A Shielded Cage

Bill Johnston responds to the Scottish Government's Covid-19 Decision Making Framework with a warning that the Ending Lockdown strategy must not result in age-based discrimination.

Covid-19 and the over 70s:  Towards healthy ageing as the new normal' for Scotland.  

The recent Scottish Government paper Covid-19 A Framework for Decision Making is a welcome opening shot in the debate on the next stage in managing coronavirus.  The paper projects the idea of a new normal' for Scotland consisting of two main elements. Firstly a cautious easing of the current lockdown restrictions to allow social and economic life to recover some form of normal functioning.  Secondly a much more ambitious approach designed to - “Renew our country, building a fairer and more sustainable economy and society”.

Some important areas are avoided at this point, principally answers to the how questions of the lockdown exit strategy. We need detailed plans and specific protocols for areas like testing, contact tracing and reopening schools to show that a methodology for getting us to the early stages of the new normal exists. Otherwise it will be hard to judge how well the Scottish Government is coping with the crisis and how confident people can be that safe, practical and progressive measures are being constructed.   This design work need not be delayed as examples such as contact tracing in Germany and reopening schools in Scandinavia can be rapidly assessed and adapted.  Closer to home Craig Dalzell's paper on testing is a good measure of the level of detail needed.

Nonetheless the emphasis in the decision making framework on human rights and listening to the people of Scotland is very welcome. The progressive approach of looking to a different and better socioeconomic situation after Covid-19 is equally welcome. The crisis has shown that the real key workers' in society are not bankers and hedge fund owners, but health and care workers, educators, retail staff, drivers etc. The recent spate of infections and deaths in Care Homes has highlighted the long-term neglect of social care across the UK.  That neglect is not a clinical feature of the Coronavirus affecting old people, it is a result of years of UK Governments underfunding the NHS and kicking the issue of adult social care into the long grass. The surge in deaths in care homes is a stark example of how poorly older people have come to be regarded in modern Britain.

Consequently this article looks at both the immediate and longer-term options in relation to older people in our ageing society and offers the Scottish Government some important suggestions on both issues. This is essential given that people over 65, and in particular over 70, have been widely acknowledged by medical experts as particularly vulnerable to the virus. It is also crucial because Scotland has an ageing population and that is the fundamental reality of any new normal' in the coming years.

The Over 70s and the Lockdown: Human rights at risk.

There is a danger of a failure to respect human rights and equity of treatment if governments try to apply an arbitrary age criteria for the operation of social restrictions and provision of health and social care as a response to Covid-19.  Lord Bethall, health minister, speaking in the House of Lords illustrated this danger (Amelia Hill, Guardian 23 April) by refusing to deny that all over 70s would be required to stay in extended lockdown.  Bethall came under heavy criticism from other peers who pointed out the breach of human rights involved in locking down people who were not actually known to be infectious, and the many negative consequences for their general and mental health of prolonged isolation.

Bethall's opinion seems to have been based in a misunderstanding of the medical view that the over 65s and the over 70s in the population are exceptionally vulnerable, particularly when individuals within those groups have underlying medical conditions.  However whilst age can be respected as a reliable proxy for the likelihood of a very poor outcome in individual cases of Covid-19, it should not be used as a blanket criterion for regarding citizens differently in respect of medical treatment, or restrictions on their movements.   

To put this in context, sex (male) and race (African Americans and BAME citizens in the UK) are now emerging as reliable indicators of poor outcomes of Covid-19.  We would not tolerate discriminatory treatment based on those characteristics, so there is no reason to take treat age any differently, even if a Tory member of the Lords thinks we should.

An anti ageist position on Covid-19 should not be a surprise to Lord Bethall and others of his viewpoint.  On 20 March the British Society of Gerontology issued a public statement on Covid-19 rejecting “…the formulation and implementation of policy based on the simple application of chronological age.” In making this point they stated “… it is wrong and overly simplistic to regard people who are aged 70 as being vulnerable, a burden, or presenting risks to other people”.  The Gerontologists are clear in their support for measures to control the spread of Covid-19. They are equally clear that those measures should be based in evidence and research and not crude assumptions about the nature of age and ageing.

The Gerontologists went on to point out that such a crude binary categorisation of risk based on arbitrary age points could encourage younger people to feel less concerned about Covid-19 and perhaps less willing to follow public health advice.  Equally a simplistic division by age points may undermine social cohesion and reinforce the existing culture of ageist stereotyping, prejudice and outright discrimination against older people in the UK.

In essence older citizens should not be arbitrarily excluded from society or medical treatment, and sweeping age-discrimination should play no part in how we manage Covid-19.   Whilst physical distancing and other measures are deemed essential to slow the spread of coronavirus that should not be used as an excuse to discriminate against older citizens or anybody else.   The application of lockdown social constraints and protocols for admission to hospital, allocation of beds, ventilators and other treatments on the basis of age is discriminatory.  It should play no part in the new normal' for people in Scotland or other parts of the UK during or after the Covid-19 crisis.

Anti Ageist Decision Making and Covid-19: Some proposals.

In developing policy from the Decision-Making Framework the Scottish Government should:

    • Reject arbitrary decision-making based on age or any other protected characteristic.  
    • Adopt the British Society of Gerontology statement on Covid-19 to inform policy and practice in relation to older people.
    • Build on existing work across government on the rights of older people such as A Fairer Scotland for Older People: A Framework for Action, 2019..
    • Collaborate with the Equality and Human Rights Commission (EHRC), Age Scotland, the STUC and other relevant organisations.
    • Explore the case for a National Health and Social Care Service. Professor Pollock's editorial in the British Medical Journal, April 2020 argues for this as a response to the failings exposed by Covid-19.  
    • Influence the other rUK governments to reject ageist decision-making and ensure the human rights of older people during the pandemic and beyond.

This is urgent work and needs to be taken up immediately to prevent injustice and needless harm. It is also essential that Scottish Government broadcast this approach widely with the public and through the media to clarify progress and combat ageist attitudes.

A National Recovery and Renewal Plan For Scotland: The basis of the new normal.

An overriding criticism of the UK government's approach to Covid-19 is that they knew the NHS was unprepared for a surge in hospital admissions caused by an event like a pandemic.  This lack of preparation was due to the clearly documented effects of underfunding on staffing, bed capacity etc. going back at least 10 years.  The Tory 2019 election campaign acknowledged the need for increased funding by pledging investment in the NHS. Their first budget(s) in 2020 had to include massive emergency spending to bolster the NHS against Covid-19. The Tories must also have known about Exercise Cygnus a pandemic simulation, which apparently exposed grave weaknesses in preparation at the time of the December 2019 General Election.  

Boris Johnson and his government went into the pandemic with their eyes open and have no excuses for what has followed. They must be forced to create a proper National Recovery Plan for the UK. If they don't, or it is inadequate, then the Scottish Government should be prepared to diverge from the rUK in the interests of the Scottish people.  

The basic demands on a National Recovery Plan should include:

    • Immediate refunding and longer-term regeneration of the NHS to increase current capacity, and invest in strategic change. The immediate objective being better preparation for winter(s) 2020/21 and beginning to clear the backlog of treatments delayed by the Covid-19 crisis.  
    • A full review of Pubic Health provision, Primary Care and Preventative Medicine.
    • Creation of an urgent plan to reform Social Care services during 2021/22.  

The Scottish Government is perfectly capable of advocating this agenda with their rUK partners and supported by the SNP group at Westminster. In any case the SNP should champion such an approach for Scotland at the May 2021 election as a basis for the new normal.

Healthy Ageing as the New Normal: A global perspective on renewal.

UK governments of the last decade have created the conditions where the NHS and the Care Sector are under extreme pressure and lives are being lost to Coronavirus. Large sections of the economy are frozen' by the lockdown and the government is spending enormous sums of public money to keep them on life support. To put this to rights we should have an expectation of a renewal plan to go alongside the post-War Beveridge and Marshall Plans.  A response on this scale needs to be articulated by the Scottish Government as the real framework for creating the new normal.

The World Health Organisation's (WHO) Plan for a Decade of Healthy Ageing 2020-2030 is highly relevant to defining what a new normal' for Scotland might be like.  Whatever President Trump might think of the WHO, it is the key global focus on health and deals with all of the issues facing Scotland today.  These include as a basis for renewal the need to:

    • Ground socioeconomic policy in the nation's demographic facts.
    • Eliminate inequality.
    • Eradicate ageism at all levels of society.
    • Add years to life and benefit as a society from greater longevity.

Taken together with the good intentions and values expressed in the Scottish Government's Covid-19 Decision Making Framework, the WHO programme offers a decade long agenda for the new normal' to make up for the last decade of the old abnormal.

Conclusions.

The Covid-19 crisis has amplified every socioeconomic inequality and foregrounded the question of what constitutes the common good and how we achieve it.  

We are all making great sacrifices by adhering to the lockdown and we deserve to be heard on what the new normal should look like.  Making our voices heard is the best tribute those of us who survive can pay to those who have lost their lives.