COVID-19 and the NHS—“a national scandal”

27 March 2020 — The Lancet

Richard Horton

“When this is all over, the NHS England board should resign in their entirety.” So wrote one National Health Service (NHS) health worker last weekend. The scale of anger and frustration is unprecedented, and coronavirus disease 2019 (COVID-19) is the cause.

The UK Government’s Contain–Delay–Mitigate–Research strategy failed. It failed, in part, because ministers didn’t follow WHO’s advice to “test, test, test” every suspected case. They didn’t isolate and quarantine. They didn’t contact trace. These basic principles of public health and infectious disease control were ignored, for reasons that remain opaque. The UK now has a new plan—Suppress–Shield–Treat–Palliate. But this plan, agreed far too late in the course of the outbreak, has left the NHS wholly unprepared for the surge of severely and critically ill patients that will soon come. I asked NHS workers to contact me with their experiences. Their messages have been as distressing as they have been horrifying. “It’s terrifying for staff at the moment. Still no access to personal protective equipment [PPE] or testing.” “Rigid command structures make decision making impossible.” “There’s been no guidelines, it’s chaos.” “I don’t feel safe. I don’t feel protected.” “We are literally making it up as we go along.” “It feels as if we are actively harming patients.” “We need protection and prevention.” “Total carnage.” “NHS Trusts continue to fail miserably.” “Humanitarian crisis.” “Forget lockdown—we are going into meltdown.” “When I was country director in many conflict zones, we had better preparedness.” “The hospitals in London are overwhelmed.” “The public and media are not aware that today we no longer live in a city with a properly functioning western health-care system.” “How will we protect our patients and staff…I am speechless. It is utterly unconscionable. How can we do this? It is criminal…NHS England was not prepared…We feel completely helpless.”

England’s Deputy Chief Medical Officer, Jenny Harries, said on March 20, 2020: “The country has a perfectly adequate supply of PPE.” She claimed that supply pressures had now been “completely resolved”. I am sure Dr Harries believed what she said. But she was wrong and she should apologise to the thousands of health workers who still have no access to WHO-standard PPE. I receive examples daily of doctors having to assess patients with respiratory symptoms but who do so without the necessary PPE to complete their jobs safely. Health workers are challenged if they ask for face masks. Even where there is PPE, there may be no training. WHO standards are not being met. Proper testing of masks is being omitted. Stickers with new expiry dates are being put on PPE that expired in 2016. Doctors have been forced to go to hardware stores to buy their own face masks. Patients with suspected COVID-19 are mixing with non-COVID-19 patients. The situation is so dire that staff are frequently breaking down in tears. As one physician wrote, “The utter failure of sound clinical leadership will lead to an absolute explosion of nosocomial COVID-19 infection.” Front-line staff are already contracting and dying from the disease.
The NHS has been wholly unprepared for this pandemic. It’s impossible to understand why. Based on their modelling of the Wuhan outbreak of COVID-19, Joseph Wu and his colleagues wrote in The Lancet on Jan 31, 2020: “On the present trajectory, 2019-nCoV could be about to become a global epidemic…for health protection within China and internationally…preparedness plans should be readied for deployment at short notice, including securing supply chains of pharmaceuticals, personal protective equipment, hospital supplies, and the necessary human resources to deal with the consequences of a global outbreak of this magnitude.” This warning wasn’t made lightly. It should have been read by the Chief Medical Officer, the Chief Executive Officer of the NHS in England, and the Chief Scientific Adviser. They had a duty to immediately put the NHS and British public on high alert. February should have been used to expand coronavirus testing capacity, ensure the distribution of WHO-approved PPE, and establish training programmes and guidelines to protect NHS staff. They didn’t take any of those actions. The result has been chaos and panic across the NHS. Patients will die unnecessarily. NHS staff will die unnecessarily. It is, indeed, as one health worker wrote last week, “a national scandal”. The gravity of that scandal has yet to be understood.

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