Cowper’s Cut: Schrodinger’s Virus

I’m hearing mixed messages on whether the problems with personal protective equipment availability are resolved. My sense is that for community, mental health (including the police) and social care providers, as well as acutes without Type 1 accident and emergencies, real problems persist in more than a few places.

Equally, the combined use of the military and NHS Supply Chain is currently believed to ensure adequate supplies of PPE to acute providers with type 1 A&Es. Clearly, I hope that this is correct, and that the supply to the above-listed sectors will improve fast.

What we will see now with PPE supply is that “the story” will lag behind the reality. There will be ongoing reports of supply inadequacies and shortages from clinicians who disagree with the royal colleges’ definitions of what PPE is needed in which care setting.

It’ll remain a problem in this way because politicians and system leaders were miles off the pace on this crucial issue. Once you’re asking clinicians to risk their lives, you equip them right. Full stop, end of story. Clinicians should not have had to be emphasising and reiterating the importance of adequate PPE to the point where the national media noticed.

There was a very simple question that a well-run system should have been asking itself from the outset: nationally, who is responsible for counting the current weekly rates of use of PPE for the NHS and social care (based on previous run rates per case), and ensuring that it is balanced by supply?

In work experience health and social care secretary Matt Hancock’s Friday presentation, he outlined a “comprehensive PPE plan”. Don’t worry, it’ll probably be alright anyway. (Oh, and it was nice to win my battle of getting Mr Hancock to stop describing ‘save lives and save the NHS’ as a “strategy”, and instead to use the correct word “plan”. Now, can you please stop him using “Herculean”?)

Tech disruptor requests government support

Fans of industrial-strength chutzpah will have raised a wry smile if they spotted that Ali Parsa (whose former employer, workers’ co-operative Circle (now part-owned by US HMO Centene Corporation) are buying out BMI) signed a letter to the Chancellor asking for a taskforce to deliver some unspecified support to the UK’s high-tech sector.

This seems like heroic grifting from Babylon, given the context of their having raised half a billion pounds in venture capital last year. As Imperial College Health Partners’ Axel Heitmueller neatly put it, “this is a golden opportunity to sensibly clear out an overinvested tech space, particularly in digital health”.

Quite so. The socialisation of capitalists’ losses in the 2008 global financial crisis drove political choices that gave us a decade of austerity. The simple principle here should be that if the government has to bail an organisation out, then that organisation is effectively a utility, and so should be governed and regulated accordingly.

There is a deep irony in a self-styled tech disruptor making the poor mouth to government in this way, at a time when the tech sector has made significant contributions to the NHS’ adapting to covid-19. Other tech players in the primary care market have been altering and facilitating access, with significant success. (The NHS in general has been changing and innovating at what I am absolutely not going to describe as “scale and pace” during this crisis. And we’re going to need to capture all the good bits of these changes.)

System shocks have caused real disruptive innovation. If Babylon were as good and as innovative as its PR has always claimed, it is hard to see why they would do this. Perhaps the penny has dropped that Babylon’s self-styled USP is USC.

What has just got through the net?

Data and information are required to develop the intelligence that will help us successfully combat this pandemic. The NHS technology leadership bodies – NHSE/I and NHSX – have concluded deals with global data/IT companies including Palantir, Microsoft and Google to help with the data management and modelling requirements around covid-19.

There are always concerns about how data shared with tech companies will be used: sometimes, these concerns are well-founded. Sometimes, they are not.

The NHS tech leaders’ assurances that “all NHS data in the store will remain under NHS England and NHS Improvement’s control. Once the public health emergency situation has ended, data will either be destroyed or returned in line with the law and the strict contractual agreements that are in place between the NHS and partners” is welcome. It will be welcome if there is a regular review of this, involving trusted and independent data experts: this public health emergency may be with us for some time, with recurring flare-ups.

Some tech products that have been made available to the NHS are temporarily free. That’s nice, and often they are better than some previous tools – but we always need to keep an eye on the cost of free, and think about what we do once the free period stops. The old tech industry adage is that “if you’re not paying for it, you’re not the customer: you’re the product being sold” comes to mind. What is the cost of free? What rules have been bent, and what precedents have been set? What have companies been offered in return for providing AI and other data support services? Has the market been developed and tested in areas like videoconsulting?

Overall, we need this stuff to work. So it’s great to see fast innovation and adoption – and let’s not forget how we can also make use of existing and longstanding systems to help NHS staff working remotely co-operate and share data.

The cost and the price

The respected Institute for Fiscal Studies has looked at the likely economic and health and care impacts from the covid-19 pandemic in two linked pieces of new research. It notes, as many others have, that there are costs of the care being foregone through cancellations and through fear, which “will disproportionately affect older individuals, and those from less affluent backgrounds, both in the short and the medium term.

“In the medium and longer term, the economic downturn itself will have persistent negative health effects, with these effects being worse for some groups than others … Evidence shows that the detrimental impact of adverse economic shocks can persist for many years … combined, these effects are likely to exacerbate existing geographical and socioeconomic health inequalities”.

Of course, the NHS must also now plan for the un-met need that will start to appear some weeks after the epidemic’s peaked. There will also be “new” mental health issues, developing as a direct consequence of lockdown: anxiety, agoraphobia …?

There will be mental health care needs among some of the front-line staff, after what they are currently seeing.

And this is before we mention the serious question of how we tackle the current, very long waiting lists: the cancer backlog, the referral to treatment backlog and the fatberg that is the non-RTT backlog.

An interesting piece in this week’s Financial Times also proposed that we need more effective “healthcare buffers”, an interesting analogy by John Flint, former CE of HSBC.

The inevitable paradox that the IFS and FT pieces show is that while the NHS will surely have a first-class case for improved capacity of workforce, capital and kit, it will be making this case in a damaged economy. How damaged depends on how long the current period of economic intubation and ventilation has to last. Economically, the issue of the effects of Brexit has not disappeared: it has probably been postponed, as Mark Dayan implies in his new Nuffield Trust piece.

As well as the “where to invest?” questions, there will be the “how much change to keep?” ones. It will bring us back to the appropriate role of regulation, and the balance between the local and the central. As we are currently seeing, sometimes you really want centralisation, and quite often you really don’t.

Centralised where necessary, localised where possible? The problem is that defining which is which requires good and dynamic judgment. I’m hopeful that we see a better balance of management responsibility between clinicians (who ultimately, run everything) and general managers. Of course, doing that means we need more clinicians (which we do already).

Do as Mr Hancock says, not as he does

But we need to end on a lighter note, and thank heavens for the gift that keeps on giving who is our first work experience health and social care secretary, Matt Hancock. My colleague Rebecca Thomas’ exclusive story for HSJ reveals that senior NHS managers have been sharing stories of Mr Hancock’s webcast meetings conducted with between 10 and 20 colleagues in the same room as him, and thus in no way coming close to practicing safe social distancing.

Oh dear.

Before one such meeting got under way, the packed room could be heard criticising the (now sacked) Scottish chief medical officer for visiting her holiday home: this places that incident firmly after Mr Hancock’s infection with the covid-19.

I sometimes wonder if I have been too harsh about Mr Hancock. Then something like this happens, and I realise that I haven’t been nearly harsh enough. Did nobody in that room have the balls or the brains to say anything?

The irony that it is Mr Technology, the Appman himself, who has actually had covid-19, who is flouting the government’s own advice in this blatant way, is exquisite.

Schrodinger’s virus

I leave you with an idea whose originator I haven’t been able to identify: that covid-19 is Schrodinger’s Virus. This notion is a homage to “Schrodinger’s cat”: a famous paradox designed to explore some of the issues around quantum physics, whereby matter can exist in two different states simultaneously.

The argument is as follows:

“Because we can’t get tested, we can’t know if we have the covid-19 virus or not

“We have to act as if we have the virus, so that we don’t spread it to others.

“We have to act as if we’d never had the virus, because if we have’t had it, we’re not immune.

“Therefore we simultaneously have and don’t have the covid-19 virus.”

Stay well, and good luck.