News from the Front Line 21.04.20.

We are being fed a narrative. The story is that “we are all in it together.” Like the “spirit of the Blitz”. But we are not. The Government is spinning a story to make itself look like the helpless victim of events outside its control, at worst. And in a superhuman flight of fancy, actually IN control at best. Meanwhile it has been systematically cutting NHS funding to the bone, ignored the findings of its own pandemic drill, Exercise Cygnus, and preferentially awarding contracts to firms which are big Tory Party donors, as we have reported in previous blogs.

We are not “all in it together” any more than, during World War II, our parents, grandparents and great-grandparents were. No wonder those who had borne the brunt of the war elected a government in 1945 that would introduce the National Health Service, the Welfare State and free education for all (to the age of 24 or more  for those who could benefit from it, thereby benefitting the country at the same time).

The Tory line is that everyone in the world wants PPE and ventilators, and it’s not the Government’s fault that there are shortages. “It’s a competitive market out there,” said Dominic Raab. Yes. But why then did the Government behave as though it had all the time in the world in January, and in February, and in March? On 13th April, The Guardian listed THIRTEEN occasions when the UK was invited to meetings with EU countries to share “bulk-buying” procurement of necessary items, and either attended but did not join in the shared action, or did not attend at all.

Meanwhile, the Government (finally) asks British Industry to help in the production of 30,000 more ventilators and the BBC reports on 26th March, that the Government has ordered from  Dyson (which makes vacuum cleaners). Rather than a firm in the medical equipment industry which already makes ventilators. The technology for sucking up dirt is quite different from that required for ventilating people whose lungs are not properly functioning, as I explained in an earlier blog; but Dyson is a friend and donor of the Tory party.

NHS budgets have been cut relentlessly since Thatcher was Prime Minister. Following the forecasting Exercise Cygnus, the government’s advisers recommended that in the event of a pandemic , personal protective equipment (PPE) should be provided “for all hospital, community, ambulance and social care staff who have close contact with pandemic influenza patients”. But recorded minutes of a then-Department of Health (now Dept Health and Social Care) meeting, quoted by The Guardian on 27th March, have revealed that in 2017 the advisers were told to “reconsider their advice” because of the cost involved: “following these recommendations would substantially increase the cost of the PPE component of the pandemic stockpile four-to six-fold”.

Then reports of deaths of frontline workers from Covid-19 start appearing in the press and on TV and Radio news. On 10th April Hancock says “PPE must be treated as a precious resource.” Can he be blaming the medical profession for wasting PPE? On 11th April nineteen deaths are recorded among health care workers. This is the day after the press were told that it was inappropriate to record such information.

17th April BBC News announces medics have been asked to re-use gowns. Some hospitals report that they will run out in 24 hours. Then the following day Sky News also reports that NHS staff were advised to “re-use PPE ahead of the expected weekend shortage.”

Public Health England (PHE) guidelines until now were that doctors and nurses treating Covid-19 patients should work with protective, waterproof, full length surgical gowns, plus a mask, a visor or goggles and double gloves – so that droplets containing the virus did not get into their mouths or noses.

These guidelines have now been reversed and doctors and nurses asked to wear washable medical gowns, or non fluid-repellent equipment, with a thin plastic apron when proper gowns run out.

An anaesthetist after a shift reported to us that Intensive Therapy Unit (ITU) nurses were still using bin-liners as improvised PPE. And that a lot of the outsourced staff had totally inadequate protection. He confirmed that the big issue was PPE and the other consumables: drugs, infusion equipment, breathing systems, and body bags – as well as experienced ITU nurses, and hardware like haemofilters” (which are used to do the work of the kidneys in intensive care in the case of renal failure).

Although the Guardian is the main source of our timescale, the same newspaper gave Chris Hopson of NHS Providers a platform to start re-framing the PPE shortages and to try and blame the shortages on China. Our informant told us that the shortages were predictable and avoidable, and far more widespread than we realised. It seemed to him that Number 10 was controlling the news agenda: stories about the nurses who took care of Johnson displaced criticism that could have been made when the death toll passed 10,000; and  deaths in New Hampshire displaced the news of dead NHS workers.

No employer should ask staff to undertake work that is unsafe for them – and in the case of Covid-19, unsafe for patients. Doctors and nurses are within their rights to refuse to endanger themselves. Nursing Notes on 26th March reported that the British Medical Association’s Chair of Council, Dr Chaand Nagpaul had said: “A construction worker wouldn’t be allowed to work without a hard hat and proper boots. Even a bee-keeper wouldn’t inspect a hive without proper protective clothing. And yet this Government expects NHS staff to put themselves at risk of serious illness, or even death, by treating highly infectious Covid-19 patients without wearing proper protection. This is totally unacceptable.” So far, however, neither the BMA nor the Royal College of Nursing has called on workers to refuse to work without proper PPE.

We – and they – must support staff who do refuse to run major risks, and place the blame where it lies.

The anaesthetist we spoke to said that the Tories had mismanaged COVID on a monumental scale. The UK has far fewer ITU beds than other EU countries. He told us that Hancock thought putting ventilators next to beds created thousands more ITU beds: he didn’t realise you need other equipment and trained staff! (this is the Minister of Health.) And then he lied to the public, saying there were thousands of empty ITU beds. He doesn’t realise there’s more to intensive care than ventilators. The doctor told us they had run out of equipment, staff, drugs and PPE…. And his department agreed that they could not allow colleagues to be coerced into entering ITU areas without adequate PPE.

Later he went on to say that that we never had the resources to provide intensive care on the scale required…. That rationing care was something nobody wanted to do, but that it was impossible to provide safe care on the scale required. This was always going to happen. It was already happening with haemofiltration. There are not enough machines for the number of patients with renal failure. They are now moving devices (intended for continuous use) around between patients, giving them intermittent filtration, which would be impossible to defend at an inquest.

Hancock has tried to grandstand, with rhetoric about being on a war footing. It would have been better to have used eligibility criteria for organ support but the Tories worried about adverse PR and headlines eg about age discrimination. So instead of any criteria, it is a case of first come first served. The worst sort of rationing.