When a local school rang me as duty doctor for my 10,000 patients on Monday 24 February, to complain of a number of cases of a febrile illness, having returned 48 hours earlier from a half term ski trip to the Italian Alps I suspected what we have come to know as COVID-19.
I declined them face-to-face appointments as we had no PPE, save for gloves. When central supplies did come, around a month later, they were expired '07/2016' and rebadged with a cheap sticker.
Even then, all we got were plastic pinnies and simple fluid-repellent masks to last us about a week - when the WHO was advising FFP3 masks, cuff covers, visors and gowns. Some batches of the rebadged masks have been found not to be safe and practices advised to destroy them.
https://t.co/knmgKcw6ew Oh dear. I feel a rant coming on.... 1/— Katie Bramall-Stainer ???????????????????????????? (@doctor_katie) July 6, 2020
How many of us became unwell, or unwittingly passed on the virus to others? How many potentially died from that catastrophic failure to plan for the inevitable?
Even though 20 years ago as an undergraduate at UCL medical school, I had been taught by Professor Jim Ryan, who in a prescient day’s teaching in UCH emergency department, made us all wear PPE and talked us through what we would need to do as frontline clinicians in a civilian emergency or global pandemic.
Professor Ryan - who a few years later led the response at UCH during the 7/7 terrorist attacks - said these eventualities were as certain as cancer, heart attacks and strokes. This should not have been a surprise. We had warning.
I’ve had the privilege to be in a leadership role for my profession for almost 20 years. I sat on the BMA’s UK GP committee during the 2009 H1N1 swine flu pandemic and heard first hand how the medical profession liaised with public health, government and local authorities at that time.
How each winter we would plan for potential surges in excess mortality. Put aside stores of PPE. Keep logistical plans on the shelf ready to be used out of the blue. 2020 is starkly different to 2009 - years of austerity has cut any capacity there might have been in the NHS.
Systems are in deficit to the tunes of millions. As a GP, commissioners would like me to prescribe and investigate less, refer fewer but see more patients, and diagnose more cancer. Not an easy maths puzzle.
Local authorities are in crisis and we see that no more than in the multimorbid sequelae of those in poverty. But what to bring on the UK after years of public sector cuts - the largest single episode of deliberate self harm that is Brexit.
Brexit prioritised politics over preparation. Those pandemic logistical action plans were unaffordable. PPE allocations were swept aside as a luxury we probably won’t need, so probably shouldn’t bother with.
Public health has been decimated as a medical specialty over the past decade. Public Health England (PHE) itself is a strange body that seemingly issues guidance but doesn’t have the mandate to ensure NHS England commissions it - and NHS England doesn’t have the funds to commission it anyway.
So it doesn’t. And public health is left in limbo - a hot potato thrown between emergency departments and GPs: it belongs to neither and neither are funded to provide it.
So when I declined to bring in the febrile ski trip that February morning, I called PHE for advice. We knew this was coming. We should have had ready stocks of PPE. We should have had notifiable illness algorithms to follow. We had neither.
In the absence of a reliable IgM diagnostic test we should have put in place simple contract tracing. It isn’t rocket science. It’s the preventative arm of every sexual health clinic in the world. It didn’t need to be difficult, and it was bizarre to doctors that it wasn’t being done.
Test and trace
In the absence of a reliable IgG antibody test and knowing what we know about other coronaviridae, we should have put in place a policy of universal face masks on public transport/shops as far back as February. The febrile skiers returning from Italy should have been screened at Heathrow airport and advised what to do if they became unwell.
Quarantine should have been enforced as it was for the Brits flown back from Wuhan. This isn’t the luxury of the retrospectoscope. Medical social media was alive with discussions and debates over these concerns as far back as February citing South Korea’s example.
I am privileged to be the GP who represents, supports and advises all the GPs and surgeries that care for the 1m patients across Cambridgeshire.
In those early weeks the silence from government was deafening. Cambridgeshire LMC issued advice on a weekly, if not daily basis to practices. We put in place a ‘No PPE No See’ policy on 10 March, rapidly transforming consultations to video/phone, undertaking essential emergency home visits in private PPE that GP federations had sourced themselves at their own initial expense.
COVID support fund
Later, the government would refuse to reimburse any PPE that conferred ‘too much’ protection, only reimbursing the plastic pinnies, fluid repellent masks and gloves. Endless public goodwill came together to produce visors at cost price. Thank God.
Three months on, despite promises from government, England’s GPs still haven’t received essential COVID-19 monies promised by the Treasury to cover additional costs for PPE and staff costs. This is appalling.
And then it hit. And it was awful. Heartbreaking tragic stories have been shared across media. Those in caregiving roles will know of many more that didn’t reach print, but were no less painful, unfair and cruel. RIP. There was also a worry about what would happen if or when care homes were hit.
3 months on, despite promises from government, England’s GPs still haven’t received essential Covid-19 monies promised by @hmtreasury to cover additional costs for PPE & staff costs. This is appalling. @bma_gp— Katie Bramall-Stainer ???????????????????????????? (@doctor_katie) July 6, 2020
And then it hit. And it was awful. 21/
Some GP practices advised homes to lock down prior to the government advice. Those decisions saved lives. But those care home staff - often on derisory contractual compensation for sickness absence - where was their PPE? Where was their ability to refuse to accept COVID-positive patients into COVID-negative homes to clear those essential hospital beds for the next poor influx?
But it was ok! Because prime minister Boris Johnson clapped for us every week. He doesn’t take the knee because he ‘doesn’t believe in gestures’ but he would happily clap for carers in front of cameras -while scrapping those nurse bursaries which later had to be embarrassingly reinstated.
And the public have generously donated over £130m to NHS Charities - which will only give your little area of the NHS money if you pay their £1,000 annual membership fee.
Which might be OK for those big hospitals and trusts, but is no use to your local surgery, GP or independent community pharmacy. Dominic Cummings made a mockery of public health messages; a grave misjudgment by a man who prides himself on being able to take the temperature of the nation.
I hope the nation returns the sleight at the ballot box. We get what we vote for, and we voted for a craven cabinet of sycophants, prized only for blind re-tweeting and nodding heads in unison over their leader’s latest ‘oven ready’ glib strapline.
In trying to identify where the government has gone wrong, it’s a struggle to understand where it has gone right. Doctors are looking ahead to autumn and winter with dread. How to roll out a socially distanced seasonal flu vaccination programme? How can we jab the greatest number safely?
NHS England has yet to produce an operating procedure for this, of course. A government that refers to ‘Super Saturday’ when easing lockdown rules hasn’t considered the very real prospect of a novel pandemic influenza strain. It’s overdue.
But it probably won’t be this year, so let’s not worry about it eh? What’s the worst that can happen?