Overview

Our opening statement at the start of the Inquiry’s first module, which focuses on resilience and preparedness, sets out four key areas in which we believe the UK entered the pandemic significantly underprepared and lacking resilience.

Opening statement made by the BMA, 13 June 2023

1. Doctors and other healthcare workers were on the frontline of the UK’s response to Covid-19, and they worked tirelessly to treat and care for patients with Covid and those with other healthcare needs. In doing this, they put themselves at increased risk from the disease itself and from the stress and pressure of working through a public health crisis of this scale. 
2. For many doctors and other healthcare workers, deficiencies in pandemic planning and resilience, had and continues to have, a significant impact on their day-to-day lives. An examination of the decade before the pandemic, and of the UK’s readiness, is essential to ensure that the UK is better prepared in the future.
3. This statement seeks to highlight four key areas that the BMA considers should be explored within the Module 1 hearings, to assist the Inquiry to identify what went wrong and to make appropriate recommendations for much needed change and improvement. It is based on the views and priorities of the BMA’s membership, including the overriding priority of all doctors, to deliver the best care and treatment for patients.
4. The BMA has gathered extensive feedback from its membership over the course of the pandemic and since, and selected examples are included within this statement to illustrate the points made.
   

   
   First: there was a failure to prepare adequately for a range of pandemic threats

5. The UK’s pandemic planning was predominantly focused on an influenza-style pandemic. This narrow focus was an oversight, particularly as there had been relatively recent coronavirus outbreaks, including SARS in 2002 and MERS in 2012.
6. One consequence of the predominant focus on an influenza-style pandemic was that the UK’s response to Covid-19 failed to properly consider the potential for aerosol transmission of the virus. This in turn impacted the public health measures put in place, including the focus on hand washing and the delay in mandating mask wearing for the public.
7. For doctors and other healthcare workers, the failure in considering aerosol transmission resulted in insufficient stocks of appropriate PPE and inadequate Infection Prevention and Control in healthcare settings. As one SAS doctor in Scotland said ‘The PPE guidance was based not on safety, but rather the lack of preparedness. 
8. Shockingly, this is the case even now.  The current IPC guidance continues to put staff and patients at risk by erroneously stating that Fluid Resistant Surgical Masks are adequate protection for healthcare workers carrying out routine care for covid positive patients, rather than specifying respirators such as Filtering Face Piece Respirators (often referred to as FFP2 and FFP3 masks), which are recommended by international guidance and by the BMA.
9. The limitations of surgical masks were well known prior to the pandemic, highlighted, for example, in a research report by the Health and Safety Executive in 2008. The HSE report noted that, while surgical masks may reduce residual aerosol risk to some degree, they might not sufficiently reduce the likelihood of transmission and, consequently, surgical masks should not be used in situations where close exposure to infectious aerosols is likely. This same 2008 report also predicted the crisis of PPE supply -  including the following statement, “the widespread use of respirators might be difficult to sustain during a pandemic unless provision is made for their use in advance”. As the regulator entrusted with the protection of worker health, the Health and Safety Executive will be in a position to help the Inquiry understand what more should have been done to mitigate the risks to workers of an airborne virus.
10.  The BMA has heard from countless doctors who are concerned about the failure to provide adequate protection, including a GP in Northern Ireland who complained that there was, “no attempt by the Health and Social Care Board to follow the science on airborne transmission and [the] need for staff to have FFP3 masks and HEPA air filters”.
11.  Governments could and should have been better prepared for the foreseeable risks to doctors and healthcare staff. This would have reduced the serious harm that affected so many of the BMA’s members and the wider healthcare workforce, many of whom are today still suffering with long COVID acquired in their workplace.

    
    The second key area to highlight is in respect of the failures to implement the recommendations from pandemic planning exercises

12.  While the UK did carry out a planning exercise based on a coronavirus (Exercise Alice in 2016), this exercise did not sufficiently prepare for a wider range of infectious disease threats and, crucially, key lessons from this exercise, as well as transferrable learning from pandemic influenza exercises, were not implemented.
13.  One of the most significant failures in this regard, again, concerns the availability and provision of appropriate PPE. The recommendations from Exercise Alice, Exercise Cygnus also in 2016, and Exercise Iris in 2018, were to review current PPE stocks, to create a pandemic stockpile of PPE, to ensure staff had clear instruction and training in the use of PPE and infection control, and to develop a whole system approach to distribute PPE.
14.  However, the failure to implement these recommendations and to properly maintain the PPE stockpiles before the pandemic meant that PPE quickly ran out when Covid hit, and there was no effective plan in place to replenish it through effective procurement systems or local manufacturing capacity. This led to many healthcare staff being forced to work unprotected from the virus, placing them at significant risk.
15.  The fact that in March 2020, NHS England assured the Health and Social Care Committee that there was sufficient supply of PPE nationally, despite stock containing less than two weeks’ worth of most equipment, suggests serious failures of planning and preparation.
16.  Frontline staff often had to go without PPE, buy their own, use homemade, donated, or expired items, and reuse single-use items. Staff also had to use items that were out of date, with multiple expiry stickers visibly layered on top of each other. Many felt pressured to work without adequate protection, with consequences for their mental and physical health. In a BMA survey as part of its COVID-19 Review, 81% of respondents reported not feeling fully protected during the first wave of the pandemic. And feeling worried or fearful to speak out about a lack of PPE was more commonly reported by doctors from an ethnic minority background and those with a disability or long-term health condition.
17.  Commenting on the wholly inadequate supply of PPE, a GP in Northern Ireland said, “We were sent 6 pairs of gloves and 6 aprons in an envelope approximately 3 weeks after the start of lockdown” . And a doctor in England recalled how they, “made our own, and bought our own when we could find any, we depended on friends sourcing FFP3 masks, my son’s school 3D printing visors”.
18.  These failures of planning and preparation also led to PPE being procured from organisations with no experience of manufacturing PPE, resulting in PPE being produced and delivered that was unsuitable for use, at huge public expense. It also led to the ludicrous spectacle of doctors making aprons from bin liners because they were sturdier than the PPE equipment provided.
19.  Another serious failure to implement the recommendations of planning exercises included the identified need for further work to ensure adequate contact tracing and testing capacity (identified in Exercise Iris).
20.   The UK made a number of decisions ahead of and during the Covid-19 pandemic in relation to contact tracing, which hampered the response. Little consideration was given within pandemic planning policies and strategies to detect and contain the spread of the disease, but rather the emphasis was on how to respond in a situation where there was already significant mortality and morbidity. For pandemic planning policies to be comprehensive and effective, both strategies need full consideration.
21.   The decision to abandon contact tracing on 12 March 2020 was ostensibly because the UK was moving from the ‘contain’ to the ‘delay’ stage of the pandemic although it later emerged that this decision was at least partly due to a lack of capacity. Contact tracing was not reinstated for several months, with Wales being the last nation to restart contact tracing on 1 June, a critical period during which there was sustained transmission of the virus.
22.   These issues were compounded by a lack of testing in the community and the NHS. The shortfall in testing capacity is partly due to the UK Government’s failure to utilise the 44 pre-existing NHS laboratories and an overreliance on both the private sector and the seven Lighthouse Laboratories. The expense and effort of using these alternative laboratories, which operated independently of public health and NHS infrastructures, and used different software and systems, was unnecessary and created unhelpful fragmentation.
23.   The failure to adequately prepare for the testing capacity that was needed, left healthcare workers and their patients at increased risk of exposure to Covid-19, particularly at the beginning of the pandemic. Tests were not available for incoming patients or even for staff themselves.
24.   As one resident doctor in England told the BMA, ‘There was a delay in allowing testing of all patients with possible COVID symptoms. I was seeing patients in A&E and being told I could not test them because they had not travelled to relevant countries. When testing was later allowed some of these patients unsurprisingly ended up testing positive. I saw these patients with no PPE due to hospital rules around when PPE was allowed to be worn.’ 
25.   A further failure to implement key recommendations from planning exercises is in respect of the need for surge capacity in the health service (identified in Exercise Cygnus and Exercise Pica in 2018).

    
    This issue is closely connected to the next, and third key area, which is that the public health system was not in a position to scale up its activity to respond to the pandemic due to a decade or more of reduced funding, resource cuts, and reorganisations that caused fragmentation in the system

26.   Public health systems across the UK entered the pandemic without the necessary resources, workforce, capacity, and structures to respond at the speed and scale required.
27.   The reforms introduced in England by the 2012 Health and Social Care Act, which moved responsibility for public health into local authorities, fractured the links between public health specialists and NHS colleagues, meaning communication and information sharing was compromised during the pandemic.
28.   One public health doctor told the BMA that: ‘The separation of public health into Local Authorities and Public Health England meant that many public health consultants and teams in Local Authorities became deskilled in health protection work. This put a huge burden on the whole workforce, with Health Protection consultants having to manage the majority of the response, and provide detailed guidance and support to local authority colleagues, who felt unconfident and unprepared for dealing with infectious disease outbreaks.’ 
29.   The reforms also left public health services vulnerable to cuts in local authority spending settlements in the years preceding the pandemic.
30.   This decline in funding has coincided with a decline in the size of the public health workforce, and to meet the Faculty of Public Health’s recommendation from 2021 for number of full-time equivalent public health specialists per capita , the workforce would need to increase by 59% (England), 32% (Scotland), 18% (Wales) and 97% (Northern Ireland).

    
    The fourth and final key area to highlight is that the UK entered the pandemic with poor population health, widening health inequalities and health services that had been consistently underfunded and understaffed.

31.   In order to holistically assess the state of the UK’s preparedness, it is also important to consider the high levels of population ill-health and health inequalities. Before anyone had heard of Covid-19, gains in life-expectancy – a key measure of our nations’ health – had already started to stall while health inequalities were widening after a decade of austerity. Severe cuts to public health service and social security funding – amounting to billions of pounds since 2010 – have negatively impacted the availability of services that are essential for good population health. This in turn hindered the UK’s ability to respond effectively to the Covid-19 pandemic.
32.   There had also been a marked deterioration within health and care systems in the decade leading up to the Covid-19 pandemic, caused by a failure to invest to ensure adequate capacity, staffing and infrastructure.
33.   For instance, the UK went into the pandemic with a very low total number of hospital beds relative to its population, and very low numbers of ICU beds, which significantly hampered its ability to cope with the number of patients needing hospitalisation with Covid. This combined with workforce shortages and already high waiting lists, meant that the health service had no ability to step up capacity to cope with the increased demand from Covid-19, alongside the continuation of existing services.
34.   As one Consultant in England told the BMA: “Being understrength to begin with in terms of staffing, and already working with bed occupancy at or above 100%, pre-pandemic meant no headroom for managing the eventual large increase in demand that came…” .
35.   These failures to ensure a resilient, well-resourced health and care system were brutally exposed by the pandemic, and the systems are now in an even worse state, with more people now waiting for care than ever, – a staggering 7.4 million patients in England alone - , unsafe bed occupancy levels, acute staffing shortages, neglected infrastructure and deteriorating equipment.
36.   This, in the BMA’s view, is the elephant in the room when considering issues of planning, preparation and resilience, and unless it is acknowledged and addressed, the same mistakes are destined to be repeated.