The UK’s public health response to Covid-19
bmj.com
bmj.com
The government is currently telling anyone who will listen that hospitals have all the PPE they need. However, local nurses and doctors are co-ordinating with volunteers to supply hand sewn PPE because they've been told they can only order PPE for the autumn. My mother is having material delivered and is hand-sewing PPE for the local hospital. Yet the government claims this isn't needed. So whilst this review is pretty damning, let's remember this situation is far from over.
The fact that the PM's political advisor was in the scientific advisory meetings tells you all you need to know.
I don't think any government is going to come out of this scoring 100%.
* Being complacent about the country's testing capacity
* stopping testing outside of hospitals once the containment phase was deemed over
* PPE logistics. (tough global problem)
* Support for care-homes.
* Westminster's lack of care when it comes to coordinating the loosening of lock-down with the devolved countries
It was arguable that they should have started lock-down earlier, but given that the number of acute beds in the NHS wasn't overwhelmed, that's arguable.
If you look at stuff like the furlough scheme, support for individuals and freelancers so people don't suffer too much economically by being locked down, it a pretty good and swift response.
* unclear and delayed response to pandemic,
* frequent lying and misinformation put out by ministers,
* considering herd immunity with no vaccine,
The list goes on and on ...
Yes, the furlough scheme, is decent. But smacks of just throwing money at the problem to save the day. It's not a coordinated response, and we'll be paying for it for generations.
I repeat my assertion. Thanks.
What I find remarkable is that eastern European countries like Hungary, Poland and Czechia have done remarkably well during this crisis. Also, countries like India and Sri Lanka have barely been affected. What are the reasons?
Sure the UK was slow at testing but there are still ways of getting a private testing kit for yourself in the UK. Thus, it's very easy to blame the UK government for the high death rates and slow response when you have people risking their own health by ignoring government advice across the UK and not taking their own responsibility to be socially distant, i.e clapping for carers whilst being very very close together.
Therefore in the UK, it's everyone's fault for not taking this pandemic seriously enough (All the UK media outlets comparing it to the flu and SARS 2003 death rates), unlike other countries locking down their borders and testing very early.
[0] https://www.thelocal.de/20200429/german-coronavirus-testing-...
The NHS already has its inefficiencies whilst being a public health service and is already slow enough to get an appointment given its long waiting times to see the GP which is why some go to private healthcare to bypass this.
If you have a private test, and that says you have covid-19, and then you die from covid, your death is not counted as a covid death in the daily figures. It might eventually be counted as a covid death by ONS.
https://coronavirus.data.gov.uk/about
> The UK total is not the sum of the 4 National totals as the pillar 2 cases cannot currently be included in the National totals. All other data on this website are based only on cases detected through pillar 1. Information about the different pillars is available on GOV.UK.
The UK has had a health crisis for 20+ years, and that is obesity / poor-diet / little-exercise. We are one (it not most?) obese country in Europe, and we are seeing people with diabetes and heart-conditions to be people at most risk of COVID-19. It will take a generation to put this right - and my hope is that people in the UK will realise they need to sort their health out in case COVID-XX comes around.
Every country has a different population size which means the total number of deaths needs to be normalised in order to be comparable.
Belgium has the highest death rate per million population in Europe - 79.25
The UK is 4th in Europe behind Belgium, Spain and then Italy.
https://coronavirus.jhu.edu/data/mortality
The fact we're 4th does warrant some concern as Spain and Italy were hit hard before us.
But then all these death statistics are compiled using different definitions anyway, so there's no useful direct comparison right now.
Belgium, for example, include all suspected covid deaths in their figures whereas the UK does not.
So probably best not to jump to conclusions until some thorough and rigorous global modelling/analysis has taken place.
The UK however has only just started testing people outside hospital, and has only just started including deaths outside hospital in its figures. (And even then, not all cases confirmed by tests are included. We have a complex system of "pillars" and only some of those are included). Yet, despite not including all deaths, we're still 4th in the table.
Within a small area with a >40% IR, the excess death rate reached 270% (in France), so it could be worse, but it still bad.
No, the Conservative government has shown a level of ineptitude that is off the scale. You list the areas where the government has failed - essentially everything that would have made a difference to the number of deaths.
In March, the medical director of National Health Service England, Stephen Powis, said that if we were able to keep deaths below 20,000 then "we will have done very well in this epidemic." UK deaths have now reached 50,000+ and will likely rise further.
The number of acute beds in the NHS was overwhelmed! They were converting operating theatres into ITUs; they dropped the nurse to patient ratios from 1:1 to 1:6; they cancelled elective surgeries to cope with the surge.
The other thing they did is to tell care and nursing homes that elderly people with covid would not be admitted to hospital and would have to die in the home. They also discharged elderly people with suspected covid back to those homes.
People say the festival is outside so it's lower risk. That's ignoring the fact that people take trains to get here and they take buses to get from the town centre to the race track. They also meet in cafés, pubs and betting shops, although this year that was far quieter than previous years.
Letting it go ahead was a baffling choice.
That problem is made worse in the UK because of the lack of planning and political disruption to NHS infrastructure.
See for example the fucking shambles of Movianto[1] https://www.theguardian.com/world/2020/may/14/coronavirus-uk...
We used to have NHS Logistics Authority, which changed to NHS Logistics, which was sold off to DHL Supply Chain (but managed by NHS Business Services Authority) and that was a disaster so we now have NHS Supply Chain. This waxing and waning of ideology (centralised control vs localism; NHS provision vs private provision) causes huge amounts of waste and harm in the NHS. It's also not as simple as tories=bad, labour=good. Selling it off to DHL happened under a Labour government; bringing it back under NHS Supply Chain happened under a Conservative government.
I've known some unscrupulous management consultants who would just recommend the opposite of what the current state was just to generate work.
So this is a tough one. Most organisations will have general rules about not bad-mouthing the organisation publicly and running comms through s comms office. I absolutely agree people should be able to whistle-blow, but if you were managing a hospital you'd probably be wanting people not to go grumbling to the press.
Your "grumble" is likely someone else's "professional concern".
There is this study (https://www.hsj.co.uk/exclusive-deaths-of-nhs-staff-from-cov...) that suggests deaths are amongst NHS staff are not over-represented.
There is also a remarkable correlation between the cumulative UK deaths from covid-19 in the UK population and among health and social care workers. Accepting a lag of one to two days, the ratio is very close to 1:200 so the deaths among health and social care workers are approximately 0.5 per cent of all deaths, suggesting they are not overrepresented.
That is the only study I could find that tried to look at excess deaths for NHS staff. I think their suggestion that deaths are not overrepresented is not backed by their data because it doesn't look like they are adjusting for difference in base mortality rates between NHS workers and the general population. However, considering how people are claiming lack of PPE is killing NHS staff you would think someone would have checked by now whether NHS staff are actually dying at a higher rate!
When NHS deaths were around ~80 I ran my own model adjusting by age and found 10 excess deaths. However, the way I interpolated the deaths in the population to NHS age bands was very dirty and I didn't adjust for sex and race. The NHS has BAME groups overrepresented in their work force and these groups have higher mortality rates.
Most governments failed when they didn't start to tax the sh*t out of unhealthy food and ingredients.
"Preliminary evidence suggests that the severity of symptoms associated with Covid-19 and the eventual outcome of being infected with this virus are associated with the health status of individuals prior to infection. Among the factors linked to an increased risk of hospitalization and mortality are overweight/obesity, insulin resistance and diabetes: these lifestyle-related diseases [...]" https://onlinelibrary.wiley.com/doi/epdf/10.1002/oby.22849
"he floated an approach to “build up some degree of herd immunity” founded on an erroneous view that the vast majority of cases would be mild, like influenza"
as far as anyone knows, they are. the (limited) data we have is making a strong case for that.
and in any case, 'some degree of herd immunity' wasn't the policy, it was (and still is) an inevitable outcome
we'll need to wait on Roche's antibody test to have a robust sense of how succesful our delayed lockdown (or sweden's complete lack of lockdown) worked
[1] Excess meaning those people would not have died for some time yet - decades for those front-line workers who were in their 30s/40s/50s.
My reference to 'limited data' relates to the other side of the coin -- the long tail of people who have had it and who haven't died.
We have solid projections of what number that might be based on random sampling and extrapolation. But we need a decent antibody test (and frankly, time) before drawing any conclusions.
And all the evidence I've personally seen suggests that SARS-CoV-2 trains your immune system -- and that consensus is that it will. And if you accept that, you accept that some degree of herd immunity is an inevitability.
It was the policy. They were pursuing herd immunity. They were talking about cocooning vulnerable people so everyone else could go about their normal activity, get infected, and develop herd immunity. We have government advisors saying this.
The UK strategy was to not pull the trigger on lock down too early, and then to flatten the curve in a way that fills our front line health service's capacity without overstretching it.
All while increasing numbers of beds, ventilators and distributing PPE as widely as possible.
That's broadly what's happened.
"There's going to be a point, assuming the epidemic flows and grows as we think it probably will do, where you'll want to cocoon -protect- those at-risk groups so that basically they don't catch the disease, and by the time they come out of their cocooning herd immunity has been achieved in the rest of the population".
It's clear from this that the policy was to achieve herd immunity. Without a vaccine the only way to get herd immunity is to let everyone catch it. You don't want vulnerable people to die so you cocoon them, but you want everyone else to get it as soon as possible.
This is why mass events (eg, cheltenham gold cup) were allowed to go ahead; this is why the lockdowns were late and weak; and this is why so many people in the UK have died.
a great many things have gone wrong -- but I don't think the overarching UK strategy, or even the timing of executing it -- has necessarily been one, based on existing data
I feel though there is a lot of political propoganda going on. This MP complained about a lack of PPE at a care home she worked in, but the care home sacked her for lying as they said they had plenty.
https://www.bbc.co.uk/news/uk-england-nottinghamshire-525680...
They cut her hours from 8 shifts over the two months of the height of the UK peak to 0 afterwards.
Agreed, sounds like someone blowing smoke up somewhere dark.
https://www.bmj.com/content/bmj/369/bmj.m1932/F1.large.jpg
It is timeline graphic of the growth of the virus per country and actions taken by each country.
Looked at this before, at first I thought it was weekends being under reported, then people going out on weekends, etc. — but now starting to think it might be the R0 (reproduction number) is very high and the virus burns itself out among a social network.
Any ideas what is the source of those humps?
Here are some of the most basic things no one seems to have figured out yet:
- As of today, there have been 23,953 deaths in England. Of those, exactly 33(!) involve someone <= age 40 without a co-morbidity. Across all ages, 95%(!) of deaths are people with a co-morbidity, typically diabetes (26%). Why does this disease attack so many diabetic people? What should we do to best treat or prevent it in that population? [1]
- Why is the transmission rate in London so low now (R = 0.4, < 25 infections a day) while still high everywhere else in the UK (R = 0.7 - 08)? Is that because the lockdown in London is somehow different or better or because some critical segment of the population is immune now and slowing down transmission? Or something else? [2]
- Why weren't the Nightingale Hospitals (field hospitals) needed? Were we just wrong about the need for ventilation? Was the lockdown super effective? Or something else?
- How many people are currently immune? Different studies in place the immunity rate in London anywhere from 10% (tests) to 29% (statistical models). Several studies suggest that there is significant cross-immunity with preexisting coronaviruses causing much slower spread, but it's too early to know for sure and that could be totally wrong.
- Why do some scientists think this will be a serious, on-going epidemic and others think the disease will "burn itself out" [3]? Is that based on science or wishful thinking? Because the difference in the best course of action would be significantly different if we knew the answer with a strong degree of certainty.
- Why do some places with lax lock downs have lower death rates than places with severe lock downs? Why aren't we seeing big upticks in deaths in the US where they are just willy nilly opening the economy? Is it just lagging indicators or are we not totally sure yet how this disease spreads in the community?
- How soon will we get an effective therapeutic? Will we really have a somewhat effective vaccine from Oxford in September or might we never have a vaccine? Will it matter anyway as immunity builds up in the population? How long are people immune?
- What is the actual cost of locking down in terms of lives lost as a side effect in the long term due to economic, social and psychological effects? Is it minuscule or significant?
Again, there will be plenty of time to bash the UK government after this is over. But it seems very early to be proclaiming that anyone has any idea what the right course of action was. This epidemic could totally vanish this year or it could go on for years. No one has any idea.
[1] https://www.england.nhs.uk/statistics/statistical-work-areas...
[2] https://www.mrc-bsu.cam.ac.uk/now-casting/
[3] https://www.telegraph.co.uk/news/2020/05/16/coronavirus-coul...
No.
1) The actual number is 34,796 https://coronavirus.data.gov.uk/
2) That only includes people who were tested positive for covid-19. That's only tests carried out by government labs, not private tests. We've only just started to include deaths that happened outside hospital.
> Why weren't the Nightingale Hospitals (field hospitals) needed?
Because we didn't transfer elderly people from care and nursing homes to hospital. We left them to die in those homes.
Because we cancelled elective procedures, we converted operating theatres to ICUs, we changed nurse:patient ratios, to create surge demand.
Because we didn't have enough ICU nurses to staff Nightingale:London.
Of those, exactly 33(!) involve someone <= age 40 without a co-morbidity. Across all ages, 95%(!) of deaths are people with a co-morbidity, typically diabetes (26%). Why does this disease attack so many diabetic people? What should we do to best treat or prevent it in that population? [1]
I guess the idea was that military medical services would have moved in to run the Nightingale hospitals if things got really bad?
I'm glad the Nightingale hospitals were not used, as they were set up if we had to scale response massively.
But I think we really need to look at the deaths and where they occurred. I have a feeling in some areas they've pushed people out of hospital to keep the hospitals ready for the worse cases. A neighbour works in a hospice and she said her place and the local hospital do not have patients. So we need to look at the balance of avoiding sending people to hospital which could make it worse vs being in hospital with the virus. - Has this made the death rate worse than it could have been? - Has this made the care home issues worse as well? - How has this affected the accuracy of the reporting of deaths
Testing, to me appears to be an absolute joke, I think they are defining tests as having taken the swabs and not processed it. (as the 40k of tests were home tests that had been sent out) I saw my nearest test station (Portsmouth) last Sunday, the only cars there were the people that worked there. I'm wondering what the hell the government has done to increase the actual capacity from taking the test to processing it. I feel this is being avoided in the media, we just hear we're doing X tests a day.
Now I can understand if people are showing the common symptoms of covid-19, then testing isn't much help unless you want to know the strain etc. But if we're talking about people with mild symptoms that aren't on the government symptom list, then that's could be a big issue for the R value. The government only just updated that list yesterday. I had a slight cough and had breathlessness, my peak flow was around 650, doctor doesn't think it's asthma or covid, but then went on to talk about how his colleagues had mild symptoms and didn't feel right. The right thing would be to just test. Without testing we could be missing out on a lot of information that could shape how we respond to covid-19 in the following years.
Personally I think it will be quite some time before we get a better understanding of the deaths. People will be needing to go through the death and medical records to understand why patient X died. My mum has a friend who father died out of the blue and it classed as covid, despite no symptoms.
As for PPE, the government has failed, we've seen the interviews with suppliers who have been ignored by the government. It wouldn't be that hard to get someone to inspect items initially, then have it sent to some location for further distribution. Seeing hospitals wearing home made masks and 3d printed face shields isn't right, the NHS/government purchasing/logistics has failed here. The government should have taken a larger interest in the production and distribution of PPE early on, even having control over the export. I'm all for free market but we need some centralisation to know what we have and capacity to produce so we know it's going to the right areas.
The idea of a "cliff-edge" is yet to materialise.
Meanwhile -- before COVID19 -- Sterling devalued by about 20%, the government began borrowing heavily to cover a yawning revenue gap, an economic slowdown cost the UK economy more than the gross total of all UK payments into EU funds since joining in 1974 (many of which were redistributed right back in the UK), and we have a prime minister who, when told that the Confederation of British Industry was worried about his Brexit policies, famously said "f*ck business".
Remember February/March, when everyone was sitting paralysed in the oncoming headlights of COVID19, wondering if it was going to be bad and if it was going to be necessary to make any changes? That's where we are with the end of the Brexit transition period, right now.
It's a bit worrying.
https://www.nuffieldtrust.org.uk/news-item/70-years-of-nhs-s...
Doesn't seem contentious to me that if the NHS has had the investment it perhaps deserved over the last 10 years then this might have contributed to a less than ideal overall performance?
Public Health is a function of local authorities (not the NHS), and local authorities have had their funding slashed and that has been seen in the difficulties in test, track, and trace. We're not even able to test everyone who needs a test. We certainly can't track and trace people.