Closing statement made by the BMA, 19 July 2023

1. After six weeks of hearings, it is clear that the UK entered the pandemic with critically under-resourced and under-funded health and public health services, and that there were repeated failures in pandemic planning and preparedness, including in relation to the PPE stockpile and the implementation of recommendations and learning from previous pandemic planning exercises. These failures gravely hampered the pandemic response and placed doctors, other healthcare workers and patients at increased risk when the pandemic hit. 
2. This statement highlights four key areas of deficiency in pandemic planning and resilience – first, the failure to ensure that doctors and healthcare workers were adequately protected when responding to a pandemic, second, the lack of capacity and resourcing available to provide an effective response, third, the specific failure to ensure there was an adequate test and trace response, and fourth, the government structures and processes in place for civil contingencies.  
3. Dealing first with the issue of the provision of PPE to doctors and other healthcare workers. The Inquiry has heard repeatedly in this Module that the planning for PPE, including the stockpile, was inadequate for a pandemic event. 
4. This, coupled with the distressing accounts of healthcare workers about the circumstances in which they were required to work without adequate protection while exposed to a deadly disease, is damning evidence.     
5. Right from the outset of the pandemic there was huge concern within the BMA’s membership about this issue, with doctors describing how they were instructed to remove their masks, accused of scaremongering, and others expressing concern at the absence of FFP3 respirators, and the inadequate consideration given to the risks of aerosol transmission. One GP from England told the BMA that: 
   
   "We were seeing patients who had COVID but because of the advice that was behind the curve, they were deemed to be low risk…We needed proper protection with FFP3 masks, but these were not considered necessary and were not provided. It was in April 2020, whilst wearing inadequate PPE that I caught coronavirus from a patient.”  ​
6. Tragically, there are doctors and healthcare workers who died because of Covid-19 infection acquired in their workplace, and significant numbers are suffering from long-Covid. 
7. The BMA has very recently (on 4 July 2023) published a report about the impact of long-Covid, titled, “Over-exposed and under-protected: the long-term impact of Covid-19 on doctors”, which is informed by a survey of over 600 doctors suffering from long-Covid. The report establishes that a lack of preparedness for a pandemic, and poor risk-management in health services contributed to many doctors contracting Covid-19 at work. 
8. A key finding of this report is the lack of access by staff to FFP3 respirators, which are the type of filtering face piece respirators that provide maximum protection from infection transmitted by aerosol. 77% of the respondents to the BMA survey who acquired a Covid-19 infection in the first wave of the pandemic believe that they were infected while at work, and only 16% of respondents had access to these more protective FFP3 respirators at the time they were infected. 
9. There is evidence before the Inquiry that this lack of availability of FFP3 respirators was because cost considerations were prioritised ahead of safety, leaving doctors and healthcare workers inadequately protected while delivering healthcare.  
10.  And it’s not just a question of volumes of PPE, there was also a failure to ensure that there was PPE available to suit a diverse range of facial features, including for smaller, often female face shapes, for staff from some ethnic minority backgrounds and for staff who wear a beard or hair covering for religious reasons. Respondents to BMA surveys during the pandemic were more likely to report failed fit testing of respirators if they were from ethnic minority backgrounds as these are usually manufactured for white, male face types. Clara Swinson, Director General at the Department of Health and Social Care, accepted that these issues were not adequately considered as part of pandemic planning prior to Covid-19.
11.  The BMA’s position is that the adequacy of the PPE stockpile is firmly within the scope of Module 1 as a matter of planning and preparedness. However, it also recognises that PPE is a cross-cutting issue with relevance to Modules 2, 3, and 5, and that in these circumstances you will not yet be able to make final findings and recommendations about where responsibility lies, and why the stockpile remained deficient for so long in the knowledge of the risks posed to healthcare workers.    
12.  Nevertheless, it will be important, in the BMA’s submission, that this appalling failure to protect doctors and other healthcare workers is reflected within the Inquiry’s Module 1 report.  
13.  Similarly, healthcare workers, including those more vulnerable to Covid-19, for example due to factors such as age, ethnicity, sex or underlying health conditions, did not receive timely and adequate workplace risk assessments which could, if undertaken and acted upon, have prevented the death and long-term illness of some workers. 
14. The UK Government failed to ensure that employers met their responsibilities under health and safety law and did not provide sufficient guidance or support for employers to undertake risks assessments.  
15.  The BMA raised concerns on multiple occasions that these legally required risk assessments were not being undertaken within healthcare settings. However, it was not until 24 June 2020, three months into the pandemic, that NHS England issued a letter reminding employers to undertake risk assessments for their staff. In these circumstances the BMA felt compelled to develop its own risk assessment tool for healthcare environments, and the fact that it was required to take this step, is clear evidence of the failure to plan and prepare to keep healthcare workers safe in their place of work.   
16. In relation to capacity and resources, the Inquiry has been told that in addition to adequate planning, it is necessary to have the resilience and the resources to implement the plans and to pivot and adapt, in response to changing circumstances. On Monday, in his evidence, the current Chair of the BMA’s UK Council, Professor Banfield, told the inquiry that the BMA had for a number of years been highlighting the issue of capacity within the health service to all four governments and raising concerns that prior to the pandemic there wasn’t the capacity needed to run the health services as it was. 
17. He is not alone in this regard, and over the course of the hearings, the Inquiry has heard from numerous witnesses across a range of fields of expertise that public health and health services in the UK are suffering from a lack of resources, equipment and capacity which impacted their ability to respond to the Covid-19 pandemic. These have included: 
    
    
    • Professor Heymann, who noted that preparedness is not just about a strong public health system and discussed the need for NHS surge capacity. 
      
      
    • One of the key recommendations from Professor Whitworth was to have sufficient reserve capacity within the health system. 
      
      
    • Dr Marmot & Professor Bambra talked about how the funding of healthcare has been inadequate since 2010 and waiting times have doubled.  
      
      
    • Dame Sally Davies commented that there was no resilience in the NHS and that compared to similar countries the UK was bottom of the table on numbers of doctors, nurses, beds, intensive care units, respirators and ventilators.  
      
      
    • Jeremy Hunt, the former Secretary of State of Health told the Inquiry that he became convinced as Health Secretary that the NHS needed more capacity.
       
    • Rosemary Gallagher from the Royal College of Nursing spoke about how workforce resilience is essential in order to deliver healthcare services and that the UK went into the pandemic 50,000 nurses short which put staff at risk when seeking to surge capacity.  
      
      
    • Nigel Edwards of the Nuffield Trust told the Inquiry that some hospitals had to make very major engineering and structural changes to accommodate high flow oxygen at the outset of the pandemic, a point echoed by Professor Banfield in his evidence. This, he said, indicated a broader issue about the way hospitals have been designed and built in the UK, which is to strip out any kind of redundancy, to compress spaces that are available, to save money where that is possible by reducing to the lowest tolerance that sits within the guidance. 
       
    • Mr Edwards also said that many health systems, but the UK in particular, have traditionally run with very low margins of spare capacity, which means that having a plan for how to deal with a sudden surge or emergency is very important, but it also limits the scope of that plan because the level of spare capacity in the system is relatively low. 
      
      
    • Dame Jenny Harries referred to a 40% reduction in the funding of Public Health England in real terms over the course of its life. 
      
      
    • And Sir Jeremy Farrar, the Chief Scientist at the World Health Organisation, sets out in in his witness statement that public health, clinical care, care homes, health services and the NHS were chronically underfunded for what they were expected to deliver during the period 2010-2020. Efficiency was the singular focus and spare capacity, resilience, and support for the staff within the NHS and all allied services was neglected. He said, “This was a system that was not really coping with normal pressures and there was no spare capacity when a crisis hit.” 
    
    
18.  The Inquiry has also heard about specific concerns that the public health system was hindered in their pandemic response because of the continuing impact of the structural reforms introduced in England by the 2012 Health and Social Care Act, which fragmented the system and fractured links between public health and NHS colleagues, and of the subsequent years of budget reductions and funding cuts. As early as 2011 (prior to the implementation of these reforms), in response to the consultation on the government’s influenza pandemic preparedness strategy, the BMA had raised concerns that the proposed reorganisation of the NHS and the public health system which would result from the Act jeopardised a coordinated and integrated approach and asked the government to consider the knock-on effects of these reforms on the strategy. In the same response, the BMA also called for the involvement of public health doctors, with specialisms in health protection to be enshrined in the pandemic response system.
19.  Duncan Selbie, the former Chief Executive of Public Health England, agreed with Dame Jenny Harries that there was a ‘difficult transition’ and that the links between NHS staff and public health specialists became fractured and affected community infection prevention and control. He told the Inquiry that “one of [his] greatest regrets was that strengthening the relationship between public health and local government came at the expense of having removed that capability and experience from the NHS”. 
20.  Moving from resourcing to planning, the Inquiry also heard evidence about the dual failure to adequately plan for a coronavirus type pandemic, and separately to plan to prevent the spread of the disease (rather than simply manage its impact). A major consequence of these failures was that there was no contingency to carry out mass testing and tracing, leading to the abandonment of contact tracing on 12 March 2020 which left the UK without any effective measures for controlling the pandemic at this critical time. 
21.  However, the UK did have existing diagnostic capability, within 44 NHS laboratories that simply was not fully utilised, and Dr Kirchhelle’s evidence to the Inquiry, when asked about criticisms made of Public Health England that they had been reluctant to engage with private testing laboratory facilities, is instructive in this regard. He said: 
    
    “I think that in the UK case it’s a slightly odd criticism, because the UK has a significant sequencing public capability within the NHS and it also has significant sequencing capabilities within the university sector of which Public Health England were naturally aware because they were working with all of these laboratories prior to the pandemic…It’s very interesting to see the NHS capabilities perhaps not being used as strongly as some observers would have wanted them to be used in 2020”. 
    
22.  Similarly, there was significant expertise and capacity to carry out contact tracing within local authority public health functions, which again wasn’t properly utilised. Professor McManus, president of the Association of Directors of Public Health, told the Inquiry why it was so important to engage with Directors of Public Health, who were trained and expert in contact tracing and knew their local areas and local communities. He said “they have capabilities that could have been shaped rapidly, like on test and trace which improved markedly when local Directors of Public Health and local authorities became involved”. However, at the start of the pandemic the UK Government did not even have an up-to-date contact list for all of the Directors of Public Health.  
    
23.  Finally, turning briefly to the government systems and processes for ensuring resilience and preparedness, the BMA’s position is that there is an urgent need for clear accountabilities and responsibilities to be established. 
24.  The process by which learning from expert reports and exercises is implemented is woefully inadequate. Over the last 6 weeks, the Inquiry has questioned many witnesses about the failure to implement recommendations, and there are too many instances to mention in the time available, save to say that concerns and recommendations about the need to ensure adequate PPE, risk assessment processes, test and trace capability, and adequately resourced and staffed public health and health services, have been raised repeatedly since at least 2003 following the SARS outbreak, and yet by the time the pandemic struck almost two decades later, they had still not been properly implemented. 
25.  These failures are partly explained by the vacuum of responsibility for the implementation of recommendations. Public Health England told the Inquiry that they just ran the exercises but were not responsible for implementing their recommendations. Similarly, there was no clear process by which those who commissioned and instigated exercises knew whether and how recommendations had been put in place. An example of this being Exercise Alice instigated by the then Chief Medical Officer in 2016 in response to MERS.  
26.  The quality of decision-making, such as the composition of the PPE stockpile which was dictated by considerations of cost rather than safety, is also a serious cause for concern, particularly when considering the views expressed by Oliver Letwin, who told the Inquiry that the revolving door of ministerial and official appointments tends to undermine experience, efficacy, and the ability of ministers and officials to be able to do the job with which they are tasked. In this regard, the Inquiry has heard about a concerning lack of knowledge and awareness at senior levels within lead government departments, including in relation to key documents such as the 2011 UK Influenza Pandemic Preparedness Strategy.
27.  The Inquiry has also heard about failures to engage and to share information with key stakeholders, for example the Exercise Cygnus report, which was only published in 2020 following a judicial review challenge brought by a doctor. 
28.  Add all of this together: the failure to implement learning; the lack of clarity around roles and responsibilities; concerns about levels of knowledge and expertise; cost cutting; and a tendency towards unnecessary secrecy, and it was inevitable that there would be failures to plan and prepare properly. 
29. Sir Jeremy Farrar told the inquiry that we are living in a pandemic age, and before the next pandemic inevitably hits, there is an urgent need to establish clear and coherent decision-making processes, responsibilities, and accountability. In addition, it is imperative that key public services, in particular health and public health services, are safe working environments and are adequately resourced.