BMA speaking note closing oral statement, 27 November 2024

1. The evidence heard during this module has reinforced the BMA’s belief that, while a pandemic or health emergency is always likely to put enormous strain on healthcare systems and the people who work within them, the severity of the impact was not inevitable.

2. What is more, almost five years on from the start of the pandemic, the UK’s health systems are in an even worse position to cope with day-to-day care, let alone an emergency. Waiting lists across the UK are around 9.4 million, there are severe staff shortages, bed numbers remain far too low, the UK’s maintenance backlog sits at £17.3billion, staff mental health and morale is in crisis, and population health and inequalities have worsened.

3. Against this background, the task of your Inquiry has never been more urgent and critical, and this statement highlights the key areas of evidence that the BMA asks you to take into account as you develop your report.

4. It is in four main sections. First, the lack of capacity within the UK’s healthcare systems. Second, the failure to protect healthcare workers from harm. Third, impacts on staff and patients. And fourth, recommendations. 

Capacity

5. In respect of capacity, the Inquiry’s Module 1 report found that health and social care services were running close to, if not beyond, capacity in normal times.  

6. This lack of capacity includes insufficient numbers of staff and beds, as well as inadequate physical and digital infrastructure. And during the past ten weeks of hearings, this inescapable reality has been reinforced by almost every witness, including the Inquiry’s experts, all four CMOs and CNOs, the heads of all four health services, and the political leaders of all four governments.

7. It is vital that, when the next emergency occurs, the UK’s health systems start from a far more resilient baseline.

8. In respect of staffing, when the pandemic began the UK had a shortfall of around 40,000 doctors per capita compared to OECD averages. There were nearly 40,000 nursing vacancies in England alone, a shortage of around 2,000 midwives and obstetricians, 50% too few anaesthetists, a 10% critical care vacancy rate and too few GPs to meet patient demand.

9. In the words of a Consultant from a BMA survey, “What I needed most during the pandemic were the colleagues I was already missing”, and to redress this shortfall will take time and significant investment, because, as described by Professor Summers, you “can’t just magic up” the staff you need.

10. In addition, ageing estates meant that infection control measures could not always be fully implemented. Witnesses described working in unsuitable spaces, with large open bays, an inability to distance between beds, a lack of side room capacity to isolate patients, and a lack of ventilation. In the words of Michael McBride, there is “no doubt” that the fabric of NHS estates increased the risk of nosocomial infections. Over 9,000 deaths are attributable to nosocomial infection in England alone, and we have heard many moving stories of those whose loved ones were admitted to hospital in circumstances unconnected to Covid-19, only to become infected and tragically die.

11. Regarding the debate about whether the NHS was overwhelmed, the BMA points to the fact that vast swathes of care had to be cancelled and patients who would normally have received treatment did not. Healthcare workers were physically and emotionally overwhelmed and they still bear the scars today. To downplay these impacts, intentionally or not, is a mistake.

12. The BMA accepts that the decision to run the NHS in this way is a political one, however, the Inquiry proceedings have laid bare its catastrophic consequences, which are destined to be repeated without fundamental change.

Protection from harm

13. Moving to the failure to protect staff from harm. 

14. Witnesses including Professor Sir Chris Whitty and Dr Warne, have confirmed that healthcare workers were at higher risk of infection from Covid-19, and ONS data suggests that this increased risk was six times that of the general population. 

15. Despite this increased risk, the Health & Safety Executive abrogated its responsibility to protect staff by failing to challenge the adequacy of the IPC guidance, to act on concerns raised by organisations such as the BMA, and to ensure that employers complied with their health and safety responsibilities.

16. The HSE’s guidance on RIDDOR (the Reporting of Injuries, Diseases, and Dangerous Occurrences Regulations) inexplicably sought to discourage the reporting of infections by setting an unnecessarily high threshold for reporting. In the first two years of the pandemic, Medical Examiners found 357 cases of healthcare worker deaths from workplace exposure in England alone, compared to just 170 deaths reported through RIDDOR in England, Wales and Scotland combined. Indeed, BMA analysis of ONS data found that the number of healthcare workers who died during the pandemic may be almost five times higher than the number reported through RIDDOR.
 
17. Accurate, detailed and transparent reporting is vital to understand the spread of infections, to ensure workplace safety, to facilitate access to compensation for staff with Long Covid, and to recognise and pay tribute to healthcare workers who died while caring for others. And in this latter regard, the approach of the NHS during the pandemic is in stark contrast to the way in which other organisations such as the armed forces, police force and fire service honour those who die in service. 

18. In relation to PPE, some witnesses have stated that the UK never ran out of PPE, and that the problems were with distribution. However, the BMA’s position is that if a healthcare worker who needs PPE does not have it readily available, and is thereby exposed to risk of serious injury, then this is a PPE shortage, regardless of whether the problem relates to distribution or stock quantity.

19. The Inquiry has heard shocking evidence about the lengths to which healthcare workers were forced to go to source PPE, including wearing makeshift items out of bin bags, ski-masks, swimming goggles and cagoules, while others purchased equipment from DIY stores. In an example provided to the BMA by a GP in England, “We had no PPE. Our first delivery was a box of 20 masks…This was for a surgery of 22,000 patients and 50+ staff. We made our own face shields with the use of a 3D printer loaned to us and we made aprons from bin liners”.

20. In respect of Respiratory Protective Equipment such as FFP3, the Inquiry has been provided with a very significant amount of information about airborne transmission, and the BMA will address this issue in detail within its written closing statement. 

21. For present purposes the BMA simply restates its position, in light of the evidence heard during the hearings and briefly responds to points made by those who argue against the wider use of FFP3.
     
22. It was known prior to the pandemic that coronaviruses are transmissible through aerosols (not merely droplets), and that Respiratory Protective Equipment (RPE) provides far greater protection against an airborne virus than a Fluid Resistant Surgical Mask (indeed Fluid Resistant Surgical Masks are not even classified as PPE). The recommended RPE for routine treatment of SARS-CoV-1 in 2013 was FFP3, and decision-makers were aware from the very outset of the pandemic that SARS-CoV-2 could transmit via aerosol.

23. In response to this risk from a deadly disease a precautionary approach should have been taken through the recommended use of FFP3 for all staff caring for patients with, or suspected to have, Covid-19.

24. Instead, FFP3 was restricted to just intensive care and to Aerosol Generating Procedures through a combination of concerns that intensive care might run out of FFP3, fears that staff might refuse to work if the recommended RPE was not available, and an overreliance on droplet transmission.

25. Worse, once the evidence in support of aerosol transmission became clear, the IPC Cell stubbornly refused to change their approach, seemingly more worried about not wanting to look like they had got it wrong, and advancing before this Inquiry a series of ‘after the event’ justifications such as comfort and the need for further studies.

26. The BMA has been astonished by the doubts expressed at the effectiveness of FFP3 respirators. As mentioned, there is clear evidence of their superiority, and witnesses, including Inquiry experts, have provided evidence that those working in intensive care experienced lower levels of infection because of the enhanced protection available to them.

27. Further, if the efficacy of FFP3 is seriously in doubt, why are they recommended for intensive care and Aerosol Generating Procedures.

28. Attempts to justify the failure to recommend FFP3 based on considerations of comfort are equally surprising. PPE can be uncomfortable, but this is nothing balanced against the need to protect against a deadly disease transmitted by everyday actions such as coughing, sneezing, talking, and breathing.

29. These arguments are simply a continuation of the stubborn refusal to acknowledge the risks of aerosol transmission, to recognise that they got it wrong and to take remedial action.

30. In the words of a doctor in Scotland, “the PPE guidance was based not on safety, but rather the lack of preparedness. False platitudes of staff safety were peddled out, when in fact staff were left at higher risk”.

31. Staff confidence in the IPC guidance is essential for safety, and the widespread loss of confidence is a very serious concern. It is a matter of regret that the opportunity has not been taken to restore confidence by properly explaining the risks faced by staff and the extent to which supply shortages were a factor.

32. Importantly, Covid-19 is still circulating today, and staff still do not have access to adequate RPE. The IPC guidance in all four nations continues to recommend a Fluid Resistant Surgical Mask for routine care of Covid patients and while in Scotland and Wales, staff can request RPE if they have concerns, in the BMA’s view, this is not a sufficient guarantee of protection and is likely to exacerbate existing staff inequalities.

Impacts on staff and patients

33. This brings me to the third section; impacts on staff and patients.

34. Available data records over 860 covid related deaths of healthcare workers across the UK. But given there is no reliable system for recording this information, the true number is likely to be higher.

35. In addition, many staff continue to be severely impacted by Long Covid, leaving them unable to work, train and undertake day-to-day activities. Again, exact figures are not known but the latest ONS data from March 2023 estimates this to be 4.4% of the workforce, which is tens of thousands of healthcare workers.

36. The ongoing consequences on staff physical health were described by a secondary care doctor in England, who told the BMA that “my second Covid infection has left me with damage to my spinal cord. I now walk with crutches and cannot walk more than about 200m without them. I also have bladder and bowel problems and have to intermittently catheterise. There is not a day that goes by where I don’t have some form of pain”.

37. Sadly, there are many more similar accounts, including the evidence of Nicola Ritchie of the Long Covid Physio group, and Dr Nathalie MacDermott of CATA, both of whom developed Long Covid after working without the necessary RPE, and are now suffering debilitating consequences which prevents their return to full time work.
 
38. In addition to these serious impacts on physical health, powerful testimony from witnesses such as Professor Fong highlighted just how traumatic the last few years have been. Professor Fong described a member of staff telling him that it felt like “a terrorist attack since this started and we don’t know when the attacks are going to stop”. He also described staff in one hospital who “were so overwhelmed that they were putting patients in body bags, lifting them from the bed, putting them on the floor, and putting another patient in their bed straightaway because there wasn’t time”.

39 Staff were far more exposed to death and critical illness than they had ever been before. In the words of a secondary care doctor working in Wales: “It was horrific. The patients were incredibly sick, there was a general feeling of being helpless…you’d do everything you could, and they’d just suddenly die, and there was nothing you could do. Having to do end of life discussions over the phone, family members being unable to visit. It was bad, very bad”.

40. And because they were inadequately protected, staff feared for their lives and readied themselves for the possibility of death. They were terrified about passing infections to family members and went to extreme lengths to avoid this, including sleeping in their cars, changing clothes outside, and living in temporary accommodation. 

41. The sheer scale of the traumas experienced by staff is unprecedented. The Inquiry’s intensive care experts reported data from late 2020 that 50% of ICU staff met or exceeded the criteria for a mental health disorder.   

42. This points to a mental health crisis within the NHS and it is a crisis that is continuing. A survey by NHS Charities Together from earlier this year found that over three in four NHS staff are currently struggling with their mental health and two in three report that morale is the lowest they have ever experienced. Meanwhile data from NHS England showed that over a quarter of all staff sickness days in 2023 were due to stress-related illnesses.

43. Staff also suffered moral distress when capacity constraints meant they were unable to deliver the care that they wished. Lack of capacity meant that staffing ratios had to be stretched to unsafe levels, patients could not be escalated to the next level of care, there were increased numbers of critical care transfers, and there were horrific difficulties accessing ambulances. These concerns about patient care were so severe that doctors raised them with the GMC.

44. Finally on impacts, infections and exposure were not experienced equally. The Health Service Journal estimated that over 60% of staff who died in the first month were from ethnic minority backgrounds. The gender bias within PPE design meant that female staff often struggled with poorly fitting PPE that left them at risk. While migrant and outsourced workers were disproportionately forced to work without adequate PPE. They were also more likely to be allocated to higher risk environments and were less able to voice their concerns.

Recommendations

45. Lastly, recommendations.

46. Before proposing a number of specific recommendations, we make two general observations about capacity and safety.

47. It is the BMA’s firm belief that any improvements in surge capacity will prove inadequate during a future emergency if health systems start from the same baseline as 2020, and we repeat that capacity is now worse, not better, than five years ago, which is a damning indictment.
 
48. It is therefore vital for the Inquiry to make recommendations that will ensure all healthcare systems have capacity for both day-to-day and emergency situations. As highlighted by Professor Sir Chris Whitty, the resourcing and configuration of the NHS is a choice, and one that can be made differently.

49. Regarding safety, there is an urgent need for improved protections for healthcare staff and patients in all settings. Any repeat of the experiences of Covid-19 is unthinkable, but again, this is exactly what will happen without urgent and fundamental change.

50. Our closing written statement will set out proposed recommendations in more detail, but for now we highlight the following nine areas. 

• a. First, urgently update the IPC guidance across all four nations to reflect the evidence of aerosol transmission by recommending FFP3 for the routine care of patients with Covid-19.
• b. Second, require a precautionary approach in future emergencies to ensure maximum protection for healthcare staff and patients, with IPC guidance that is explicit about the risks and is updated when new evidence becomes available, backed by a stronger more proactive Health and Safety Executive.
• c. Third, ensure that pandemic preparations include plans for rapidly scaling up the use of PPE across a range of settings, and a PPE stockpile that is suitable for a diverse range of face and body shapes.
• d. Fourth, we must invest to ensure healthcare systems are adequately resourced, including proper modelling of realistic workforce and bed stock needs.
• e. Fifth, we need to be able to scale up quickly when the next pandemic hits which will require streamlined programmes to bring in additional staff more easily and flexibly.
• f. Sixth, NHS estates need to be significantly improved, starting with a transparent and independently audited review of the condition of primary and secondary care estates and infrastructure, with urgent funding for the required improvements identified.
• g. Seventh, ensure that consistent and sustainable occupational and psychological support is available to all staff to improve their health at work.  This will require strong direction and leadership from the top.
• h. Eighth, improve Long Covid support services to ensure they are less variable, take a multi-disciplinary approach, and that those suffering from Long Covid receive proper support to return to work, and proper compensation where this is not possible. Moreover, implement the recommendation from the Industrial Injuries Advisory Council to classify Long Covid as an occupational disease.
• i. Ninth, address the culture of the NHS to ensure working experiences are less variable by background or protected characteristic, and that all feel able to raise concerns.

51. Finally, the BMA appreciates that the Inquiry’s Terms of Reference require that your recommendations must relate to preparations for future pandemics. However, given that the severity of the impacts of Covid-19 stem from underprepared and under-resourced health services, the BMA urges the Inquiry to be bold in its recommendations, and to address the fundamental issue of capacity head on.