I am the press officer for a major NHS campaigning organisation. It is my job – and my privilege – to listen to the voices of NHS staff and relay their messages to the public. It is my job to give those workers a voice, in order to alert people to the daily realities inside the NHS. The NHS is a publicly-funded service; the taxpayer has a right to know what life on the frontline is really like.
NHS staff have always been naturally guarded in their response. They do not sensationalise. Being a clinician carries with it a great responsibility in terms of adhering to confidentiality, and confidences are rightly kept in a professional context.
However, there are numerous examples of NHS staff being burned for justly speaking out about what are public safety concerns. Understandably staff are therefore very wary (and, yes, frightened) of saying something that may lay them open to disciplinary action.
Amid the struggle against the coronavirus pandemic, NHS England, the government body that oversees the English NHS, is now controlling media communications and even people’s personal social media accounts are being monitored. Staff have been instructed not to speak out about their concerns at a time of huge national public interest. Not only are senior management dictating who staff should speak to and about what, but in doing so they are also denying them a form of expression. NHS Trusts are asking NHS staff to regulate their emotional response during the most stressful period they have ever encountered.
Since coronavirus first began to impact on the NHS, I’ve heard several times a day of people’s legitimate concerns and fears over the lack of protective equipment and testing – and with good reason. The government has not been listening to healthcare staff through the normal communication channels and they are proving dangerously slow to react to what NHS staff are telling them. The only sure way to put pressure on the government and make them listen is publicly, by speaking openly to government and the people through the media. Gagging NHS staff is nothing more than an attempt at a cover up for the dire way this government has handled the pandemic from the top.
The lack of personal protective equipment and virus testing for frontline staff is a scandal. Staff are being sent into battle with no armour; their lives are being put at risk because the government has failed to provide them with suitable clothing to protect them from this potentially deadly illness. Doctors and nurses are now even crowdfunding for face masks and gloves in one of the richest countries in the world. Staff are still not being routinely tested for the virus so are unwittingly passing on Covid-19 to their patients, families and loved ones.
These issues are set against a backdrop of an NHS that has been critically underfunded and understaffed for a decade, so it is unsurprising and perfectly natural that even those who were previously silent have now felt it necessary to speak up.
All this hero worship of late makes most NHS workers quite uncomfortable. Eyes roll and the standard response is: “I’m not a hero, I’m just doing my job.” Nevertheless, that’s how they are viewed by the public at the moment, and with good reason. Yet NHS staff have been overlooked and taken for granted for far too long. The small breaks they have lately been offered have not come without a fight. Petitions for free staff parking have been created by concerned members of the public, and Johnson and co have had to concede. The mass public admiration is no more than they all deserve. It’s just a shame it’s taken a worldwide pandemic to force the government to see it.
I hope my colleagues continue to be the incredibly brave and selfless individuals that they are in speaking out and holding this disastrous government to account, and I hope people outside of this bubble understand the hard truth of the situation.
Doctors and nurses are the canaries in this unexplored mine. When they make a noise, it’s our responsibility to listen.
Tonight, Clap with Clout – NHS workers need more than a clap, they need Personal Protective Equipment – and Testing.
- Allyson M Pollock, professor of public health1,
- Peter Roderick, principal research associate1,
- KK Cheng, director2,
- Bharat Pankhania, clinical senior lecturer 3
- Correspondence to: A Pollock
On 24 February, there were nine confirmed cases of covid-19 in the UK. On the same day, the World Health Organization recommended countries outside China with imported cases or outbreaks “prioritize active, exhaustive case finding and immediate testing and isolation, painstaking contact tracing and rigorous quarantine of close contacts.”1
On 22 March—when there were 5683 confirmed UK cases—Michael Ryan, executive director of the WHO health emergencies programme, repeated the message on the BBC: “What we really need to focus on is finding those who are sick, those who have the virus, and isolate them, find their contacts and isolate them.”
This is entirely unexceptional. Case finding, contact tracing and testing, and strict quarantine are the classic tools in public health to control infectious diseases. WHO says they have been painstakingly adopted in China, with a high percentage of identified close contacts completing medical observation. In Singapore, Vietnam, and South Korea meticulous contact tracing combined with clinical observation plus testing were vital in containing the disease. This combined with strong measures to enforce isolation for travellers returning from high incidence areas obviated the need for a national lockdown and closure of all schools in Taiwan and Singapore.23
The mathematical model used by the UK government clearly shows that rigorous contact tracing and case finding is effective:4 the prediction of 250 000 deaths was predicated on what would happen without contact tracing.5
Contact tracing started in the UK but stopped early in the epidemic.6 How effective it was is questionable, especially in England and Wales, which made covid-19 a notifiable disease only on 5 March,78 two weeks after Scotland9 and a week after Northern Ireland.10 This, coupled with the lack of surveillance and testing of those contacting primary care, suggests the number of confirmed cases is an underestimate.
The reasons why tracing was stopped, against WHO recommendations, have not been published. It seems to be connected to a shift from “contain” to “delay” in the government’s action plan,11 when contact tracing was replaced rather than supplemented with other control measures.
One reason seems to be a lack of tests and testing facilities. However, testing is a support not a substitute for tracing or medical observation, which is crucial. Current tests for the virus require careful validation and have low sensitivity, resulting in many false negative results, especially in the pre-symptomatic phase when viral load is low. As many as 40-50% of patients tested negative initially in China, and so the definition of confirmed cases was changed to include those with clinical symptoms.1213
Need for local response
Another factor is the decision to treat the situation as a single national epidemic rather than scores of local outbreaks each at different stages, needing to be tackled locally. National figures conceal huge variation in confirmed cases, ranging from over 400 in Birmingham and Hampshire to fewer than 20 in Blackpool, Hartlepool, Darlington, and Rutland. In Scotland the first case was identified on 1 March, and Orkney and the Western Isles still have no cases.
In the much less severe H1N1 flu pandemic in 2009, this same approach “seriously impaired the ability of local agencies to respond in a flexible, timely and pragmatic way to the rapidly emerging situation.”14
Matters have worsened since 2009. Central control in England was entrenched by the 2012 Health and Social Care Act, which created Public Health England (PHE) to protect the health of the public in England and gave local authorities the duty to improve the health of their local populations. PHE is legally in charge of communicable disease control and sits outside the NHS and local government in its regional hubs and field epidemiological services. Directors of public health in local authorities have little scope for proactively taking local control.
These changes are exacerbated by the decimation of public health and laboratory facilities for testing. The decrease in numbers of consultants in communicable disease control and community control teams,15 together with swingeing local authority cuts since 2010, have reduced the chances of a strong local response. Local pathology and virology services have been centralised and partly privatised, leading to a fragmented mix of for-profit and public laboratories and serious staff shortages.16171819
Listen to disease control evidence
The scientific evidence has been dominated by behavioural science and mathematical modelling, with communicable disease control and public health sidelined. This leads to a lack of scientific challenge, as in the 2009 flu epidemic.20
So what now? WHO’s mantra of “trace, test, and treat” must be followed. It is not too late to adopt WHO Guidance.2122 A second and third wave of the epidemic is likely. Contact tracing must recommence. This means immediately instituting a massive, centrally coordinated, locally based programme of case finding, tracing, clinical observation, and testing. It requires large teams of people, including volunteers, using tried and tested methods updated with social media and mobile phones and adapting the manuals and guidance published by China.2324
The structure and capacity of our depleted healthcare system is now largely driving the response to this epidemic. It will continue to do so until services that support local communicable disease control are rebuilt and reintegrated.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare BP is a former consultant in communicable disease control.
Covid-19: Contact tracing requires ending the Hostile Environment
In order for contact tracing to be viable, all sections of the community must be willing to be contacted by NHS or public health staff. The community includes “overseas visitors” on the receiving end of the Government’s “Hostile Environment” policy, who may fear that any contact will incur NHS charges or lead to their being reported to the Home Office.
Unlike the UK, the Irish government has declared that all people – documented or undocumented – can now access healthcare and social services without fear. Undocumented immigrants and asylum seekers in Portugal have been granted the same rights as residents, including access to medical care, during the current state of emergency. In South Korea, undocumented immigrants can be tested without risk of deportation.
It is simply not good enough for the UK to add 2019-nCoV to their list of exemptions from charges, which few people will know. To fight this epidemic and protect everyone’s health, all barriers to accessing NHS treatment – including charges and reporting of debt to the Home Office – should be suspended immediately.
Competing interests: I am a member of Keep Our NHS Public
(Sent to KONP steering group by Greg Dropkin, retired, Liverpool)
By Katherine Hignett 30 March 2020
- Many trusts experiencing serious shortages of gowns
- Procurement trade body told gowns were included in national stockpiles
- NHS Supply Chain expecting more gowns Monday
- PPE-only supply chain expected to begin operations midweek
Gowns for front-line staff were not included in the national pandemic stockpile of personal protective equipment, procurement chiefs have been told.
Trust procurement leads have raised concerns over dwindling gown supplies. Health Care Supply Association chief officer Alan Hoskins tweeted he could not order the products through NHS Supply Chain, even after escalating the matter to NHS England.
Mr Hoskins’ tweet on Sunday, which has since been deleted, said: “What a day, no gowns NHS Supply Chain. Rang every number escalated to NHS England, just got message back — no stock, can’t help, can send you a PPE pack. Losing the will to live, god help us all.”
Senior procurement leads told HSJ that major trusts, including Barts Health in London, ran out of gowns at the end of last week. Calling the supplies situation “extremely bad,” one source said there were “virtually no gowns left in the system” and no communication from NHS Supply Chain as to when more would be available.
One trust procurement director told HSJ: “Senior people have been repeating the line that ‘there is no shortage of supplies, just a few minor transport difficulties’ for a few weeks now – and that is not helpful. It is not as if they need to look too far – HSJ and other media have been pointing it out constantly. The supplies situation is still extremely bad. The HCSA posted a tweet about the critical gown shortage yesterday – only to receive a series of calls from the centre – not to update, but to ask them to take the tweet down.”
On Monday morning, the HCSA said it had confirmed that gowns were not included in the national pandemic stockpile of PPE equipment. The DHSC and NHS SC have been using this stockpile for FFP3 masks since 10 March.
The trade body, which represents NHS procurement staff, stated on Twitter that NHS SC had instead been shipping stocks of gowns built up in case of a no-deal Brexit.
On Friday evening, NHS SC told HSJ it was expecting to receive gowns today (Monday), which soon should be available for order.
A spokeswoman said: “We are continuing to engage with our customers through our account management team and provide updates on the daily customer webinar on PPE product availability.
“We’re working closely with our suppliers to manage stock levels of the identified key product lines outlined in Public Health England’s guidance. We have stock on order from the UK and European countries in addition to suppliers based in the Far East to continue to secure a pipeline and replenish our stocks to help ensure these products are delivered to the front-line.”
HSJ has approached NHS Supply Chain, the DHSC and PHE for comment on the pandemic stockpile, and has approached Alan Hoskins for comment on his tweet. An NHSE spokesman declined to comment.
NHS Supply Chain and the Department of Health and Social Care have come under fire in recent weeks for delivering inadequate and unpredictable supplies of both PPE and “business as usual” stock to trusts.
This has intensified with the deaths of two consultants from covid-19 and reports of staff being unwilling to treat patients without World Health Organisation-compliant PPE.
On Sunday, NHS Providers chief Chris Hopson said a PPE-only supply chain was being set up so that NHS Supply Chain could focus on non-PPE stock. The new supply chain is expected to begin operations by the middle of this week.
Richard Horton FRCP FMedSci, (Editor, The Lancet): Lancet Offline: COVID-19 and the NHS – “a national scandal” March 28th 2020.
“When this is all over, the NHS England board should resign in their entirety.” So wrote one National Health Service (NHS) health worker last weekend. The scale of anger and frustration is unprecedented, and coronavirus disease 2019 (COVID-19) is the cause. The UK Government’s Contain–Delay–Mitigate–Research strategy failed. It failed, in part, because ministers didn’t follow WHO’s advice to “test, test, test” every suspected case. They didn’t isolate and quarantine. They didn’t contact trace. These basic principles of public health and infectious disease control were ignored, for reasons that remain opaque. The UK now has a new plan— Suppress–Shield–Treat–Palliate. But this plan, agreed far too late in the course of the outbreak, has left the NHS wholly unprepared for the surge of severely and critically ill patients that will soon come. I asked NHS workers to contact me with their experiences. Their messages have been as distressing as they have been horrifying. “It’s terrifying for staff at the moment. Still no access to personal protective equipment [PPE] or testing.” “Rigid command structures make decision making impossible.” “There’s been no guidelines, it’s chaos.” “I don’t feel safe. I don’t feel protected.” “We are literally making it up as we go along.” “It feels as if we are actively harming patients.” “We need protection and prevention.” “Total carnage.” “NHS Trusts continue to fail miserably.” “Humanitarian crisis.” “Forget lockdown—we are going into meltdown.” “When I was country director in many conflict zones, we had better preparedness.” “The hospitals in London are overwhelmed.” “The public and media are not aware that today we no longer live in a city with a properly functioning western health-care system.” “How will we protect our patients and staff…I am speechless. It is utterly unconscionable. How can we do this? It is criminal…NHS England was not prepared… We feel completely helpless.”
England’s Deputy Chief Medical Officer, Jenny Harries, said on March 20, 2020: “The country has a perfectly adequate supply of PPE.” She claimed that supply pressures had now been “completely resolved”. I am sure Dr Harries believed what she said. But she was wrong and she should apologise to the thousands of health workers who still have no access to WHO-standard PPE. I receive examples daily of doctors having to assess patients with respiratory symptoms but who do so without the necessary PPE to complete their jobs safely. Health workers are challenged if they ask for face masks. Even where there is PPE, there may be no training. WHO standards are not being met. Proper testing of masks is being omitted. Stickers with new expiry dates are being put on PPE that expired in 2016. Doctors have been forced to go to hardware stores to buy their own face masks. Patients with suspected COVID-19 are mixing with non-COVID-19 patients. The situation is so dire that staff are frequently breaking down in tears. As one physician wrote, “The utter failure of sound clinical leadership will lead to an absolute explosion of nosocomial COVID-19 infection.” Front-line staff are already contracting and dying from the disease.
The NHS has been wholly unprepared for this pandemic. It’s impossible to understand why. Based on their modelling of the Wuhan outbreak of COVID-19, Joseph Wu and his colleagues wrote in The Lancet on Jan 31, 2020: “On the present trajectory, 2019-nCoV could be about to become a global epidemic…for health protection within China and internationally… preparedness plans should be readied for deployment at short notice, including securing supply chains of pharmaceuticals, personal protective equipment, hospital supplies, and the necessary human resources to deal with the consequences of a global outbreak of this magnitude.” This warning wasn’t made lightly. It should have been read by the Chief Medical Officer, the Chief Executive Officer of the NHS in England, and the Chief Scientific Adviser. They had a duty to immediately put the NHS and British public on high alert. February should have been used to expand coronavirus testing capacity, ensure the distribution of WHO-approved PPE, and establish training programmes and guidelines to protect NHS staff. They didn’t take any of those actions. The result has been chaos and panic across the NHS. Patients will die unnecessarily. NHS staff will die unnecessarily. It is, indeed, as one health worker wrote last week, “a national scandal”. The gravity of that scandal has yet to be understood.
From Double Down News 27th March 2020
20th March 2020
In October 2016 the UK government ran a national pandemic flu exercise. It was codenamed Exercise Cygnus. The report of its findings was not made publicly available, as part of the general antipathy towards the NHS in general by the Conservative party. But the then chief medical officer Sally Davies commented on what she had learnt from it in December 2016. The public will now pay with their lives for deliberate government inaction and total disregard towards their primary function – to protect us all.
You can read the – “Emergency Preparedness, Resilience and Response (EPRR)” document HERE – “that participated in Exercise Cygnus, a three-day exercise looking at the impact of a pandemic influenza outbreak, and the significant impacts on health delivery a widespread pandemic in the UK would trigger.”
“We’ve just had in the UK a three-day exercise on flu, on a pandemic that killed a lot of people,” Sally Davis told the World Innovation Summit for Health at the time. “It became clear that we could not cope with the excess bodies,” she ominously warned. One very predictive conclusion was that Britain, as Davies rightly said, faced the real threat of totally “inadequate ventilation” in a future pandemic. Davies was, of course, referring to the need for ventilation machines, which keep oxygen pumping in patients critically ill with a respiratory disease such as coronavirus.
Despite the severe failings exposed by Exercise Cygnus, the government’s planning for a future pandemic did not change after December 2016. The government’s roadmap for how to respond to a coronavirus-like pandemic has long been available online, and the three key documents – the 70-page “Influenza Pandemic Preparedness Strategy”, 78-page “Health and Social Care Influenza Pandemic Preparedness and Response” and 88-page “Pandemic Influenza Response Plan” – were published in 2011, 2012 and 2014 respectively. What is striking about this exercise and subsequent published plans was that these plans were properly tested and emphatically failed, yet these documents were not rewritten or revised and provided no new preparedness recommendations towards what would happen in the event of another virus outbreak, which was expected in due course. Except for one thing. That the health services would not be able to cope.
All these documents and plans share a common failure – not one of them mentions ventilators. In typical warcry theatre for the purposes of rallying the troops, as it were, Matt Hancock, the Health Secretary, told British manufacturers on 14 March, “If you produce a ventilator, we will buy it. No number is too high.” It’s as if they read Davies comments only last week, thought they might get caught and reacted to stave off yet more criticism of their casual handling of the state.
The result is that the government has no stockpile of ventilators at all. All three of the plans refer to stockpiles, but only of antivirals, antibiotics and personal protective equipment for NHS staff. As for the latter, many NHS frontline staff from ambulance crews, to porters and medics are already complaining they have run out and facing being ‘cannon fodder’ in these warlike hospital circumstances that Hancock now realises will become a reality.
Hancock’s pleas come six weeks after the first cases were reported in Britain and two months after an epidemic was called in China.
As the 2011 preparedness strategy puts it, “Critical care services are likely to see increases in demand during even a mild influenza pandemic. In a moderate or severe influenza pandemic demand may outstrip supply, even when capacity is maximised… it may become necessary to make decisions concerning the priority of access to some services.”
And yet, the government failed to heed any of the warnings, the strategy or plans put forward. In this, the government has failed in its primary duty – to ensure citizens are safe.
Downing Street officials have, according to the Sunday Times on 15 March, found their planning efforts to be quite literally non-existent. Even with pre-existing pandemic plans, an official is quoted as saying they, “never went into the operational detail”.
The government devised an atrocious plan of not tracing, tracking and isolating the infected to flatten the curve – but to simply to control the infections and ensure everyone got it for what they termed ‘herd-immunity’ and leave everyone to cope, including the NHS. The death toll was modelled in these circumstances by Imperial College and its findings were so bad – it even caused the Trump administration to U-turn, let alone Boris Johnson’s defective team to take notice.
Assumptions laid out in 2018 by the Scientific Pandemic Influenza Group on Modelling, or SPI-M – a working group of 10 academic teams – predicted that 4 per cent of cases will require hospitalisation; this is in line with estimates for Covid-19 at around 5 per cent, the disease that is caused by the virus Sars-Cov-2, both commonly referred to as coronavirus.
SPI-M’s modelling also assumes that a quarter of those hospitalised will need a ventilator; this, too, aligns with the World Health Organisation’s findings on coronavirus in China, and at the moment is even proving to be an under-estimate.
In short, at least 1 per cent of all cases can be expected to need ventilation or between 400,000 and 530,000 people. Modelling released on March 16 by the same team at Imperial College, which has informed government planning, suggests a 1.3 per cent rate. However, that rate has since risen in Italy.
New modelling and older data, in line with predictions made in previous studies based on coronavirus pandemics all corroborate and say the same thing. Quite why Boris Johnson’s government decided to steer away from their own highly detailed predictive reports prepared by the best experts and away from all the evidence and international advice is a mystery.
The modelling by SPI-M in 2018, (which is even available online) uses data that goes as far back as the 1957 influenza pandemic in the UK. It is regarded as the best data for predicting the outcome of a pandemic in Britain. This model states that during the peak, which is now expected to arrive in Britain in late May or June, 15 to 20 per cent of all coronavirus cases will hit the NHS every week for three weeks. Assuming only a 1 per cent rate, rather than the higher rate in Imperial’s latest modelling, the number of patients needing a ventilator would, therefore, range from 60,000 per week to more than 100,000. Each ventilator needs to be used for an average of 10 days.
The United Kingdom has 5,000 ventilators.