Rationing of Oxygen is necessary in Essex, and long term covid patients are for GP care: why not?

Constanza Pierce reports in Pulse 29th Jan 2021: GPs to manage long Covid patients as specialist clinics suspended

GPs in Essex are set to manage patients with long-term symptoms of Covid-19 as clinics have been temporarily suspended across the area.

It comes as Essex is facing an ‘ongoing critical incident’, with severe pressures across the NHS leading to rationing of home oxygen supplies for patients.

GP leaders warned that the workforce is being stretched ‘too thinly’ and will burn out ‘sooner or later’.

Last month, new NICE guidance recommended that GPs should consider referring long Covid patients to specialist clinics as soon as four weeks after acute infection, after ruling out other diagnoses.

But Mid and South Essex CCGs told GPs earlier this month that local long Covid clinics have been suspended for six weeks due to ‘system pressures’.

An email briefing said: ‘In direct response to the growing levels of Covid infection and subsequent increase of admissions into our acute and community services, we are unfortunately having to suspend the provision of Long Covid Clinics for a period of six weeks. …….

Meanwhile, home oxygen services are rationing supplies in Essex as hospitals in the area struggle with high oxygen demand, forcing some patients to be transferred to alternative sites.

The email briefing said: ‘In response to the material growth in oxygen usage within hospitals, at vaccination centres and by ambulance services, BOC, as a provider of oxygen cylinders to the whole NHS as well as in patients’ homes, is being asked to meet an unprecedented demand for cylinders for acute/Covid need.’

While demand is ‘currently under control’, BOC will ask patients for permission to reduce their home oxygen supply on a ‘temporary basis’ to ‘mitigate risks’ of a ‘further increase’, it added.

This will apply to patients who have not replenished their oxygen supply ‘for some time’ and who are due a service or risk assessment, as well as those calling for a top-up who are ‘not a high-user requiring frequent replenishment’.

It comes as Pulse revealed that GPs in Essex have been asked to go into hospitals and help discharge patients to free up capacity.

Last month, NHS England announced that 69 long Covid clinics were in place around the country, with more sites expected to open in January.

But GPs warned that access to the clinics is patchy, with only one fifth (21%) of GPs saying they currently had access to a clinic in their local area.

Recession “more harmful than virus”…..?

Chris Smyth reports in the Times 30th Jan 2021: Recession “more harmful than virus” in reporting from the Scientific Advisory Group for Emergencies.

….However,, the absence of restrictions this winter would have led to more than 200,000 extra deaths in the three months to March, according to the estimates. This includes 76,000 extra deaths resulting from an overwhelmed NHS being unable to care for Coronavirus patients properly.
The calculations are the latest attempt by the Department of Health, Office for National Statistics and the Governement’s Actuary’s Department to quantify the indirect costs of the pandemic, ranging from the disruption to NHS care to the long term harms casued by increasing unemployment. The modelling has been published under pressure from lockdown-sceptic Tory MPs.

It concludes that it is impossible to know what the results of not imposign restrictions would have beenon the economy, saying the sickness and fear caused by uncontrolled infection would have had “significant economic costs, potentially greater than those associated with the restrictions”…..

…The authors stress “These are not projections, predictions or forecasts and represent one example of the potential impact of the pandemic”.

Midwifery in Crisis. A disgraceful reflection on the declining standards and tribalism across the health services. This is not confined to one trust but is endemic, and especially at unpopular and remote District General Hospitals.

Nothing changes over 2 years,despite a report and a warning that we are not doing well enough.Systemic repetitive risks are taken with women’s lives, and the lives of their babies. Despite being “exposed” the risks continued 2 years later with no change in outcomes. Tribalism in the midwifery professions is mainly at fault. it extends to medical school training, and needs emergency intervention. The doctors may have contributed by their attitudes but they have to be in charge …

The risks in having babies in rural areas – midwifery-led units questioned by consultant.

The cost of not preventing the death of babies – is higher than we can afford. NFC could be another way for politicians to display honesty. They are unlikely to take it.

NHS is unsafe, says chief

26th Jan 2021 Chadwick Lawrence Solicitors. MPS TOLD POOR TRAINING AND BULLYING ON NHS MATERNITY UNITS A RISK TO SAFETY

BBC News 15th Jan: Bedford hospital: ‘Risk of baby abduction’ at ‘inadequate’ maternity unit

15th January 2021Erica Rolfe for the Bedford Independent reports Inspectors rate Bedford Hospital maternity services ‘inadequate’ demanding significant improvement

Routine inspections were put on hold in March 2020 as a result of the Covid-19 pandemic.

However, inspectors returned to the hospital on 5 November 2020 to carry out an unannounced focused inspection of the maternity services, after staff raised concerns about the safety of the service which could lead to risk of harm to patients.

At the CQC’s last inspection of the maternity service in August 2018, several concerns were identified, and the service was rated Requires Improvement overall.

It was then served with requirement notices for regulation breaches.

Kingsley Napley reports on the Ockenden Review: First Report Sets Out Key Themes and Learning Points for NHS Maternity Services for Lexology Jan 21st 22021- When completed, the Ockenden review will likely be the largest clinical review of a single service in the history of the NHS. (But will the politicians take notice?)

….Future Improvements When the Ockenden review is completed it will likely be the largest number of clinical reviews relating to a single service in the history of the NHS. Sadly, it has come too late for the women and families who have already lost babies and loved ones as a result of avoidable mistakes in maternity care at SaTH. The review however represents an opportunity to learn from past mistakes, which in turn will lead to better outcomes for babies and mothers in the future.

Encouragingly, Louise Barnett, SaTH’s chief executive, has committed to implementing all of the actions outlined in the interim report. The hope is the first report and the full review that follows will improve safety in maternity care not just at SaTH, but at all maternity services across England.

The Independent reports this positively (Hard in the circumstances) as New Training for NHS maternity staff to boost babies’ safety.

Matthew Limb: Disparity in maternal deaths because of ethnicity is “unacceptable” | The BMJ

Urgent action is needed to tackle systemic biases contributing to unequal mortality outcomes in ethnic minority women and women facing multiple problems and deprivation, say experts.

The authors of a new analysis of maternal deaths in the UK,1 issued by Oxford University’s Nuffield Department of Population Health, say that the coronavirus pandemic is likely to have worsened the disparities they have highlighted.

Black women are four times more likely than white women to die in pregnancy or childbirth, says the seventh annual report from MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries).1 Women from Asian ethnic backgrounds face a twofold risk, and women living in the most deprived areas of the UK are almost three times more likely to die than those in the most affluent areas….

The report said that these figures were “fundamentally unchanged” from those documented in the 2019 report and that, despite encouraging responses to this disparity from groups including the NHS and government agencies, sustained focus was needed.

…Marian Knight, lead author for MBRRACE-UK and professor of maternal and child population health at the University of Oxford, said that disparity in maternal mortality simply because of a woman’s ethnicity was recognised as “unacceptable.” She added, “It is equally unacceptable for women with pre-existing medical conditions such as epilepsy to receive a lower standard of care simply because they are pregnant.”

The analysis reported a “concerning rise”—almost doubled from the previous three years—in maternal mortality due to sudden unexpected death in epilepsy (SUDEP). In many instances these deaths were linked to inadequate medicine management for these women either before or during their pregnancy.

Knight said, “Systemic biases prevent women with complex and multiple problems receiving the care they need. This needs to be addressed urgently, particularly since the impacts of social and ethnic inequalities, multiple disadvantages, and epilepsy are likely to have been amplified during the covid-19 pandemic.”

We can handle the truth about Rationing. Its the Politicians and the Media that cannot.

I have a former colleague and friend who genuinely believes that we should continue to ration covertly. At least he agreees that we ration. In normal times he would have a paternalistic attitude to the average citizen. But we are not all average, and we are individuals,and the first duty of a doctor is to “Put the patient at the centre of his concern”. This is impossible where state services don’t match up and are of very variable standards around the country. Looking after a patient to the best a Dr can means assessing their concerns, and whether or not they would like to exercise choice. The fact that some choices are not available in any particular health service is not relevant. In an emergency situation raioning becomes obvious, and overt, but it is still there less obvious and covert in normal times and all around the world.

David oliver asks “Can we handle the truth on Rationing?” in the BMJ ( BMJ 202;372:n209 ) but on line this changes to “Covid shows the need for transparency in prioritising acute care”.

truth-on-rationing-oliverDownload

As the covid-19 pandemic has exceeded last spring’s
peak, many NHS leaders are warning that the NHS is
overwhelmed. What we really mean is that hospitals
are overwhelmed—that people who could benefit
from admission or treatment may be denied it because
there’s no room. In extremis, that may mean
battlefield-type triage: deciding who gets to live or
die, with intensive care units already running at twice
their normal bed base, on borrowed staff and
borrowed beds, and with capacity for surgery
compromised.
The Medical Protection Society and other medical
organisations recently called for emergency
legislation to protect doctors from legal action if they
have to decide how limited resources are allocated.1 2
With oxygen delivery systems under pressure and
record numbers of patients on non-invasive
ventilation, it may prove necessary—as happened in
northern Italy last spring—to choose between
patients, or groups of patients, who might benefit
from potentially lifesaving treatment. In Italy some
fairly crude cut-offs based on age were reportedly
used.
This is different from what we routinely do when not
facing a pandemic emergency—prioritising treatment
depending on whether that individual patient has
much chance of benefit or whether the risk of harm
is greater. We also take patients’ and families’ views
into account. And even that scenario can prove
problematic with a media and public not always ready
for an open discussion of these realities. So, when it
comes to deciding who gets the ventilator, the CPAP,
the ICU, or the HDU bed—the “who gets to live or die”
scenario—I do wonder whether our society is ready
for a realistic public conversation. Still, surely it’s
better to have it openly rather than using some system
with no chance for discussion, public engagement,
or consultation, with no explicit local or national
guidance or decision support tools.
The Daily Telegraph recently ran the headline “Crisis
triage protocol is a brave attempt to ensure what
happened in northern Italy is not repeated in
Britain,” saying that “doctors need an ethical system
for rationing critical care if hospitals are overwhelmed
. . . currently there is no national guidance.” On the
same day it reported, “Covid rationing plan tells
doctors to pick patients to save by lottery,” next to
a story on “twice as many critically ill patients in
hospitals as at the peak of the first wave.”
The meat of the story was a paper entitled “Ethical
decision making when demand for intensive care
exceed s available resources,”first published in the
Journal of Medical Ethics in November 2020. The original paper had described the iterative, multidisciplinary process and consultation in
developing a local document for “fair allocation of
critical care resources in the setting of insufficient
capacity.” The authors, based at the Royal United
Hospital in Bath, had argued that it was better to have
a transparent, standard decision tool, with strong
ethical and legal components, than to leave such
decisions ad hoc to clinical teams on the day. This
never became official policy in Bath, let alone the
wider NHS. Bath hospitals responded to the Telegraph
that “it is a research document for purposes of wider
discussion . . . when resources are sufficient,
decisions are based solely on what is best for each
individual patient.”
But the perceived need for such a hasty public
rebuttal, as well as the tone of a newspaper report,
risked undermining a brave and clinically led attempt
by staff in one hospital to do the right thing, to foster
transparency and honesty about prioritisation or
rationing of scarce care. It left me wondering whether
the press and public were ready for a frank discussion
about prioritising acute care, especially in a pandemic
when we’re all emotionally spent and uncertain about
what’s to come.
It reminded me of a line from the film A Few Good
Men: “You can’t handle the truth.”

• 

• 

We have reached an unintended target! And different health outcomes and resources now divide us all. The profession knows how incompetent our rulers are..

100K deaths was unintended. Once the Test and Trace was privatised, and before that the people and resources dedicated to Public Health were downsized, and the former NHS was devolved into 4 dispensations, it was inevitable that politics would be allowed to use health to divide us all.
The press is full of the failure of government, and its slowness to respond, but in reality the seeds for this collapse were present in the multiple cuts made on social care, health and public health over at least 6 dispensations over 20 years. The long term incompetence and deafness to the profession’s advice. The honest denbate has not yet occurred. Exit interviews don’t happen. The shortsage of diagnostic and nursing people, already terrible before covid, will continue and get worse, as will the sickness rate for health employees.

The Times headline 27th Jan 2021s: How the UK reached 100,000 Covid deaths but part of the explanation of our figures may well be that they are more accurate than many other countries. The graphics are revealing, but one table reveals that the rate of deaths for different ethnic groups is not that different.

“There were 7,776 deaths registered in the UK in the week ending January 15 with the virus mentioned on the death certificate, bringing the total since the beginning of the pandemic to 103,602.”

deaths-by-ethnicity-012021Download

global-cases-as-uk-reached-100kDownload

In the most recent BMJ Fiona Goodlee opines on the mood of the profession: Hope is being eclipsed by frustration ( BMJ 2021;372:n171 )

ere is a palpable sense of hope in the air.1 Perhaps it’s that, in the UK, the days are lengthening and spring is on its way. Or that, having reached a terrible peak, covid cases here are falling. Or that vaccines are rolling out across the world, and Joe Biden is in the White House.2

These signs of hope are real but alloyed with the hard realities of dark days ahead. Health systems and staff are under unprecedented pressure, their physical and emotional resources stretched to breaking point. Doctors and nurses are exhausted or absent because of sickness or the need to self-isolate. Many will experience moral distress or its damaging sequel, moral injury, caused by the gap between what you think should be done for a patient and what can be done under constraints beyond your control.3 In the UK it may not yet, or ever, be about whether a patient can be ventilated. But there will be times when you are unable to give patients the care they need. Covid is exacerbating the effects of chronic underfunding. Ever lengthening waiting lists mean delays that will cost lives.

When the prime minister, Boris Johnson, sought to justify a third lockdown, he cited the terrible prospect of the NHS being overwhelmed if he didn’t act. He talked of a “medical and moral disaster” in which doctors and nurses could be “forced to choose which patients to treat, who would live and who would die.”4 This rhetorical flourish helped to make the decision that he didn’t want to make seem inevitable and beyond his control. Now he must acknowledge that health professionals are facing these decisions every day. He must enact emergency legislation to protect doctors and nurses working in the heat of the pandemic from legal action if they act in good faith.45

Beyond individual moral distress and injury lies the global risk of “catastrophic moral failure.”6 “Vaccine nationalism” has seen rich countries buying up supplies, abandoning the world’s poor and serving only to prolong the pandemic. The World Health Organization is calling for fair allocation to countries in proportion to population size. An alternative prioritisation would focus on reducing harm to health and economies.7 Worldwide shortages of vaccine are inevitable. Delaying the second dose will help. The man who led the development of the University of Oxford and AstraZeneca vaccine tells us there is direct and indirect evidence to support this approach.8

But we can’t simply wait for vaccine rollout. Nor are lockdowns anything other than a pause button. Much, much more needs to be done to avoid viral transmission and mutation.9 Where is the strategy for the coming months, once lockdown lifts?10 Where are the basic public health measures to help people who want to self-isolate but can’t afford to or who live in overcrowded accommodation?11 Why blame and shame when what is needed is practical support?12

More palpable than hope is the deepening frustration at government inaction, missteps, and continuing incompetence.

The Marmot Review 10 Years On – Health Equity in EnglandAd·www.health.org.uk/marmot-review10 years on, and health inequalities are widening and life expectancy is stalling. We examine what progress has been made and propose recommendations for action. Important Health Research. Improving Health Care. Informing Public Policy.

Start the week in 2017 with Sir Michael Marmot

The Today programme with Sir Michael Marmot on R|adio4 27th Jan 2021

• 

• 

Many governments and many ministers of health have made mistakes… They should be candid.

Successive ministers of health are responsible for the nursing shortage. And they are not accountable!!

NHSreality wants scapegoats – and suggests the successive ministers of health (for England). Allyson Pollock might agree..

Rationing by chaos is cruel..

Hospital job vacancies top 100,000 due to bad planning. NHSreality adds political short termism, & high sickness and absenteeism..

Waste in the Health Services. It;s mainly due to staff absenses…

NHS is unsafe, says chief

Update 28th Jan: The Times Letters

100,000 DEATHS FROM COVID-19
Sir, You are correct to argue that the government’s handling of the Covid-19 crisis demands scrutiny (“100,000 and Counting”, leading article, Jan 27). The crisis has resulted from a failure to learn rapidly about the best way to respond. The prime minister and select members of his cabinet have ignored expertise in the devolved administrations, and regional and local government. Feedback from those at the forefront of the Covid-19 response in schools, care homes and public health has not been sought and acted on. Mistakes made early in the pandemic have been repeated, for example in delays in imposing a lockdown in the autumn that would have saved lives. The government has lacked curiosity about the experience of other countries and has drawn on too narrow a range of scientific advice. It is not too late to improve if ministers are willing to share leadership with others, learn rapidly from mistakes, and act on the best available evidence.
Professor Sir Chris Ham
Chief executive of the King’s Fund 2010-18; Solihull

Pride is no reason to vote Nationalistically. The money IS important..and so are the outcomes..

Wales and Scotland are different geographically and demographically to England and the results of the different health systems should not be compared until some time after this is over. Wales has free prescriptions, Scotland free Social Care, and both are overspending compared to England, and yet their life expectancy is less. Waiting times, for cancer, especially in Wales, are longer. The money IS important..and so are the outcomes..

Letters to the Editor in the Times today. Union in crisis as voters call for referendums.
Sir, The poll published at the weekend should not be ignored (“Union in crisis as polls reveal voters want referendum on Scottish independence and united Ireland”, thetimes.co.uk, Jan 23) but neither should its suggested outcome be taken as inevitable. “Don’t know” groups are important. In Scotland, for example, much has been said about the performance of the first minister, compared with the prime minister, during the pandemic. It is true that her daily TV appearances have been generally well received by the Scottish public at large, the perception being that Scotland has fared better than England in dealing with the virus. The level of deaths in care homes and the much slower rollout of vaccination for the over-80s are but two aspects that might suggest otherwise. Then there is the matter of the financial support from the Treasury, for which little credit is given by the SNP government and which has had to be channelled via Holyrood rather than directly to the businesses concerned. Only when the health crisis has abated and once a thorough and coherent analysis of the SNP proposals can be made should any consideration be given to yet another “once in a generation” referendum.
Derek Stevenson
EdinburghSir, Once Brexit had been “done” it was inevitable that independence and the creation of a new “Untied” Kingdom would re-emerge, and that Nicola Sturgeon would change the Braveheart battlecry of “once in a generation” to that of “democracy”. If, as is equally inevitable, there could be a material impact upon the whole of the UK, these reawakened principles of democracy must surely require that all British voters should have a chance to vote, not just those of Scotland, Northern Ireland and Wales.
Timothy Young, QC
London WC2
Sir, Amid the commentary defending the UK there is no consideration that Boris Johnson now leads an English nationalist party. Add in population asymmetry and the UK fails as a polity, due to the dominance of a right-wing minority enabled by first past the post. Scotland must leave the UK as our potential can only be realised by having the type of governments that we vote for — good or bad.
Declan Jones
Glasgow

Where does the money come from, and who gets most for health per capita? An English backlash is possible: a movement to separate England away form its percieved “ingrate” neighbours.
GDP and the 4 Health Services (Former NHS) – No prospect of reducing the waiting lists quickly enough to correct mortality and morbidity reductions..
The NHS.. can only function on the basis of rationing (since demand for healthcare is, in effect, limitless if “free”).

Private Health Care is expanding… and it’s strength reflects the weakness of the 4 Health Dispensations
The value of the UK’s health information – and only partial value at that
What models of funding are best for a healthy and just society? No other country has chosen our system, even after 70 years and our Olympic boasting. The public need to be led into realising why not..

Addressing the “black hole” in the health budgets – wait for political denial.
Other countries have sensibly funded healthcare. (Scandinavia and NZ), & “the schemes used by most countries on the Continent are preferable to the NHS model.
NHS funding advice: GDP worth debating… Showers of money will not work..
…political “unsayables”. Behind closed doors nearly every politician admits that the current system for paying for health and social care is decades out of date.
David Oliver: The best health system – we are world class for equity, but not for outcomes
Stop the NHS runaway train before it’s too late. The health service is consuming all our wealth ..

Saving the NHS – Political parties are in denial over how to fund the growing pressure on the health service. We need an honest debate about new means of paying for it

• Basic Principles of public health are ignored, distorted, or manipulated.
• Covid – An accidental benefit – “Fewer Self Harming incidents in adults”.
• Fear of Covid-19 is delaying treatment for cancer patients, leading to complications and a lower survival rate
• NuffieldTrust warns of pitfalls in restructuring the English Health Service..
  to 4 Health Ministers: Let retired nurses, doctors, paramedics and medical students have practice based training to vaccinate.
  The Minister should sieze the moment when money appears to have no value, to reform Social Care.

• 

Where does the money come from, and who gets most for health per capita? An English backlash is possible: a movement to separate England away form its percieved “ingrate” neighbours..

We in the UK belive in self-determination, and the prospect of the disunited kingdom breaking up into its constituent parts is a great disappointment to many of us. NHSreality was not in favour of Brexit, but now that it has happened and a small temporary majority has shown us how badly we need “rules” for referenda, we also need to acknowledge the likely break up of the UK. Referenda are opinion polls, and ancient Grecians in the home of democracy, argued against everyone being involved. Ireland and many others have taken note and changed their rules so that temporary opinions swayed by media cannot cause change without reaffermation after a period of time, and a substantial rather than a mere majority.
Wales is the poorest part of the UK, and has £9,391.00 revenue per capita, compared to Scotland £12,058, and that is 2.5% below the UK average. Spending is £13,698.00 and £14,,829 respectively, compared to a UK average of £13,196. Once the English Independants get a realisation of how much they subsidize the celtic fringes, could resentment arise? With an overspending and underproducing Wales getting free prescriptions, no wonder the WG cannot afford to offer proper “choice”, or independent second opinions. Scotland without its oil and both countries without their subsidies will not be affluent places, and the emigration of their youth, if thats what it becomes, could get worse. In an era of false information and dubious sources, an English backlash is also possible and a movement to separate England away form its percieved “ingrate” neighbours..

The idea that the Scots and the Welsh should have a trial period of governence without subsidy in the update letters at the end will appeal to many. Wales is the poorest so the hit will be hardest there,but the English do get a lot back: the smartest and most aspiring tend to leave and boost the labour market, enhancing England’s economy. It is self servingly logical to evict the Scots and Welsh from being joined to England for fiscal and legal purposes. But it would be of short term benefit compared to the gains in staying together. But then we did not listen on Brexit either..

Writing in The Sunday Times 24th Jan 2021 David Smith opines: England’s great river of cash keeps nations afloat

The tide has turned politically in favour of independence in Scotland but the economics remains firmly against it. As part of the UK, Scotland’s high levels of public spending are, in effect, subsidised and made possible by English taxpayers, particularly those in London and the southeast.

The picture for the UK, confirmed in figures from the Office for National Statistics, is that London, the southeast and the east of England are the big revenue generators.

In a normal year, they all run budget surpluses, while every other region and nation runs a deficit, in some cases a substantial deficit.

The Scottish government’s own figures, contained in its annual government expenditure and revenue Scotland exercise (Gers), tell the story. In 2019-20, the last fiscal year, public spending per head of population in Scotland was £14,829, 12.4 per cent above the UK average of £13,196.

In contrast, revenue raised in Scotland, including a so-called geographical share of North Sea oil (Scotland receives the oil that would fall within its notional share of the UK North Sea), is below the UK average. Scottish revenue per head in 2019-20 was £12,058, 2.5 per cent below the UK average of £12,367.

The difference between spending and revenues is borrowing, or the budget deficit, and even before the great explosion of borrowing in the current fiscal year as a result of the coronavirus crisis, Scotland had a budget deficit of more than £15bn.

Expressed as a percentage of gross domestic product, the Scottish deficit was 8.6 per cent, compared with 2.5 per cent for the UK as a whole; more than three times as big.

Supporters of independence say these figures bear no relation to what the state of the public finances would be for an independent Scotland, but it is hard to see why. To make its public finances manageable, Scotland would have to reduce public spending significantly or raise more in taxes. The Gers figures were used as the basis for the work of the Scottish Fiscal Commission, established by the SNP (Scottish National Party) administration.

For Wales and Northern Ireland, where the political picture is different in terms of support for breaking away from the rest of the UK, the economics is also against any such move.

Wales, the poorest part of the UK with the exception of northeast England, has lower public expenditure per head than Scotland, but also the lowest level of revenue per head in the UK.

In 2018-19, the latest year for which official figures are available, Welsh public spending per head was £13,698, 6.7 per cent above the UK average for that year. In contrast, revenue per head in Wales was £9,391, just 77 per cent of the UK average. An independent Wales would have an even bigger budget deficit per head than Scotland.

There is a similar picture for Northern Ireland. It combines the highest public spending per head in the UK — more than 15 per cent above the UK average — and low levels of revenue. Its budget deficit per head is the biggest of any part of the UK, according to ONS figures.

This raises an additional issue for Northern Ireland. Those who favour breaking away from the rest of the UK would want, not independence, but reunification; a united Ireland. But the Irish economy, less than a seventh of the size of the UK, could not take on the burden of high-spending Northern Ireland.

A united Ireland would require a very long engagement and, in all likelihood, a substantial dowry for Northern Ireland to take with it from the British government. There would have to be a big shift in the policy position of the Westminster parties for that to be possible.

Update 24th Jan 2021 (Pride is no reason to vote Nationalistically. Wales and Scotland are different geographically and demographically to England and results of the different health systems should not be compared until some time after this is over.) Letters to the Editor in the Times today. Union in crisis as voters call for referendums.

Sir, The poll published at the weekend should not be ignored (“Union in crisis as polls reveal voters want referendum on Scottish independence and united Ireland”, thetimes.co.uk, Jan 23) but neither should its suggested outcome be taken as inevitable. “Don’t know” groups are important. In Scotland, for example, much has been said about the performance of the first minister, compared with the prime minister, during the pandemic. It is true that her daily TV appearances have been generally well received by the Scottish public at large, the perception being that Scotland has fared better than England in dealing with the virus. The level of deaths in care homes and the much slower rollout of vaccination for the over-80s are but two aspects that might suggest otherwise. Then there is the matter of the financial support from the Treasury, for which little credit is given by the SNP government and which has had to be channelled via Holyrood rather than directly to the businesses concerned. Only when the health crisis has abated and once a thorough and coherent analysis of the SNP proposals can be made should any consideration be given to yet another “once in a generation” referendum.
Derek Stevenson
Edinburgh

Sir, Once Brexit had been “done” it was inevitable that independence and the creation of a new “Untied” Kingdom would re-emerge, and that Nicola Sturgeon would change the Braveheart battlecry of “once in a generation” to that of “democracy”. If, as is equally inevitable, there could be a material impact upon the whole of the UK, these reawakened principles of democracy must surely require that all British voters should have a chance to vote, not just those of Scotland, Northern Ireland and Wales.
Timothy Young, QC
London WC2

Sir, Amid the commentary defending the UK there is no consideration that Boris Johnson now leads an English nationalist party. Add in population asymmetry and the UK fails as a polity, due to the dominance of a right-wing minority enabled by first past the post. Scotland must leave the UK as our potential can only be realised by having the type of governments that we vote for — good or bad.
Declan Jones
Glasgow

Sir, Nicola Sturgeon and the SNP should not be judged on the relatively low number of Covid-19 cases in Scotland compared with England. The geography and population spread of the two countries are quite different. Rather they should be judged on the vaccination rate. In this respect Boris Johnson is well ahead. I am sure that the inefficiency of the SNP in this relatively straightforward task will make the people of Scotland fully aware of their inability to run the country independently.
Alistair Forsyth
Aberlady, East Lothian

Update 31st Jan 2021: The Times letters shoow the start of the backlash.
As your report on the future of the UK noted: “England’s great river of cash keeps nations afloat” (News, last week). To solve the problem with Scotland, Westminster should enact a bill allowing a referendum on independence next year — and it should include a clause suspending the Barnett formula as it applies to Scotland for the intervening period.

This would ensure Scottish voters realised that the largesse doled out by the Scottish National Party (SNP) depends largely on English money.
Jane Haworth, Thames Ditton, Surrey

Full English
Many of us from across the political spectrum, not least Theresa May, warned that Brexit would lead to the break-up of the UK. Your polling reveals it is doing so. The response to it, however, fails to understand what is really happening.

It is England that is on the move, not Scotland, Wales or Northern Ireland. We English are seeking democracy and an end to the appalling elitist government that does us such harm. Mistakenly, we took it out on Brussels and not the real culprit: Westminster.

Now, to save our long tradition of liberty and self-government, we must finish the job. We must encourage our neighbours to go their own way and stop wasting valuable time on an increasingly punitive effort to “keep them”. Only then can we throttle the Lords, have fair elections to the Commons and free our country.
Anthony Barnett, co-founder, OpenDemocracy

Courtesy call
If the Scots and others are permitted to have an independence referendum, would it not be a courtesy to the English to seek their view as well? We subsidise these nations and see little in return. I would at least like the chance to express my opinion.
Brian Goodland, Winchester

Decrees of separation
Your coverage reminds us that Wales is the poorest part of the UK, barring northeast England. You miss the point that Wales is poor despite having been controlled by the UK government for centuries.

This feels like the psychological abuse in an unhappy marriage, with chronic bickering, put-downs and belittling. An amicable divorce would benefit both parties.
Dr Nia Owain Huws, Caernarfon, Gwynedd

Basic Principles of public health are ignored, distorted, or manipulated.

Misrepresentation and reporting are also part of the “availability effect”. See below

Bing Jones, a former associate specialist in Haematology lets fly in his opinion piece in the BMJ: Covid thrives on half truths and lies – January 14, 2021

The UK government’s half truths are dangerous, but the greater threat is when scientific and medical professionals tolerate them, says Bing Jones

Covid-19 is thriving as our government steadily loses public trust. The UK is seeing over a thousand covid-19 deaths a day, our policies are failing, and we are doing as badly as anywhere. Meanwhile, our government consoles us with rosy pictures of vaccination bringing normal life within months. It’s another optimistic projection disguising negligent failure. 

Failures veiled by hopeful half truths have been our diet for nearly a year now. Yet telling only half the truth erodes public trust. Vaccination will of course be a relief for many people. But it will not be enough on its own and cannot disguise the inexcusable fact that we still lack effective, basic public health tools. We don’t test effectively, find enough contacts, or support enough people to isolate. Basic principles of science and public health are routinely ignored, distorted, or manipulated by a government seduced by new technology and privatisation. The media and many professions passively collude. We have allowed the government to get away with half truths, unproven technology, and bad science. Both the media and scientific and medical professionals can see the poor public health policy and bad science happening before us, but too often fail to call these obvious government deficiencies out. It is as if we have all come to expect no more than half truth and lies. And a half truth is a lie. 

Allowing different households to gather at Christmas was obviously going to be disastrous. “Moonshot” mass testing has never been properly evaluated and may even be making matters worse, according to some experts. NHS Test and Trace does not actively seek out those who need tests, it fails to reach their contacts in a timely way, and then fails to isolate both cases and contacts effectively. Our inability to isolate effectively is a central, enduring disgrace that is too often ignored by reporters and doctors, who are happier to talk about future plans and new solutions rather than inadequate basic practice. Either this government has been advised badly by professionals, their advice has been ignored, or a mixture of both. 

Much of the NHS is working inhumanly hard because of these policy failures. It’s time for those who can see defective policy to speak out against half truth and misinformation.

The new covid-19 variant is now exploiting our public health failures. We are defended only by a full house of ineffective tools, while erosion of trust has diminished the effectiveness of lockdown. We have good surveillance but we don’t have the tools to use the data. In March we had no proper strategy, a delayed lockdown, disabled local services, inadequate personal protective equipment, discharge to care homes, and we gave up on contact tracing. Now, we still have no strategy; have only flawed, slow testing (waiting for patients to come forward is so silly); flawed, slow tracing; a gross lack of support for people to isolate adequately; schools that have not been made safe; and a dubious Moonshot mass testing programme. Test and trace is heavily privatised and local services have only token powers. We know the challenges are enormous and changing continuously. It’s obviously essential to innovate and be optimistic. But what is inexcusable is to fail to evaluate novel technology, fail to audit, and most of all to fail to do what we know works.

The prospect of mass vaccination is a great relief but there are multiple uncertainties about its rollout. It is an unprecedented task as we are overwhelmed by the new B117 variant. Many people are keen, but there is also mistrust and existing vaccine hesitancy to overcome (around a quarter of doctors, for example, don’t get the flu vaccine). People in poorer communities have been reluctant to get tested and may be reluctant to get vaccinated. Delivery, batch testing, side effects, and escape mutants are potential problems and we are uncertain how the vaccine will affect transmission and death. These are all well understood. It’s yet another irresponsible half truth to imply that vaccination will bring us “back to normal” in months.

While vaccination is rolled out, we must insist on correcting basic public health deficiencies as recommended by Independent Sage: to find, test, trace, isolate, and support, none of which function well at present. Medical and science professionals and the media alike must expose half truths. They must then speak the full truth; object to half truth; and, if necessary, refuse to cooperate and even resign.

No one wants to rock the boat. Our healthcare workers are heroic and we may yet be able to immunise two million people a week. We will get through covid. But government misrepresentation is a cancerous threat to modern society that must be excised for the sake of this pandemic and future crises. Covid-19 is bad but it is nothing compared to the public health and wider societal challenges that the climate crisis will inevitably bring. Covid pre-empts and is part of the climate crisis, but in terms of the long term risks to society, it is tiny. 

Any government addicted to half truth is dangerous. But an even greater threat is for scientific and medical professionals to tolerate these falsehoods. We must learn to speak the whole truth.

Bing Jones, former associate specialist in haematology, Sheffield.

The availability effect as described by Stephen Reicher and John Drury in the BMJ: Pandemic fatigue? How adherence to covid-19 regulations has been misrepresented and why it matters

 That is, we judge the incidence of events based on how easily they come to mind—and violations are both more memorable and more newsworthy than acts of adherence. People sitting quietly at home and watching TV do not make a newspaper headline. People at a house party do. So, we develop a biased perception of the level and type of violations, which runs the risk of becoming a self-fulfilling prophecy. If we believe that the norm is to ignore the rules, it may lead us to ignore them too.

Covid – An accidental benefit – “Fewer Self Harming incidents in adults”.

Although the paper has not been peer reviewed it looks as if one of the unexpected outcomes of a pandemic is that self-harming (?attempts at suicide) become fewer. Presumably those that still occur are even more seriously intended or successful. Each of the 4 health services should be grateful, and one wonders how, in normal times, self harm varies compared to systems where people pay…. Self harm comes in many forms, and differently in different medical systems. ” Much of the decline stems in America from higher rates of suicide, opioid overdoses and alcohol-related illnesses — the “deaths of despair” that Profs Case and Deaton refer to. Americans “are drinking themselves to death, or poisoning themselves with drugs, or shooting or hanging themselves.” They warn that where America goes England will probably follow. In any event, in the UK there is less self-harming at present, and the threat of a Hospital Aquired Covid Infection may have helped..

Keith Hawton and others write for MedRxiv 25th November 2020 with figures from Oxford and Derby, that “there was a large reduction in the number of self-harm presentations to hospitals by individuals aged 18 years and over compared to the pre-lockdown weeks in 2020”.

Tnfortunately children and adolescent self harm may not be affected favourably, as both these were on the rise beforehand, and containment in lockdown does not help.

Conclusions A substantial decline in hospital presentations for self-harm occurred during the three months following the introduction of lockdown restrictions. Reasons could include a reduction in self-harm at the community level and individuals avoiding presenting to hospital following self-harm. Longer-term monitoring of self-harm behaviour during the pandemic is essential, together with efforts to encourage help-seeking and the modification of care provision.
There was a marked reduction in presentations following self-harm in individuals aged 18 years and over to two major general hospitals in England during the first three months following lockdown due to the COVID-19 pandemic. These findings, which are consistent with findings from other countries, might have multiple explanations. They cannot be taken as indicative of what will happen with regard to future levels of self-harm, especially as the longer-term impacts of the pandemic play out. This is a major reason for maintaining high quality surveillance of self-harm presentations to hospitals.

Sam Coates and Kat Lay in the Times August 2018: Self-harming by teenage girls doubles in 20 years – Pressures of school and social media blamed as hospital admissions rise to 13,000

Kay Lay reports Feb 2019: Self-harm hospital admissions for children double in 6 years and that Web giants ‘fuel child mental health crisis’ Children’s commissioner calls for urgent action

By Jan 8th 2021 she is reporting: The frontline NHS staff battling to keep Britain safe during coronavirus – One surgeon likens it to Dunkirk as he helps out with intensive care, a nurse says that people are sicker this time around, the staff are even sadder and there is real fear, Kat Lay writes, and there are many fewer self harming admissions.

Deaths of Despair and the Future of Capitalism – Anne Case and Angus Deaton, Princeton University Press

Fear of Covid-19 is delaying treatment for cancer patients, leading to complications and a lower survival rate

It is definately happenning in India and now the UK and the rest of the world is waking us to reality. Wartime pandemic rationing leads to collateral damage..

The Telegraph India 11/11/2020 by Dr Tanweer Shahid  

In cancer, timely diagnosis is essential. It allows the disease to be identified at a treatable stage and prevents complications. But since the emergence of the coronavirus disease, the diagnosis and treatment of cancer has been negatively impacted.

The fear of contracting the coronavirus has made cancer patients reluctant to visit hospitals, delaying treatment. A higher death rate from Covid-19 has been reported in oncology patients due to their compromised immunity, which could be disease or treatment related. The lockdown and social distancing, though necessary non-pharmacological measures, have further aggravated the problem. Cancer treatment has taken a massive hit as almost 50 per cent of patients are reaching the hospital in the advanced stages.

Delays during oncological treatment can be classified as primary or secondary. A significant proportion of time is usually consumed in primary (interval between symptom onset and first visit to the clinician) and secondary (interval between clinician visit and start of treatment) delay in a majority of oncology patients awaiting treatment, especially in low-middle income countries like ours.

Breast cancer is the commonest cancer in women worldwide. Patients in   India are relatively younger compared to the West. Breast conservation surgery is a safe and feasible option. A young woman diagnosed with stage II breast cancer in March was advised conservation surgery. She could not comply due to logistics. When she came back five months later, the disease had advanced so much that breast conservation was not possible.

In about 50 per cent cases, breasts can be conserved. If the cancer is detected early, almost all breasts can be conserved. So there is a need to create awareness about starting treatment early. Though we believe in “Big or Small — Save Them All”, chances of saving the breast decreases with advance in stage. Many patients report so late that the disease has already spread to other parts of the body.

There is a fear that there will be a “cancer pandemic” after the coronavirus one. In India, 50-60 per cent of patients anyway come in the advanced stages due to lack of awareness and screening. With the pandemic, this has gone up to 70-80 per cent. We are coming across patients who are so ill that they have become untreatable.

A patient from a neighbouring state came to us with cancer of the gall bladder and severe jaundice. At this late stage, the liver wasn’t functioning properly and the patient could only be given “best supportive care”. The survival rate in such cases is very poor.

Delay is detrimental to treatment. A patient diagnosed with stage II lung carcinoma in April reached stage IV by October as he couldn’t come for treatment. This affected his survival. There are multiple examples of patients reporting too late.

One reason for delay was transport restriction. Travelling to the hospital became a problem as local trains are not running. Hiring vehicles or taking accommodation near the hospital is usually unaffordable after the already high financial burden of treatment.

Other factors too contributed, such as a patient turning out to be asymptomatic Covid-19 positive. Lack of awareness, casual attitude to symptoms, self-medication, lack of facilities or resources too added to the problem. We have had a few patients reporting late for treatment because of severe financial crisis too, as many people have either lost their jobs or are working on reduced salaries. The cost of cancer treatment is definitely high, and nearly 50 per cent of our patients do not have any health insurance.

Some patients don’t want to come fearing a chance of getting infected by the coronavirus. I often point out to them, “We have a 1-2 per cent chance of dying if we get infected by the coronavirus but there is a much higher chance of dying if treatment is delayed.”

As oncologists, we have tried to tailor treatment such that it can be completed sooner and hospital stay is minimised. Hypofractionated radiotherapy has brought down the course of treatment for breast and prostate cancer from 6-8 weeks to 3-4 weeks, and to even one week in certain cases. This results in better treatment acceptance and compliance.

Since time is an important factor in oncology treatment, delivering optimal care during the pandemic is challenging. Striking a balance between delivering and delaying treatment becomes crucial not only for patients but also for clinicians.

In any case, cancer patients and oncologists have to be on their toes to win their battles against the disease. The coronavirus pandemic is another strike against them.

The writer is a radiation oncologist at a private hospital in Calcutta

The Daily Mail 22nd Jan 2021: Half of all patients fear delays in cancer diagnosis, treatment and survival.