1. The BMA views the procurement and distribution failings during the pandemic in two parts: first, woefully inadequate preparation; and second, a lack of timely action in the early months of 2020, compounded by a number of flawed and ill-judged decisions. 

Pre-pandemic preparations

2. Starting with preparations, the PPE stockpile was not fit for purpose. The quantities of stock were far too low, and in order to have mitigated supply chain disruptions, it needed far more than just a few weeks of supply.  

3. The blinkered focus on an influenza pandemic was another serious flaw which resulted in a stockpile seriously deficient in respiratory protective equipment.

4. A further flaw of the stockpile was that it had not been properly maintained. Large numbers of items had either expired or the expiry date was unknown. In Wales, for example, a shocking 90% of FFP3 respirators in the stockpile were out of date. Staff were provided with PPE bearing multiple expiry date stickers which, exacerbated by a lack of communication, completely undermined trust and confidence.  

5. To have relied upon such a small, inadequate, and poorly maintained stockpile, based on a contingency of Just in Time overseas supply, was utterly ludicrous. It was entirely predictable that supply chains would be disrupted in the event of a global pandemic and that this disruption would last for months not weeks.  

6. Three key mitigations would have been: a larger and more diverse stockpile; the ability to stand up domestic manufacturing capability; and stronger direct links with overseas manufacturers rather than relying on contracts with distributors, which quickly collapsed. 

7. Other failings of preparedness, beyond the PPE stockpile, include:

• Ventilator shortages – the UK had far fewer ventilators compared to other countries, a limited understanding of the number of ventilators that were available, and no existing domestic manufacturing. In the first wave of the pandemic, staff and patients did not have access to the ventilators they needed, when they needed them. Localised shortages meant that anaesthesia machines, which are only designed to be used for a few hours at a time, were repurposed and substituted for ventilators, and as described by Professor Moonesinghe, this would have potentially impacted the quality of patient care. In Module 3, Professor Fong described visiting a hospital in which three patients needed establishing on ventilators but there was no room or spare staff to do so, resulting in several patients being transferred. Similarly, in this module, Lord Agnew explained that ventilator availability played a role in whether ambulances could be sent to certain hospitals. In addition to impacting patient care, these localised ventilator shortages also caused additional stress, anxiety and moral injury for staff.
• The lack of an inventory system that recorded PPE and the equipment meant that it was not known what each NHS Trust or Board held, let alone other healthcare settings such as primary, community or social care.
• And a supply chain that was unfit for purpose, with warehouses designed to hold only three weeks’ worth of stock and no plan to distribute items to the 58,000 primary, community, and social care settings in England alone that were relying on this lifesaving equipment.

Early months of 2020

8. Moving to the lack of action in the early months of 2020. Despite knowing about the threat of Covid-19 since late December 2019, it was not until early March that it was accepted that the ‘Just in Time’ contracts would fail and that the NHS Supply Chain would not be able to cope with demand for PPE, leading to a desperate scramble to set up an entirely new PPE procurement and distribution system, while simultaneously trying to acquire and distribute PPE and respond to the QUOTE “avalanche” of offers that resulted from the PPE call to arms in April 2020 . In the words of Andy Wood, of the Cabinet Office “we had to build the aeroplane as we were flying it”.   

9. The Inquiry has heard that the additional procurement staff needed for the new system were not put in place until around 21 March 2020, just two days before the UK entered lockdown. As described by Sir Gareth Rhys Williams, this initial lack of a procurement workforce led to substantial backlogs and a few hundred offers of PPE were left sitting unprocessed for a couple of weeks. For the healthcare staff forced to face a potentially deadly virus without any protection, particularly in the early months, it is painful think what difference these unprocessed offers may have made.  

10. Similarly, no proper data management systems for managing PPE offers were set up until 09 April 2020, prior to which staff struggled with an Excel spreadsheet containing nearly 1.4 million pieces of data, which did not have the functionality needed for staff to be able to effectively prioritise and manage the offers they were receiving.  

Flawed and ill-judged decisions

11. Alongside the lack of timely action, there were a number of seriously flawed decisions, and for present purposes we focus on just two. 

High Priority Lane

12. First, the High Priority Lane. It undoubtedly created the perception among both the public and healthcare workers alike that ministerial contacts were receiving preferential treatment at the expense of other potential suppliers and has caused significant damage to trust in public procurement processes. This concern was entirely predictable and avoidable and will, we suggest, be a key area for future learning. 

13. Another consequence of this perceived bias is that it has detracted from the tremendous contribution of the many civil servants brought in to deliver the new procurement system, who were working 16-18 hour days to procure PPE for frontline healthcare workers. 

Use of IPC guidance to restrict RPE use

14. The second area of flawed decision making is the use of the IPC guidance to restrict the provision of respiratory protective equipment based on a lack of supply, rather than safety. This is described within the DHSC’s own PPE Supply and Demand report as a measure to ‘reduce demand with policy’.    

15. Within disclosed email correspondence and meeting minutes there is ample evidence that senior decision makers knew in January and February 2020 that the stockpile was lacking in FFP3 respirators, that there would be a worldwide shortage with no means of procuring sufficient numbers for many months, and that fluid resistant surgical masks would not protect healthcare workers against an airborne virus. For example, emails sent during this period by Professor Jonathan Van Tam and Dr Lisa Ritchie demonstrate the awareness of decision makers that, in the context of FFP3 shortages, staff access to this vital equipment would need to be managed.   

16. What should have happened at this point was for senior decision makers to have had the courage to honestly explain to healthcare workers that the country simply didn’t have sufficient numbers of this equipment, that they would be rationed to the highest risk settings and procedures, and that everything possible was being done to procure adequate supplies. As Mr Mortimer of the NHS Confederation, told the Inquiry last week, healthcare workers, “appreciate the truth and would have been, and would still be, much more accepting of a truthful approach”. A view that was also strongly expressed by Dr Barry Jones in his Module 3 evidence.   

17. Instead, healthcare workers were subjected to the following irrational decisions:

• Nonsensical FFP3 ordering restrictions placed on NHS Trusts in February 2020 which limited orders to the preceding 12 months business-as-usual demand, despite being on the cusp of the pandemic. 
• Changes to the IPC guidance (produced by the four nation IPC cell) on 13 March 2020 at the height of concerns about FFP3 shortages, limiting their use to ICU settings and Aerosol Generating Procedures. This was six days before NERVTAG declassified Covid-19 as a High Consequence Infectious Disease (HCID) on 19 March 2020. The decision to restrict the use of FFP3 was a decision based on lack of supply not good science and clinical practice. And it bears repeating that this meant that a healthcare worker providing close contact care to a Covid-19 patient was only provided with a flimsy surgical mask rather than an FFP3 respirator. This was in no way a decision that protected staff and patients but was the rationing and demand management of essential safety equipment because of shortages, as set out in the DHSC’s PPE Supply and Demand Report at INQ000339131.
• A final example is the PPE demand modelling and subsequent procurement decisions as the pandemic progressed based on QUOTE ‘real usage’ of PPE. This was illogical given the known acute shortages of PPE and, as the oral evidence of Rosemary Gallagher identified, staff were very sparing in their use of PPE because they didn’t want to run down stocks for colleagues. 

18. This failure to honestly and openly explain the nature of the problem had two profound consequences. First, those responsible for procurement did so based on false and supressed demand, which incredibly led to a stop order of further FFP3 on 30 June 2020, whereas all that had been procured at this stage was sufficient FFP3 for ICU settings, not more general settings.  

19. Second, healthcare workers knew that they were being let down, that they were not being properly protected, and that decision makers were not being honest with them. This has caused a serious breach of trust and confidence, which is ongoing, and will not be resolved until there is an acknowledgment of the truth and a change to the IPC guidance, which to this day continues inappropriately to only recommend flimsy surgical masks for staff treating Covid-19  not the FFP3 needed to protect them against an airborne virus.  

Turning to impact on staff and patients

20. Healthcare workers described living in constant fear for their own lives and the lives of their patients, colleagues and loved ones. As one doctor told the BMA, “I felt that my personal health and my life, and the health of my family didn't matter to anyone”.  

21. Access to PPE varied widely between healthcare settings, and the focus on secondary care meant that primary, community and social care faced particular challenges with keeping their staff and patients safe, particularly in the early stages of the pandemic.  

22. As a result of a lack of protection, large numbers of staff and patients were infected with Covid-19. 

23. Significant numbers developed Long Covid and continue to experience the effects on their personal and professional lives. A consultant told the BMA that “I contracted Covid-19 in my workplace due to lack of appropriate PPE. As a result, I have suffered Long Covid and following relapse have not been able to work for 5 months. This has been devastating to lose my ability to work in a job that I love”. Similarly, in Module 3 the Inquiry heard from Nicola Ritchie, a physiotherapist who requested to use FFP3 while providing Covid care but was denied this protection based on the IPC guidance. Ms Ritchie developed Long Covid, continues to experience poor health, and is unable to resume her career. 

24. Tragically many staff who did not have access to PPE or the right PPE died, and there have also been significant numbers of deaths from nosocomial infections. 

25. In respect of equalities issues, female and ethnic minority staff experienced disproportionate difficulties in accessing well-fitting respiratory protection. Some witnesses have suggested that this problem was not known prior to the pandemic. However, guidance from the Health and Safety Executive published in 2013 highlighted that one size of respiratory protection will not fit all face shapes and sizes, and that differences will be more significant along lines of gender and ethnicity. It is important to stress that this is not simply a preference for a specific mask, a properly fitting respirator saves lives and is fundamental to safety. The Inquiry’s Module 1 report concluded that pandemic planning did not properly consider inequalities and had too narrow a view of vulnerability – and the lack of diverse PPE procurement is a glaring example of this failure. 

We wish to highlight the following recommendations

26. First and fundamentally, the UK’s pandemic preparedness needs to take a precautionary approach to the use of PPE and other equipment, and this includes having a much larger stockpile of PPE, with a wider range of items suitable for a broad range of pathogens. It needs to be properly maintained, its contents need to reflect the diversity of the workforce, and there needs to be a plan to swiftly distribute key equipment to all health and care settings. 

27. Second, there needs to be a fundamental change to the UK’s reliance on ‘Just in Time’ contracts. This includes stronger links with manufacturers in a diverse range of countries, as well as domestic manufacturing capability.  

28. Third, there need to be improvements in the information available to decision-makers during a crisis, most obviously with inventory management systems. 

29. Fourth, there needs to be greater clinical and end-user input and product specifications and procurement processes need to incorporate frontline clinical input from the outset.  

30. Fifth, steps must be taken to ensure that in a future pandemic, healthcare staff have access to the vital equipment they need to protect lives. This includes ensuring reliable oxygen supplies through upgrades to hospital estates as well as ensuring sufficient ventilator supply alongside the beds and staff capacity needed to support their use in a pandemic.     

31. And sixth and finally, to reinforce the need for transparency and honesty. Trust has been severely damaged by failings in PPE provision, the IPC guidance being used as a tool to ration access to PPE, and perceptions of preferential treatment through the High Priority Lane, and there is an urgent need to restore it.