Submission to PAC on readying NHS and social care for COVID-19 peak

 

Submission by

  • National Institute for Health Research (NIHR) Health Protection Research Unit in Emerging and Zoonotic
  • University of Oxford, Nuffield Department of Primary Care Health Sciences

to

House of Commons Public Accounts Committee Inquiry:

Readying the NHS and social care for the COVID-19 peak

Background:

We are University researchers in emerging infections and health policy responses to them.[1] Since the beginning of the COVID-19 epidemic in the UK we have been conducting research into the dynamics of COVID-19-related policy development and healthcare worker behaviour in the UK. The research is funded by UK Research and Innovation and the National Institute for Health Research. We interview key policy players and frontline healthcare workers, who speak candidly to us on condition of anonymity.[2]

In an infectious disease outbreak, health policy makers are under tremendous pressure (Brändström and Kuipers 2003). They must respond rapidly to get ahead of the epidemic, and make high-impact decisions despite uncertainty (Boin 2009). This includes scientific uncertainty about the natural history of the coronavirus (Weible et al 2020). Our remarks here acknowledge the severity of these challenges for policy makers: they are not armchair criticisms from hindsight.

 

Our evidence on the Committee’s questions:

  • availability of healthcare professionals and beds to treat COVID-19 patients while maintaining other essential health services

Senior healthcare professional managers have told us that bed and staff numbers, especially capacity in ITUs (intensive treatment units), were increased fairly quickly and effectively. However, suspending other services to focus on COVID-19 affected patients managing chronic, acute, and/or life-threatening conditions. A GP and Clinical Director in Merseyside said they worried that:

‘the indirect mortality and morbidity is going be significantly greater than the direct COVID mortality and morbidity and we’re beginning to see significant impact on mental health, relationships and conditions which we’re not managing.’ (anonymised interview, 28 April 2020)

Cancer services were among the first to restart, but as a GP partner in Merseyside highlighted, there remained important, much wider, unmet need: ‘We can’t only be looking for cancers…other things kill you as well.’

Redeploying healthcare professionals to where they were most needed (e.g. ITU) was an essential part of managing COVID-19, but these redeployed healthcare professionals needed to return swiftly their normal roles as their original services started seeing patients again. Releasing staff from redeployed roles was a difficult balance: surge capacity for a potential second wave also needed to be retained for rapid activation. This left redeployed staff frustrated and unclear when they could return to their normal roles.

  • use of consultants and other private contractors in mounting the UK emergency response

The UK response has been characterised – to a greater extent than in some similar countries – by large central initiatives employing private contractors. Certain services, such as testing, had to be very rapidly expanded, and – rightly or wrongly – public sector bodies in the UK had not been funded to put sufficient ‘surge’ capacity in place beforehand. We would draw attention to two linked issues: the merits of a centralised response, and the use of private contractors.

To take centralisation first, UK governments have long responded to major crises by the imposition of Whitehall control, taking over some responsibilities and powers from local institutions, as for example in the 2001 Foot and Mouth Disease outbreak. In the case of COVID-19, the Whitehall response has again been to take back a large measure of control from the NHS, NHS England, Public Health England and Local Authorities (LAs). In a series of fields including epidemic modelling, the Ventilator Initiative, ‘Nightingale Hospitals’, ‘Lighthouse’ testing centres, and NHS Test and Trace, new organisations have been set up by the centre, often using private contractors. The results have met with mixed success.

In relation to the centralisation of modelling, an interviewee told us that:

‘the reason we know anything about care homes is because of the group in Manchester who made connection with their local public health and local community. But not everyone has done that, and even if they did, that would still leave huge sections of the country uncovered.

‘... People have … not … thought it through … [Regarding the] reasonable worst case scenario ... information that is [meant to be] cascaded out so that local government can prepare for eventualities … it has been very unclear … [what the centre is meant to provide], and then it has been very unclear to [LAs] what … they are supposed to do with it.’ (anonymised interview, 22 April)

LAs continue to be kept in the dark about Whitehall’s plans for localised modelling. Many have commissioned their own, which – as in the Manchester example – is proving invaluable. This is threatened by the Government’s continuing lack of clarity about its intentions, notably in relation to the work of the Joint Biosecurity Centre, resulting in a form of planning blight (anonymised interview, 17 June).

In relation to the Nightingale hospitals, we have some evidence that deployments were not always effectively or sympathetically handled. A nurse told us:

‘After [the stand-down] was announced in the news, I got an e-mail from the [London] Nightingale saying, ‘Thank you very much, but we won’t be needing you,’ and I thought, ‘You know what, that is so insulting, the fact that you keep everybody waiting for like a week and then I find out from the news.’ And, you know, this has an effect on people […] It could have affected – if I had been – I mean, by my own initiative I called my manager and I said, ‘Look, I’m just at home doing nothing,’ and they said, ‘Okay, you can go back to work to your usual role, because otherwise your salary, your annual leave entitlement, everything could be affected if you stay at home.” (anonymised interview, 22 May 2020).

Turning to the government’s new Lighthouse testing centres, there have been powerful advocates for an alternative strategy which would continue, as in pre-COVID times, to delegate authority to local resources and teams, harnessing (to quote Sir Paul Nurse) the nation’s ‘Dunkirk spirit’ (Nurse 2020). Labs in facilities such as the Francis Crick Institute (of which he is the Director) could meet the modelled demand for laboratory analysis. The NHS’ and PHE’s own laboratories responded well to the need for rapid analysis of tests, and greater use of these more local resources would have saved exhausted health care workers at the end of long shifts from having to drive long distances to a test centre. Where the NHS tested its own staff on site and sent specimens to a nearby lab, whether in an NHS facility or otherwise, these problems were avoided.

A GP and Clinical Director in Merseyside describes how local labs may not have been given sufficient lead-time to prepare for testing:

‘We got the email from NHS England regarding antibody testing on Friday…and then I phoned the labs, our local labs, to find out, well, what’s the plan here? And of course no one had told them about the antibody testing roll-out that was going to go on nationally, and they had had as much notice as we had in order to be ready for this’ (02 June 2020)

Most worryingly from a Public Accounts perspective, this interviewee adds: ‘The problem about the half-baked implementation is that each time you botch it, you lose a little bit of energy from people.’ NHS staff morale and motivation, one of the key subjects of our research, is critical to successful delivery of government policy on the ground. At times, mishandling at the centre has sacrificed some of this, as in this example.

Building surge capacity onto existing institutions, instead of setting up new testing organisations, would also have avoided some of the delay and confusion which always occurs when a new organisation is rapidly built from scratch, however competent the contractors tasked with this. In reality, not all the contractors did perform well: Deloitte’s and Serco’s effectiveness at some of the testing centres (such as Chessington) has been rightly criticised, for example for the reporting of incorrect test results.

Public health practitioners also criticised the centralisation of NHS Test and Trace, and argued for the greater efficacy of local testing and tracing compared with a new national body (Scally et al 2020). We were told that the PHE specialists in contact tracing:

‘are constantly waiting for a steer from DHSC, Number 10 as to what the policy is, even … what symptoms constitute the case definition, that’s no longer decided by PHE alone. …

‘like many big projects, not enough attention is given to the nitty-gritty of operational details … things that make or break a big project. So … what seemed great as a strategy decided by someone with no public health background, actually there is a reason we do it this way’ (anonymised interview, 22 May).

A public health official gave a similar opinion: NHS Test and Trace has been:

‘an exercise in people above my position telling me they know better and in almost every circumstance they turned out not to. That’s what this whole pandemic has been like, and I won’t forget that.’ (Guardian 2020)

DHSC could adopt better-informed policies for both NHS services and public health if its access to in-house medical advice had not been severely reduced over the last generation (Sheard 2010). There is no substitute for properly harnessing existing professional skills, experience and local knowledge. The detective-work of infectious disease contract tracing is a particularly good illustration, and it is heartening that LA public health departments are now being allowed to engage with NHS Test and Trace more productively (anonymised interview, 5 June).

The use of private contractors is, then, inevitable: the point is how well it was managed in these cases. The cumulative impression left by the cases discussed here is that the government has reached for centralised private solutions without sufficient insight into the operational requirements (for instance in contract tracing), and has let corporate service providers convince it too easily that their generic capacities can smoothly be plugged into COVID-19 responses, which in fact need the detailed expert knowledge possessed only by existing professionals and the public sector bodies who employ them. The UK’s COVID-19 experience has been that contracting-out can only be effective when adequate time is available: not in the very short timescales the virus allows us. The tracing app, for example, may ultimately work excellently, but we learn from the responsible Minister that it is unlikely to be ready before the winter (Daily Telegraph 2020).

 

  • securing adequate vital supplies, including PPE, testing equipment, and ventilators

We have extensive evidence that the immense PPE procurement exercise did not always deliver effectively. We heard about delays in PPE deliveries to GP practices, PPE being delivered to the wrong place, and even in June 2020 are still hearing about shortages of FFP3 masks in a Liverpool hospital which could mean that surgery would have to stop again.

Some healthcare professionals have expressed worry that shortages of PPE may have impacted on the care they were giving to patients. A speech therapist in an East of England hospital reported to us: 

‘“We’re trying to not overuse PPE and trying to … make every contact count, I guess trying to be smarter about the way we see people. … It feels really weird … if we’re not seeing them I’m always questioning myself, you know, ‘Am I not seeing this person because I’m trying not to waste PPE?’ (anonymised interview, 12 May).

Healthcare professionals also told as that there was widespread concern that problems in the supply of PPE partly motivated changes to PPE guidance, and therefore may have put them and patients at risk. A Clinical Lead in an A&E said:

‘The debacle about PPE is a real one. The changing scenario of what PPE have we got today and what does it look like today, how do I use it. … So I just feel that if we had had clear, uniform guidance and equipment for PPE it would have been a lot less stressful from the outset. Because we have changed it so many times. … [Better to have] clarity of communication from the outset. Even [just to say:] … ‘this is not ideal, but it’s what we are going to do now, and as soon as we have got this we will do ‘X’, we will do the next thing’. It’s just the uncertainty of PPE is a nightmare.’ (anonymised interview, 23 April)

 

  • protecting and supporting vulnerable groups, including healthcare professionals

 

Healthcare professionals have highlighted risks to vulnerable colleagues who worked throughout the pandemic, such as BAME colleagues, the lack of risk assessments, and the lack of planning about how shielding colleagues could safely come back to work. A Pain Specialist nurse in London told us:

 

‘Two of my team members are Filipino nurses and there has been quite a lot of Filipino healthcare professionals who have died, by Covid. So understandably, one of them is quite worried and the other one has got health issues and is working from home – she’s asthmatic – so my team is worried.’ (anonymised interview, 22 May)

 

Healthcare professionals have been very critical about the measures put in place to protect the vulnerable, calling ‘too little, too late’. A Clinical Director in a Liverpool hospital said:

 

‘we’ve said … right from the start, the priorities to get right [were] to get the PPE and the reassurance right, to get the nursing homes and the vulnerable sorted out, and to get the testing up as quickly as possible. And they had the time to do that and I think they’ve failed with all of those.’ (anonymised interview, 15 May)

Or as Richard Horton, editor of the Lancet put it, ‘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’. Horton adds, ‘this was a national scandal’. (Horton 2020)

 

  • what capacity the NHS has now to withstand a potential second peak later this year.

Healthcare professionals tell us that local lessons are being drawn from the first phase of the COVID-19 response in primary and secondary care, but they emphasise that the backlog of clinical work and the clinical staff’s exhaustion put us in a weaker position to manage a potential second wave than we were for the first. Many report growing feelings of mental and physical exhaustion from the intensity and uncertainty of the first wave. One London ITU nurse said:

‘Lots of things are getting better but I’m finding myself in a more difficult place, where I just feel that tiredness, that uncertainty, that ‘when am I going to get back to my normal job’ – that kind of thing is really playing on my mind a lot more. I’m done, I’ve had enough, I’m feeling really flat, and really, really tired. I’ve been working full-time for 3 months when I normally only do 3 days a week, 4 days a week, short days.’ (anonymised interview, 29 May).

Emergency ways of working were kept in place longer than many healthcare professionals felt was necessary, and by their nature were unsustainable. Lack of clear timelines and a continued pressure to sustain emergency measures contributed to staff exhaustion, and difficulties planning services to move forwards in a safe and sustainable way. An Emergency Department Clinical Lead in the East Midlands explained:

‘There are no timescales, and that’s exhausting and demoralising from my perspective…We’re just stuck in a bit of a no-man’s land, really. […] I know where I think we need to get to, but I haven’t got a clear timescale, really, and I haven’t really got any push making me do it – almost the reverse, people are saying ‘don’t change anything, just carry on as long as you need to.’ But actually we do need to change … But it’s not a straightforward ‘flip it over’ because that’s not safe either.” (anonymised interview, 28 May)

 

Conclusion

We hope this testimony from the health care front line and from the policy world speaks for itself, but the research team would be happy to contribute further to the Inquiry if the Committee wishes.

References:

Boin A. The New World of Crises and Crisis Management: Implications for Policymaking and Research. Review of Policy Research 2009; 26(4): 367–77.

Brändström A, Kuipers S. From ‘normal incidents’ to political crises: Understanding the selective politicization of policy failures (pt. 1). Government and Opposition 2003; 38(3): 279–305.

Daily Telegraph, ‘Contact-tracing app will not be ready until winter, admits health minister’ 17 June 2020

Guardian, ‘England's coronavirus tracing plan 'beset by conflict and confusion', 27 May 2020

Horton R. COVID-19 and the NHS – “a national scandal”. Lancet 2020; 395(10229):1022.

Klein R. The new politics of the NHS: from creation to reinvention. 7th edition. (Radcliffe, London: 2013).

Nurse, P., speaking on BBC Radio 4 ‘Today’ programme (2 April 2020).

Scally G, Jacobson B, Abbasi K. The UK’s public health response to covid-19. BMJ 2020; 369: m1932.

Sheard S. Quacks and Clerks: Historical and Contemporary Perspectives on the Structure and Function of the British Medical Civil Service. Social Policy and Administration 2010; 44(2): 193–207.

Weible C M, Nohrstedt D, Cairney P, et al. COVID-19 and the policy sciences: initial reactions and perspectives. Policy Sciences 2020; https://doi.org/10.1007/s11077-020-09381-4.



[1] This work comes from the NIHR Health Protection Research Unit in Emerging and Zoonotic Infections at University of Liverpool in partnership with Public Health England (PHE), in collaboration with Liverpool School of Tropical Medicine and the University of Oxford (Grant No. NIHR200907). The views expressed here are our own and not necessarily those of the NHS, the NIHR, the Department of Health and Social Care (DHSC) or PHE.  We are grateful for the support of Liverpool Health Partners, and the Centre of Excellence in Infectious Disease Research (CEIDR), Liverpool.

[2] More details of our methods are available on request.

Posted on: 22/06/2020