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Inside the NHS: part one

Monday 16 November 2020


you can read inside the nhs: part two here

There was a lack of personal protective equipment and panic at our national healthcare system being overwhelmed. But were the right decisions being made in the first phase of frontline care? Did centralised control mean ventilators were overused and important lessons learned too late?


The UK government underestimated the requirements of the NHS and other health organisations when it came to PPE. As the pandemic unfolded, official advice failed to adapt. Guidelines remained out of step with the experiences of frontline healthcare workers. 

11 February
Steve Oldfield, Chief Commercial Officer at the Department of Health and Social Care reassured NHS staff that the “NHS and wider health system are extremely well prepared for these types of outbreaks”.

17 March
NHS officials told the Commons Health Select Committee that the supply of PPE in the UK was “adequate” to “keep staff safe in the months ahead” and insisted that existing stockpiles were sufficient.

But by April it was clear that the staff were not being kept safe, and the supplies were not adequate.


Early claims that the NHS was well-prepared for the pandemic proved false

18 February
An NHS briefing titled “Primary care providers and the coronavirus” stated that “The NHS and Public Health England (PHE) are well prepared for outbreaks of new infectious diseases”.

In response to the question “Are there supply issues with PPE?”, the briefing stated that

  • there was a large stock of face masks in the UK managed by PHE as part of its Pandemic Influenza Preparedness (PIP) stockpiles;
  • NHS Supply Chain had placed additional orders for PPE and was “working with wholesalers to support frontline services”;
  • NHS Supply Chain also retained an “EU exit stockpile” which included stocks of PPE.

These stocks and contingency plans proved inadequate. According to the British Medical Association’s Covid-19 tracker survey, PPE shortages for doctors working in high-risk areas at the end of April included

  • shortages of scrubs reported by more than 32 percent of doctors;
  • shortages of long-sleeved disposable gowns reported by 30 per cent of doctors;
  • no supply at all of disposable goggles reported by 11 percent of doctors.

Tests found that the standard issue 11R face mask, which was the default for care-providers, offered poor protection against inhaled particles and Covid-19. The tests showed that doubling up the masks or taping their edges increased efficacy. Ordinary usage was deemed dangerous to healthcare workers, but official NHS guidelines did not incorporate these findings.


Ventilators 

Early demand for ventilators to treat critically ill patients and prepare for further spikes in Covid case numbers led the UK government into a costly race to acquire more equipment – much of which was never used.

The DHSC sought to boost ventilator numbers by

  • buying on the international market;
  • expanding the NHS’s existing oxygen and ventilation programme;
  • announcing the Ventilator Challenge.

Numbers:

  • 8,000 – ventilators available to the NHS at the start of the pandemic
  • 5,000 – initial UK government request for extra ventilators in March.
  • 30,000 – subsequent target to be reached with the help of the Ventilator Challenge

The Ventilator Challenge involved the hasty pursuit of domestically produced devices to plug potential shortages. Many of the devices produced under the initiative were deemed unsafe.

  • The Challenge was an invitation to British industry to come up with a simple design for mass production.
  • The UK’s medical safety regulator (MHRA) was warned by a panel of external advisors at the height of the first wave that a drive to build thousands of basic ventilators risked wasting resources and delivering worse patient outcomes.
  • The MHRA reported the panel’s concerns that rudimentary ventilators could in fact harm patients.
  • Roughly £200m was spent on the challenge out of a total projected budget of £454m.
  • An order was placed in May for 10,000 Dyson CoVent machines, and according to James Dyson, £20 million of the taxpayer’s money was spent to start production.
  • By late April more than half a dozen projects were under review but five had already been cancelled.
  • Ultimately none of the basic Ventilator Challenge machines were approved for use – or required, since the NHS was able to meet demand without them.
  • Alison Pittars, dean of the Faculty of Intensive Care Medicine, said the machines were “of no use whatsoever”.

Challenge dates

  • 18 March: first MHRA specification issued
  • 31 March: OxVent, a leading participant from Oxford University, given green light to start testing
  • 10 April: specification amended to include spontaneous breathing modes (standard on most hospital ventilators for 30 years)
  • 28 April: OxVent project terminated by Cabinet Office

By late April the NHS had access to 10,900 ventilators, an increase of 2,400 over the period of the challenge. Of these, half came from private hospitals and a third from abroad according to the National Audit Office.

In addition, the Mercedes F1 team and UCL supplied 10,000 continuous positive air pressure (CPAP) breathing devices which do not require intubation or sedation and have proved effective in the treatment of Covid.

Dr Sara Hamilton, a member of the MHRA panel, told the FT it was important that lessons be learned from the process so that other countries wouldn’t repeat the mistake of rushing to build basic ventilators.


Data

Hospitals continued to collect their own data during the first wave of the pandemic, but to lighten burdens on NHS staff the service suspended central collection of data between 1 April and 30 September on several topics – including critical care bed capacity, urgent operations cancelled, elective operations cancelled and dementia assessment and referral.

The full list of affected data-sets is available here:

Additionally the Confederation of British surgery reported on 10 August that nearly 70 of its surgeons working in major hospitals had been warned against discussing PPE shortages with their departments.

Further reading

How poor planning left the UK without enough PPE | Free to read

Briefing template

Investigation into how government increased the number of ventilators available to the NHS in response to COVID-19

NEW STUDY: CURRENT PPE NOT FIT FOR PURPOSE

Statistics » Critical Care Bed Capacity and Urgent Operations Cancelled

Coronavirus: Surgeons told not to discuss lack of PPE | The Independent

How poor planning left the UK without enough PPE | Free to read