – into sharp relief.
And some governments’ indifference to the lives and deaths of populations.
We must never forget this; the government believe that one life is worth less than another – some lives can so easily be regarded as expendable.