Closing statement made by the BMA, 13 December 2023

1. This statement focuses on the impacts of government decisions on doctors and healthcare workers. The BMA recognises that a pandemic will necessarily be challenging for healthcare and public health systems and their staff. However, the scale and severity of the impact of Covid-19 was not inevitable and was made worse by poor government decisions.

2. The UK Government was slow to act, too quick to ease protections, it failed to adopt a precautionary approach, failed to adequately consider the impact of decisions on those at greatest risk, and its response to the pandemic was significantly hampered and restricted by a lack of NHS and public health capacity.

NHS capacity

3. Regarding NHS capacity the Inquiry has heard a lot of evidence across Modules 1 and 2, about the importance of NHS capacity in responding to a pandemic.

4. The response of Sajid Javid to your question, about lessons learned, typifies this shared view. He said:

“in responding to a pandemic…your available health capacity has a big…determinant.... We don’t have many beds per head in the UK, in England for example…it’s around 100,000. If you look at countries like Germany, France, other comparable countries… they have more than double, triple, sometimes quadruple the number of beds that we’ve got. Similar for ventilator units, ICU units, doctors and nurses per head…NHS capacity is absolutely key to dealing with the next pandemic”.

5. Similarly, the Inquiry’s summary of references to the likely impact of the pandemic on the NHS within government meetings and communications between 14 February and 22 March demonstrate the significance of this issue. There are 47 references to NHS capacity in March alone, including the compelling evidence from 22 March that in the worst-case scenario ITU capacity in London would be overwhelmed in just nine days.

6. This rapidly deteriorating position and the limited available capacity forced the hand of decision-makers. The 16 March measures might have succeeded in bringing down the R number, but the NHS was so close to being overwhelmed that there was no time to wait and assess their impact, and the UK went into a mandatory lockdown a week later.

Impact on doctors and healthcare workers

7. Within this system, that was already stretched to breaking point, doctors and healthcare workers were vulnerable and exposed. They were described as the ‘canary in the coalmine’ because they are the first group to be infected; and their risk of infection was six times greater than in the general population. They are the essential component of the NHS without which numbers of ICU and hospital beds are meaningless, and yet they were inadequately protected throughout.

8. The failure to provide adequate protection against the risks of aerosol transmission is an issue of serious and ongoing concern, and one which the BMA has repeatedly raised before the Inquiry.

9. Despite it being predictable in February that the virus would transmit by aerosol, the requirement for FFP3 respirators when treating patients with Covid-19 was downgraded in March to fluid resistant surgical masks (which do not protect from airborne transmission and are not PPE) and this remains the position in England today.

10. The evidence of Professor Catherine Noakes supports the view that aerosol transmission was overlooked in favour of droplet transmission. Paragraph 10.11 of her witness statement suggests a number of reasons for the reluctance to fully acknowledge this risk, including the significant resource and operational implications for hospital infection control measures.

11. It is perplexing that, just at the point when airborne transmission was becoming more widely acknowledged, a stop order was placed on further procurement of FFP3 respirators from 30 June 2020, when a July 2020 survey by the BMA found that shortages of respirators remained. The failure to adequately respond to the risk of aerosol transmission has had a direct impact on the protection of healthcare workers with 40% of respondents to a BMA survey reporting as late as July 2021 that they were not being provided with respirators despite working with Covid-19 patients.

12. In this regard, the BMA invites the Inquiry to consider the extent to which considerations of cost and practicality were prioritised over safety.

13. There is also little evidence that the potential personal impacts on doctors and other healthcare workers were considered by decision-makers. All too often the risks to the NHS were characterised as organisational, for example, references to the NHS becoming overwhelmed or the need to save the NHS, without consideration of the personal circumstances and risks taken by the people who work in it.

14. This tendency can be seen in an email chain between Number 10 and the Cabinet Office over the 13 and 14 April (referred to in the evidence of Simon Ridley and since published by the Inquiry). The emails raised concerns at reports that 20% of infections, and 10% of deaths were due to infections acquired in hospitals and that while by this time the R number had been brought below 1 within the community, it was still above 1 in hospitals and care homes. Notably these concerns were not raised in the context of patient and staff safety, but with reference to workforce absences, stories about PPE in the media and the need to avoid delaying the lifting of social measures. There was no expression of concern for the safety of the people working and being cared for in these environments and the reported response of the Department of Health and Social Care was that this was not an issue of concern.

15. Meanwhile, and as described in evidence by Professor Banfield of the BMA, doctors were updating their wills and making sure their life insurance was up to date.

16. The witness statement of Helen Macnamara demonstrates real insight into this issue, at paragraph 89, where she states:

“We kept being told that NHS capacity was elastic. My concern was that even if it was elastic that was not the same as it being infinite…It was only much later that I realised that what was meant by NHS capacity being elastic was the capacity of people working in the NHS to work themselves into the ground to keep people alive. So yes, they would cope, but the knock-on impact of that would be the consequences for the people involved. We had thought we would see the consequences of a broken NHS in the winter 2020/21. I fear that it took longer for the break to show, and we are living with the consequences of stretching it too far in terms of what is happening now.”

17. These consequences include historically high levels of waiting lists, a crisis in staff retention and recruitment, significant numbers of doctors still suffering from long covid, and moral distress and injury for doctors and other healthcare workers who felt unable to provide the right level of care, including for their non-Covid patients.

18. Finally on impact, the Inquiry is aware of the disproportionate impact of the virus on people from ethnic minority backgrounds, and of the shocking statistics in this area, including analysis by the Health Service Journal which found that 94% of doctors who died with Covid up to April 2020 were from ethnic minority backgrounds, even though this group makes up only 44% of NHS medical staff.

19. The Inquiry has heard evidence about the review by Public Health England into disparities, and particularly the impact of the pandemic on ethnic minority groups, published in June 2020. However, there has been little evidence of any tangible steps taken by Government and Ministers to address these disparities.

Public health capacity

20. Another key area where a lack of capacity significantly hampered the UK’s ability to respond to the pandemic, is the lack of public health capacity, including, crucially, testing and contact tracing.

21. The UK entered the pandemic with inadequate test and trace capability, exacerbated by many years of underfunding in local and national public health, which meant that Public Health England was unable to rapidly scale up its contact tracing capacity when Covid-19 emerged as a threat. This greatly limited the options available to decision makers, including actions to contain and suppress the virus.

22. Public Health England did in fact call for greater capacity and resources from at least the 12 February, but these calls do not appear to have been acted upon.

23. Such was the lack of focus in this area, that politicians, including Matt Hancock and Boris Johnson told the Inquiry that they had wrongly assumed that the necessary testing and contact tracing capacity existed, only to find that it needed to be built mid-pandemic.

24. The reason given for the decision to abandon test and trace on 12 March was because the UK was moving from the contain to the delay phase of the pandemic response. However, the reality is that there was no meaningful testing capability and what little testing capacity existed at this time was needed for healthcare settings.

25. The Inquiry has heard about the relative success of South Korea, which operated a more effective test and trace system, partly because of their previous experience of MERS. Just as South Korea learned from MERS, it will be important that the UK learns from the Covid-19 pandemic, and maintains sufficient test and trace capacity and capability, so that future decision makers have this essential tool available to them. However, there are signs that vital pandemic infrastructure has already started to be dismantled, something raised as a significant concern by Sajid Javid in his evidence.

26. A final point about public health relates to the range and diversity of the scientific advice available to government. In his witness statement Professor Banfield raised concern at a lack of independent public health expertise within SAGE. And Professor Peter Horby told the Inquiry that it would have been helpful to SAGE to have had greater expertise from frontline public health practitioners because, while there were people in the room with public health expertise, “that’s different from being at the frontline running a public health department in a local council or on the ground”. He said that science needs to be placed in both the policy context and the operational context, and that this would have helped refine the advice given.

The timing of early decisions

27. Regarding the timing of decisions in the early months of 2020, it is clear that much of February was lost to confusion and indecision. While a number of factors likely contributed to this, the BMA suggests that an area of focus for the Inquiry should be on the way that risk was communicated.

28. Boris Johnson was briefed on 4 February that a reasonable worst-case scenario would be up to 300,000 deaths, but it was not until a paper was produced on 28 February in which the reasonable worst-case scenario of 520,000 deaths was posited that he became alarmed. During this period the probability of the worst-case scenario occurring increased from 10% in early February to the expression used on 28 February, of “increasingly likely...although...not yet certain”. A number of witnesses have referred to the difficulties in expressing and communicating probability. Professor Whitty said that when probability was expressed in remote terms it can lead to an underestimation of the risk, and Lord Stevens said that during February there was a lot of ambiguity about the probability of the reasonable worst-case happening, and there needed to be greater clarity.

29. For the ultimate decision maker not to have fully understood the nature of such a serious threat suggests the need for better understanding and communication of risks within government.

30. That this was a collective and not just an individual failure is made clear by the widespread shock over the weekend of 13 to 15 March, as the centre (No 10 and Cabinet Office) were confronted by the realisation that the reasonable worst-case scenario would materialise much sooner than had been thought, with the very real prospect of the NHS becoming overwhelmed. This shock was described by Professor Halpern as a bolt from the blue, the penny had dropped.

31. All of this calls for serious consideration of a more refined approach to risk assessment and to the communication of risk, as suggested by Professor Horby.

The failure to take a precautionary approach

32. Over the entire period of the pandemic there was a failure to take a sufficiently precautionary approach. This is evident on a range of issues, including asymptomatic and aerosol transmission, the delay in imposing protective measures, and in seeking to open up too soon, and too quickly.

33. A more precautionary approach, for example through a focus on ventilation and mask wearing, could have been taken without significant economic impact, and, at key moments of easing throughout the pandemic, the BMA called for such an approach, which generally was not heeded.

The failure to learn lessons and adequately prepare for the second/subsequent waves

34. There is little evidence that the UK Government learned from the mistakes of the first wave leading into the inevitable second wave, despite the wide acknowledgement that it had the potential to be even worse than the first, and at a time when vaccines remained unavailable.

35. Instead, the country opened up too quickly, typified by the reckless Eat Out to Help Out initiative which was decided without scientific input despite the obvious risk of adversely impacting Covid transmission rates, and in which respect a study from 2020 suggests it was responsible for between 8-17% of new infections.

36. Once cases began to rise again, the delays and indecision through the Summer and Autumn of 2020 necessitated a further national lockdown. This was rightly referred to by Professor Angela McLean as a terrible moment, and powerfully described in her evidence, in these terms, “we delay and delay a decision, and then we have to slam the brakes on as hard as possible with the attendant social costs and economic costs”.

37. Sadly, this lack of a precautionary approach and failure to learn from mistakes continued throughout the pandemic, including through the summer of 2021, when the government encouraged the freedom narrative which contributed to the widespread view that the virus had been fully contained, only for protective measures to be required once again in December 2021 in response to the Omicron variant.

Conclusion

38. As a concluding point, it is accepted that there was a need to take account of the economic impact of the pandemic, however, there was a tendency towards a false dichotomy that the choice was between public health and the economy, when in reality these were inextricably linked.

39. It was possible to have better protected both public health and the economy, and the economy would have been supported not undermined by more precautionary public health measures. Given the inevitability of further pandemics there is an urgent need to find this balance. It will involve increasing NHS and public health capacity, coherent risk-based planning and strategies, and a precautionary approach that protects those most at risk.