Introduced by Michael Rosen
Read introduction here

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Witness 1: Professor David McCoy

Professor David McCoy is a Public Health doctor, currently working as a full-time academic at Queen Mary University of London. He is one of the trustees of the Centre for Health and the Public Interest. He has been a Director of Public Health in a London Primary Care Trust, and has a long-standing interest in health systems policy. 

 

Professor McCoy’s evidence was submitted in a research paper prepared for tonight by the Centre for Health and the Public Interest. The research is also authored by David Rowland, the Director of the Centre and Sid Ryan, the lead researcher. The research has since been published and is available at the CHPI website.

 

David McCoy’s oral evidence centred mainly on the use of the private hospital sector during the pandemic and the financial issues connected with it. 

The contract between Government and the private hospital sector 

• A contract was set up by the Government with 26 companies in the private hospital sector to block book their entire capacity. This was done ostensibly to help the NHS manage the Covid epidemic. The contract became more complicated over time and there were modifications and changes. 

• The lack of hospital capacity at the beginning of the pandemic was due to a deliberate reduction in NHS bed capacity over the past few decades both to reduce reliance on NHS hospital beds and to create opportunities for the private sector. England now has one of the lowest beds-to-patient-population ratios in Europe.

• In the initial period, March-August 2020 approximately 8000 beds would be made available to the NHS and a stated number of doctors, nurses and other clinical workers.

• It is not known exactly how much was paid, nor about the large amount of capacity that wasn't used to deal with the Covid pandemic. The private sector was not used a lot, but the Government was paying for the entire capacity, at the full running cost of those private hospitals.

• Probably capacity was used for diagnostics and non-elective procedures, but CHPI have estimated that on average there was one Covid patient per day in the private hospital sector, and probably at peak there may have been at most something like 67 patients. CHPI estimated that less NHS-funded health care was provided in the private hospital sector than in 2019.

• CHPI has estimated from contracts in the public domain that around £170 million per month was paid for the contract, but other Government sources have reported up to £200m per month or even £400m according to some NHS sources – FT sources said it was £430-£540 per month

• From April 2020 onwards, private hospitals were allowed to continue to provide care to privately funded patients and the income from that privately funded healthcare was essentially paid back to the government. 

• But essentially this meant that ‘during this period of time, the private hospital sector was able to continue with providing private health care to privately financed patients at a time when the NHS was obviously being challenged by the Covid pandemic itself.’ 

• David McCoy told the Inquiry there could have been an argument that there was an urgent need to bring in capacity, but the question was whether this was a good deal. All the CHPI data suggests that it wasn't.

• Private hospitals had been facing ‘real jeopardy’ with the Covid pandemic, said Dr McCoy, and were seeing a decline in demand from privately funded patients. ‘This deal really helped to keep those private hospitals afloat.’

 

National Increasing Capacity Framework

• As the initial contract neared the end, the Government has created a four-year funding programme, named the National Increasing Capacity Framework, which aims to allocate approximately £2.5 billion a year to the private hospital sector, covering 90 approved suppliers and costing about double the amount of NHS funded care provided in the private sector in 2018, and 2019.  

• Not only will the private sector have been maintained during the Covid pandemic but there will be a continuous stream of public funding going into the private hospital sector to meet unmet demand for semi-urgent and elective care that has built up during the pandemic, which will also potentially increase the amount of private demand for private sector healthcare.

• Prior to the pandemic, something like 18% of NHS funding was being directed towards the private sector (excluding GPs as independent contractors), so this will rise.

• This will have structural effects on the health system as a whole, increasing problems around the creation of a two-tier system and for some segments of society, a decreasing commitment to the NHS as a public service that is universal in nature.

• When asked whether the same people in government were going to repeat the same mistakes, David McCoy questioned whether they were mistakes or whether they were really part of commitment to a privatisation of the health system. He stated that ‘this will essentially erode some of the fundamental principles of the NHS, which is a publicly funded and publicly provided service across the board … which will result in inefficiencies in the delivery of health care at a population level.’

 

White Paper and ICSs will lead to more conflicts of interest

• David McCoy told the panel that while he did not know exactly how many MPs or politicians in general have a stake in the private hospital sector, conflicts of interest should concern everybody.

• Proposals in the new White Paper are a cause for concern: they include the establishment of Integrated Care Systems, where the private sector is being invited into the decision-making process of how public funds will be used and distributed within the health system, together with a lack of adequate regulation. 

Private care can destabilise health systems

David McCoy told the panel that his understanding of the literature and the evidence worldwide is that if you get the public/private interface wrong, ’you end up with a system like you have in the USA, where you have a health system that is both extremely expensive, not cost effective at a population level, and extremely inequitable.’ He added that it is possible to ‘cherry-pick certain indicators and give the impression that there are improvements’ but that if you look at health at a population-wide level, at equity and efficiency, covering all elements of health care, ‘then yes, without question

 

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Witness 2: Dr David Wrigley

Witness statement

Dr David Wrigley is an NHS GP working in Carnforth in North Lancashire. He is Deputy Chair of the British Medical Association Council, the doctors’ trade union with over 160,000 members. 

 

What went wrong with Test Trace and Isolate
Dr Wrigley told the inquiry that:

• The Public Health system has been ‘eviscerated’ through disinvestment over the last 10 years thereby allowing the Government to rationalise a turn to the private sector for Test and Trace at the start of the pandemic. The 2012 Health and Social Care Act had promised that Public Health would have a ring-fenced budget, embedded in local government, but the budgets had ‘just disappeared’. 

• The Government bypassed 44 existing NHS labs and employed private sector firms such as Deloitte to set up and manage a parallel system of testing sites, named Lighthouse laboratories, run by the private sector.

• The BMA has long-opposed deepening privatisation and outsourcing in the NHS and had significant concerns about the substandard performance of the Test and Trace system. 

• £37 billion has now been spent on Test and Trace, described by the Public Accounts Committee as ‘unimaginable costs’.

• The scale of the expenditure was justified by the Government to avoid a second lockdown. However, since then there have been two more lockdowns.

• GPs had major concerns for patients with Test and Trace: sometimes they had to travel hundreds of miles to get a test including driving on motorways when they were unwell – test results were often delayed. 

 

PPE and private procurement
Dr Wrigley informed  the Inquiry that:

• The BMA was hugely concerned about the lack of PPE; they had been contacted daily by doctors about lack of supplies, with hospitals sometimes one day or less from running out with no idea where supplies were coming from. There was also concern about poor quality PPE. 

• The Government delegated large parts of the management of the procurement process to supply chains, a complex web of external companies, that left the Government less able to respond in an agile way.  The Government’s just-in-time business model should be abandoned and instead use NHS in-house expertise which was completely bypassed. 

• The BMA had concerns over reports about procurement going outside the normal rules governing the NHS. This was not new. Previous BMA reports had highlighted contracts for goods and services being awarded to private firms with no relevant experience or expertise. 

• The Government opened up high priority lanes that led to fast track offers of PPE contracts, based not on what you know but who you knew to get these ‘golden nugget’ contracts. 

• Governance needs to be much more robust. There hasn't been proper oversight of the procurement of these deals and no transparency. Companies often hide behind commercial confidentiality as an excuse. Public notices are meant to be published within 30 days, The Good Law Project has taken the Government to court to challenge them on these issues

• Over 70 companies contacted the BMA about being able to supply good quality PPE. They had contacted the Government but hadn't received any response. This was as hospitals were on the verge of running out of PPE. These offers were passed over to the Department of Health by the BMA, but there was no response.  

• The BMA is committed to a publicly funded and publicly provided NHS, with significant and sustained funding to strengthen the NHS and local Public Health capacity and expertise.

 

History of poor service from private companies – in contrast to NHS-led vaccine campaign

Dr Wrigley told the Inquiry that:

• The companies involved such as Serco and Sitel had no experience about how to run services. In one instance they had subcontracted to a company called Hays Travel where staff had had one day’s training or less - this had caused huge concern for doctors. One Hays Travel staff member who worked on a Covid phone line stated: ‘We're not medically trained. I believe members of the public believed they were ringing medically trained people.’

• Many of these companies have poor track records. For example, in 2012 Serco had admitted to presenting false data over 250 times about the performance of its out-of-hours service in Cornwall. At one point they had had one GP covering the whole of Cornwall, but they had tried to cover this up.’ In 2018 Serco had been reported to have provided inadequate staff training at a breast cancer hotline, where patients were being assessed by call handlers with one hour’s training. 

• Companies such as these were put in charge of providing vital services and equipment to protect the workers on the front line. Not having confidence in these companies made those working with patients ‘really frightened about the equipment they were using.’

• GPs were fantastic at vaccine campaigns. ‘We do them every year with flu campaigns and we know our population. We know our patients, our patients trust us. So we were absolutely in the best place to do that.’

• The Government had to be given their due for ordering enough vaccines in good time, but: ‘It really does frustrate me when the Government or the Cabinet try and take credit for the vaccine campaign, when actually it's the NHS. It's all the staff in surgeries, hospitals and centres that have delivered vaccines. plus all the volunteers and we must celebrate the achievements of the NHS in that.’

 

The future

• At the beginning of the pandemic the NHS had on third of the number of beds per head of population compared to Germany, there was a 10,000 shortage of doctors, and a 50,000 shortage of nurses, over 100,000 vacancies. Far less is spent on the NHS as a percentage of GDP than in other similar economies. 

• The NHS had had to become a Covid service, and it then couldn’t deliver care for other conditions which was very concerning for doctors. 

• Financial support for isolation, with a decent Social Security system would mean that many would not have to worry about being able to pay the bills or pay their rent

• A Public Health-run and NHS-run Test Trace Isolate and Support system with adequate funding is what we should have done all along – and could still be done if politicians choose to do so. The BMA produced documents on this, asking for a larger proportion of the national budget for Track and Trace to be allocated to local Public Health teams to allow integration between testing being delivered at scale and contact tracing led by Public Health doctors on the ground who know their area, know their patients, but they have been completely side-lined. 

• The waiting list is a huge concern. In England, there are now 5 million people on the waiting list. Hospitals are now trying to restart again and mobilise staff back again into theatres and outpatient clinics and start all the care that needs to happen for patients. 

• Dr Wrigley told the Inquiry that increasing use of private hospitals could have a devastating effect on training of doctors, nurses and health staff. All junior doctors receive their training from their peers and their seniors, all within the bounds of providing day-to-day care. Private hospitals have no willingness to take on training because it might slow procedures down, not as many patients would be going through the theatres or outpatient clinics. The less complex patients, who could be useful for training for surgeons and others, are going through the private hospitals, and trainees would lose that vital time and experience that they need to learn how to do procedures. 
  
  PDFs 
  Public services, private profit British Medical Association
  Rest, recover, restore Getting UK health services back on track British Medical Association
   

Witness 3: Rosa Curling, Representative of Foxglove

Evidence statement

Rosa Curling is Co-founder and Director of Foxglove which is a non-profit organisation set up in 2019. Foxglove uses a mixture of investigation, campaigning and litigation to try and make sure that technology is fair for everybody.

Rosa Curling’s evidence focused on the activities of her organisation in exploring and challenging the collation of
NHS data called the Covid-19 Data Store

Rosa Curling told the Inquiry that:

• The Covid-19 Data Store was set up in March 2020. It was announced very quietly on an NHS blog and involved a series of different contracts and agreements with US tech giants Amazon, Microsoft, Google, plus Faculty and Palantir. 

• The Data Store would be a ‘single source of truth about the pandemic’ and the Department of Health had called it ‘unprecedented’ in that health and social care data was being collected from a variety of different sources, collated on a national level, and then held in one single place. 

• NHS data is almost unique in the world in that it is ‘the largest set of machine-readable health data on the planet’ with an estimated value of about £10 billion a year. 

• The data is wanted by tech corporations across the world - companies which exist to ‘aggregate and monetise data’.

• Foxglove had seen that, during the pandemic, normal rules about procurement and data protection were basically being cast aside. Foxglove wanted to make sure that those emergency arrangements didn’t become the norm without our consent. 

• The Government revealed virtually no details about the data deals with the private companies nor about the types of data which were going to be stored in the Data Store. 

• It was suggested in the press at the time that these tech companies were hoping to bed down in the NHS long-term. 

• This raised several questions: of public trust in that the companies would have access to ‘all of our most sensitive, confidential medical information’; on what security was in place to protect it; who would have access to it; on what terms; whether the Covid Data Store would come to an end when the pandemic resolved.

 

Freedom of Information requests and legal actions 

Rosa Curling told the Inquiry that:

• The Data Store could of course, partly be in the public and NHS interest, so they had made a series of Freedom of Information requests, asking for copies of the contracts and also Data Protection Impact Assessments (DPIAs), documents which are like equality impact assessments. These are basically required of public bodies, to think about what impact, from the data rights point of view, the Data Store would have for individuals.

• The deadline for the FOI requests had not been met, so Foxglove had threatened to start legal proceedings with a deadline of May 2020. 

• The contracts were eventually published on 5 June 2020, the day before proceedings were due to begin, although some information was redacted. The DPIAs were published a few days later, although completed after the event, which is not what the law requires.

• Foxglove took a second case about DPIAs in relation to the awarding of two further contracts with these companies in relation to Covid-19, and also in the case of a third contract, signed with Palantir, which is for 2 years and goes beyond the Covid-19 pandemic and concerned a series of other matters.  

• The DPIAs are not just mere legal formalities. The public has the right to be consulted about how their medical data is used and with whom it's shared.

• While the rewards for proper data use in the public interest are potentially life-saving, ‘the risks involved, going from minor embarrassment to a total corruption of trust in the medical profession, are really serious’.

• DPIAs are about ensuring accountability in a period where trust in some of our health institutions was eroded. 

• The public needs to be asked for their consent about whether they want their most sensitive, confidential information to be shared with private corporations or whether in fact, they want that data to be kept within public bodies, as a public asset for the public good. If this arrangement is going to be changed, then a democratic mandate is needed: you have to get proper consent for that to happen. Otherwise, the trust and patient confidentiality that is at the bedrock of our National Health Service are undermined. 

 

Transfer of data to NHS Digital

Rosa Curling told that Inquiry that:

• The Secretary of State has issued a Direction that GP data should be transferred to NHS Digital; in addition, from the new White Paper, some social care data will also be transferred resulting in ‘a huge mass data set of health and social care data’ to be held by NHS Digital. The data - a collation of all GP patient history and medical records - will be transferred from GP records on 1 July 2021 straight up to NHS Digital, unless you opt out. (On 8 June, the Government, facing growing pressure, suddenly announced that this date has been moved to 1 September.)

• The legal obligation is on the Secretary of State and NHS Digital to seek your consent and to notify you about this proposal. When this was attempted in 2014, every single patient was written to, and their consent was requested. This time, it hasn’t happened. There is a website and a few tweets which basically say unless you opt out then there's an assumption that you've consented. 

• Foxglove is concerned about whether that is lawful under data protection law

• There are also serious questions that arise in terms of what NHS Digital is going to do with that information: what limits do they have in relation to that data? Who can access the data? For what purposes can it be used?  Is there a meaningful consent framework that permits patients to differentiate between academic and for-profit access? 

• Health data is incredibly useful and there is a wealth of extremely important and helpful information that could certainly make our NHS services stronger. The question is whether we can make sure that that data remains a public asset for the public good rather than allowing unprecedented access to huge multinationals like Amazon, Google or Alphabet, with enormous corporate resources and power.

• The potential commercial value is indicated by Palantir agreeing to by paid just £1 for the first contract. They then got £23 million for the next. The suitability of a company like Palantir, very well known in the US, is highly questionable. It was a major Donald Trump donor. It has been criticised repeatedly by its own staff over its role in the US Immigration and Customs Enforcement [ICE agency] in relation to family separations at the US-Mexico border. We must question whether this is the sort of partner in the long term, that the NHS wants to be signing deals with or whether in fact their very involvement will undermine confidence in the health service amongst the very communities where the Government states it's trying to now shore up trust, for example, in relation to the vaccination programme.

• There needs to be a full and proper consultation process which people are given full information about any changes. 
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Witness 4: Michelle Dawson

Witness statement
 

Dr Michelle Dawson is a consultant anaesthetist, working also in critical care. She is also a Trustee of a charity formed because of the Covid-19 pandemic. Initially called Heroes, it is now called the Healthcare Workers Foundation. She has been a clinical lead in procurement since 2009.

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The beginning of the pandemic
Michelle Dawson told the Inquiry that:

• At the start of the pandemic she had watched hospitals being built in Wuhan in 36-48 hours and had thought, this is going to spread around the world. This is going to impact every country. She had felt dazed that nothing seemed to be happening (in the UK). 

• A large group of medics who talk on Twitter, around the world, were sharing information about Covid as it crossed continents but in the UK she had seen ‘absolute inaction’

• The PPE supply situation was serious. A colleague in another hospital had told Michelle Dawson at the end of February/beginning of March that they had run out of PPE, apart from for ITU.

• Because Michelle worked in procurement in the NHS in addition to her anaesthetist role, she knew about the processing and legalities. She also knew that not just the UK but ‘the whole world needs the same stuff at the same time’; that there were a limited number of manufacturers and virtually none in the UK. 

 

Forced into self-help

• Having assessed that the pandemic stock of PPE was greatly rundown, Michelle Dawson had started looking to see if she could open up supply chains through contacts. She had managed to open up a supply chain directly via the Chinese Government for 50 million FFP3 masks, the type necessary for working with Covid patients.

• ‘This was in the middle of March, when we had nothing. … At that time, we were working on Covid ICU with no PPE whatsoever, unless we went within six feet of a patient, because we had to conserve the stocks.’ Staff were going into ITU without PPE believing it was safe because patients were intubated and that Covid was within the tubing, spread by droplets, but actually it was an aerosol spread. 

• Michelle and colleagues had contacted the Cabinet Office about the China supply by phone and email and followed it up a week later, but nothing had happened. So those masks had been sold to Germany. A further offer of 30 million masks a month was not followed up either. The PPE on offer had fulfilled all the quality criteria, had the correct product codes, but they were not followed up by the Government. 

• Michelle Dawson realised it was not only the NHS not being supplied with the PPE, but also hospices and care homes, which were getting PPE via the NHS supply chain. These organisations were expected to go on their own into a global fight for PPE.

• The fight to get PPE was very aggressive because everybody needed it. ‘America was buying futures on PPE … They weren't buying what was in the warehouses. They were buying what would be made [in the future]. And then there are the people who were willing to sell stuff that was fake. There were people willing to just profiteer really, and the prices rose and rose’.

• By this stage a group of people, doctors, business people and others had got together into a charity [Heroes] and started raising money and sourcing masks from industry.

• Huge amounts of PPE were donated by companies; one businessman had couriered it out with his fleet of vans to wherever it was needed. A website was set up called frontline.com which allowed anybody anywhere in the UK to put out a plea for help if they were running out of PPE.

• The charity not only organised PPE but food drops and gifts to cheer up staff. 

• ‘Every single day at work, there's an NHS worker in tears in the changing room. Terrible because we saw colleagues dying … And we were terrified we would be the next one. And you just have to keep going in there and keep working.’

• Later on, there had been similar situations with gowns, visors and other items of PPE.

 

Ventilators

Michelle Dawson was asked to comment on the contract that was offered by the Government to Dyson: She told the Inquiry that:

• Ventilators go from very simple to exceedingly complex and the ones needed were the exceedingly complex ITU ones. 

• Proper complex ITU ventilators have different programmes and are a ‘massively complex piece of kit’ which have taken years to develop. Software has to be written. There are different parts, the consumables such as tubing and filters which have to be compatible with the ventilator. So, in the case of Dyson starting from scratch, to have all of the software written, the hardware correct, the compatibilities made, the consumables manufactured. It was going to take years.

• On the other hand, there were already multiple companies in the UK who already made fit-for-purpose ITU ventilators, who had approached the Government saying ‘we can make these, we just need funding, and then we can make these for you’. They were ignored.  

• The EU had contacted the Government saying that they were going to do an EU contract for ITU ventilators, and invited the UK to join. The Government said no. And when it broke in the press, they said that they had not received the email, which turned out to be untrue. 

• Giving Dyson a contract to make ventilators from scratch, is really asking somebody who makes vacuum cleaners to make a fighter jet or helicopter in a month. Dyson supplied the NHS with zero ventilators. Michelle Dawson wasn't aware of any new ones, at all. 

• The limiting factor in any case wasn't ventilators. It had been staff.

 

Michelle Dawson had been told that hospitals who had sourced PPE for themselves [out of necessity] outside official channels had recently been informed that they were not going to be refunded by Government, because they shouldn’t have done it, possibly costing them tens of millions of pounds.