***RANT ALERT***
I am an NHS GP, and when a local school rang me as duty doctor for my 10,000 patients on Monday 24 February, to complain of a number of cases of a febrile illness, having returned 48 hours earlier from a half term ski trip to the Italian Alps - I suspected what we have come to know as Covid-19.
I declined them face to face appointments as we had no PPE, save for gloves. When central supplies did come, around a month later, they were expired “07/2016” and rebadged with a cheap sticker. And even then, all we got were some plastic pinnies and simple fluid repellent masks to last us about a week (when the WHO was advising FFP3 masks, visors, cuff covers and gowns). Batches of the rebadged masks were revealed last week to not be safe and practices advised to destroy them. But we had all used them up months ago. How many of us became unwell, and unwittingly passed on the virus to others? How many potentially died from that catastrophic failure to plan for the inevitable?
Even when, 20 years ago, as an undergraduate at UCL medical school, I had been taught by Prof Jim Ryan (Emeritus professor of conflict recovery). In a prescient day’s teaching in UCH ED, he had made us all wear PPE, and talked us through what we would need to do as frontline clinicians in a civilian emergency or global pandemic. He said these eventualities were as certain as cancer, heart attacks and strokes. Three years later he led the response at UCH during the 7/7 terrorist attacks and has been prominent throughout the WHO’s guidance on Covid-19. This should not have been a surprise. We had warning. We were lucky.
I’ve had the privilege to be in a leadership role for my profession for almost twenty years. I sat on the BMA’s UK GP committee during the 2009 H1N1 swine flu pandemic, and heard first hand then, how the medical profession liaised with public health, government and local authorities. How each winter we would plan for potential surges in excess mortality. Put aside stores of PPE and keep logistical plans on the shelf ready to be used out of the blue.
2020 has been starkly different to 2009. Years of austerity has cut any capacity there might have been in the NHS to rock bottom, systems are in deficit to the tunes of millions. As a GP, commissioners would like me and my colleagues to prescribe and investigate less, refer fewer, but see more patients and diagnose more cancer. Not an easy maths puzzle to solve.
Local authorities are in a parlous state, and we see that no more than in the multimorbid sequelae of those in poverty.
And what to bring on the UK after years of cuts to the public sector? The largest single episode of deliberate self harm that is Brexit.
Brexit prioritised politics over preparation. Those pandemic logistical action plans gathered dust. PPE allocations were swept aside as the country got itself in ever more debt, as a luxury we probably won’t need, so we probably shouldn’t bother with.
Public health has been decimated as a medical specialty over the past decade. Public Health England itself is a strange body that seemingly issues guidance but doesn’t have the mandate to ensure NHS England commissions it. And NHS England doesn’t have the funds to commission it. So it doesn’t. And public health is left in limbo - the hot potato thrown between EDs and general practice, when it belongs to neither, and neither are funded to provide it.
So when I declined to bring in the febrile ski trip that February morning, I called a panicked PHE for advice. We knew this was coming. We should have had ready stocks of PPE. We should have had notifiable illness algorithms to follow. We had neither.
In the absence of a reliable IgM diagnostic test we should have put in place a simple contract tracing policy. Contact tracing isn’t rocket science. It’s the preventative arm of every sexual health clinic in the world. It didn’t need to be difficult. It was bizarre to doctors that this wasn’t available.
In the absence of a reliable IgG antibody test, but knowing what we know about other family members of the coronaviridae, we should have put in place a policy of universal face mask use on public transport and in shops as far back as February. That ski trip returning from Italy should have had their temperature checked at Heathrow and been given advice as to what to do if they became unwell. Quarantine should have been enforced as it was for the Brits flown back from Wuhan. This isn’t the luxury of the retrospectoscope. Medical social media was alive with discussions and debates over these concerns as far back as February citing South Korea’s example.
I am privileged to be the GP who represents, supports and advises all the GPs and surgeries that care for the million patients across Cambridgeshire. In those early weeks the silence from government was deafening. My office issued practical advice on a weekly, if not daily basis to practices. We put in place a ‘No PPE No See’ policy on 10 March, rapidly transforming consultations to video and phone, undertaking essential emergency home visits in private PPE that GP organisations had sourced themselves at their own initial expense. Later on, government stated that they would refuse to reimburse any PPE that conferred ‘too much’ protection, only reimbursing the plastic pinnies, fluid repellent masks and gloves. Endless public goodwill came together to produce visors at cost price. Thank goodness for them. Three months on, despite promises from government, England’s GPs still haven’t received the essential Covid-19 Fund promised by the Treasury to cover additional costs for PPE, protective measures and staff costs. And we don’t like the look of winter.
And then it hit. And it was awful. Heartbreaking tragic stories have been shared across media. Those in caregiving roles will know of many more that didn’t reach print, but were no less painful, unfair and cruel. For some time it had been a worry about what would happen if and when outbreaks may take place in residential or nursing home settings. Some GP practices advised independent homes to put in place a lockdown prior to the government’s advice. In many cases, those decisions saved lives. But those care home staff (who often are on derisory contractual compensation for sickness absence) where was their PPE? Where was their ability to refuse known Covid positive patients into Covid negative care homes to clear those essential hospital beds for the next poor influx?
But it was ok! Because Boris Johnson clapped for us every Thursday. He doesn’t take the knee because he ‘doesn’t believe in gestures’ but he would happily clap for carers in front of cameras whilst scrapping those nurse bursaries which later had to be embarrassingly reinstated. And the public have generously donated over £130 million to a charity that will only give your little area of the NHS money if you pay their £1000/year membership fee. Which might be ok for those big hospitals and trusts, but no use to your local surgery, GP or independent community pharmacy. Anyway, at least we are led by a government following its own orders....
The Cummins affair made a mockery of the public health messages and were a grave misjudgement by a man who allegedly prides himself on being able to take the temperature of the nation. I hope the nation returns the sleight at the ballot box. But we get what we vote for, and Britain voted in December for a craven cabinet of sycophants who were prized only for their ability to nod their heads in unison to the leader’s latest ‘oven ready’ glib strapline.
In identifying where the government have gone wrong, it’s a struggle to understand where they have gone right?
Many of us GPs are now looking to Autumn and Winter with dread. To rolling out a socially distanced seasonal flu vaccination programme. We are trying to plan for how we can safely vaccinate the largest number. No sign of an SOP from NHS England as yet, of course. A government that refers to ‘Super Saturday’ clearly hasn’t thought enough about the other very real prospect of a novel pandemic influenza strain. It’s overdue.
But it probably won’t be this year, so let’s not worry about it eh? What’s the worst that can happen?
Erratum: @DrMikeRyan is far too young to have taught me 20 years ago! My mistake - I mean another Prof Ryan trauma surgery graduate from @ucddublin! The superlative Professor Jim Ryan -
www.linkedin.com/in/jim-ryan-50719171
