Thread by @pmdfoster

So. The #Coronavirus PPE debacle. How and why did it happen? A tale of broken promises, mixed messages, failed plans and the government losing the confidence of doctors. Stay with me. 1/thread

My latest, with @SarahNev Free to read on @FT

ft.com/content/9680c2…

@SarahNev @FT It all starts with the basic problem that there wasn't enough - and the 'flu Pandemic stockpile wasn't filled with enough of the items (fluid-repellent gowns, visors) required to deal with a novel #coronavirus pandemic. See this from NHS 2017 doc /2

england.nhs.uk/wp-content/upl…

@SarahNev @FT You'll note the absence of those key items...but on March 17, when NHS leaders go in front of @Jeremy_Hunt select cmme and are asked if there is enough gear to protect #NHSheroes in weeks ahead, the answer is 'yes' and shortages are "local distribution" problems /3

@SarahNev @FT @Jeremy_Hunt These assurances were no doubt given in good faith, but it begs Q why Govt was not more alive to fact that #Coronavirus wasn't regular 'flu or that its PPE stockpiles were in adequate; and therefore when it started making preps to fill deficit - by procurement & UK production /4

@SarahNev @FT @Jeremy_Hunt Because in February the messages to NHS trusts were still soothing. Steve Oldfield, chief commercial officer at the Department of Health and Social Care writes to say service is "extremely well prepared" for these types of outbreaks /5

@SarahNev @FT @Jeremy_Hunt But increasingly - and this becomes a key point in all that - it doesn't FEEL like that to doctors on the frontline. They are facing shortages, partly because of distro challenges, which the army is drafted in to try and fix on March 23 - but fears grow/6

rcn.org.uk/news-and-event…

@SarahNev @FT @Jeremy_Hunt Now to understand doctors fears, you need to see it from their point of view - and look at the shifting guidance on PPE usage from Public Health England which raises scepticism that availability is driving guidance. Remember, the Govt starts by ensuring there is adequate supply/7

@SarahNev @FT @Jeremy_Hunt See this lovely graphic, but in January docs are using 'ebola-style' PPE, then in early Feb the first PPE guidance (now off the website, but we tracked it down) says docs need gowns, FFP3 respirator, face protection - the full monty basically - for suspected cases. /8

@SarahNev @FT @Jeremy_Hunt This is taken from a Feb 11 document obtained from a doctor's personal file - no longer available on line - but it shows you what was suggested for #COVID19 patients.../9

@SarahNev @FT @Jeremy_Hunt So then imagine what you'd think - as shortages bite - when on March 6 or 7 (again the guidance has been removed) PHE drops this guidance on you as a nurse/doctor/careworker, which downgrades PPE need. "It was a bombshell" one doc tells me. /10

@SarahNev @FT @Jeremy_Hunt It didn't help that UK guidance advised PPE that was less stringent that the WHO and EU CDC in non-ICU setting. So careworkers in general/triaging wards felt less protect just with flimsy apron, visor 'on risk assessment', mask and gloves. Compare here w WHO/EU /11

@SarahNev @FT @Jeremy_Hunt The result was that it looked to doctors as Govt advice was being tailored to suit the stockpile - the govt denies this, but if it was true, it would be reasonable, since it would be irresponsible to ask staff to wear kit they didn't have. But this became a Q of trust/12

@SarahNev @FT @Jeremy_Hunt The crazy thing is that it may be that the PHE advice is NOT wrong - that as Pat Cattini @patcp66 of Infection Prevention Society says, the KEY was visors (covid enters thru mucus membranes) and fluid-repellent gown is not necessary in wards, per UK 'bare below elbows' policy/13

@SarahNev @FT @Jeremy_Hunt @patcp66 Worth reading this piece of advice on PPE shared by St Georges doctors - it explains why gowns may only be needed for 'aerosol generating procedures' etc It's calm, measured, honest and straight - Government comms machine could learn by reading this/14

https://twitter.com/drangelah/status/1250767074340810753?s=12

@SarahNev @FT @Jeremy_Hunt @patcp66 But at this point, it's all too late. The government has lost the narrative - and the trust of doctors - so that when @MattHancock comes out on April 10 to warn PPE is a "precious" resource and hints at careworkers over-using it, he really get both barrels - see this from RCN/15

@SarahNev @FT @Jeremy_Hunt @patcp66 @MattHancock Meanwhile, what is happening to fix the problem? The govt has two options - source from overseas or make more at home, where there is limited capacity and a shortage of the special fluid-repellent fabric needed to make gowns. Let's start with overseas /16

@SarahNev @FT @Jeremy_Hunt @patcp66 @MattHancock The problem, per manager to FT, was that NHS Supply Chain co-ordination Ltd had no experience of overseas sourcing, having used UK middlemen. But suddenly they were in this dog-eat-dog marketplace, and were slow off the mark. We've all seen the results. /17

@SarahNev @FT @Jeremy_Hunt @patcp66 @MattHancock At the same time, many of the 'just-in-time' supply contracts that were supposed to have been triggered by the pandemic turned out - as Mark Roscrow, director of NHS Wales’s shared services procurement told MPs - not to be "worth paper...written on" /18

ft.com/content/8c0a29…

@SarahNev @FT @Jeremy_Hunt @patcp66 @MattHancock Yikes! So what about the Home Front? That seems to have hit the twin issue of limited capacity (fabric and manufacturing) but also bureaucratic, centralising inertia that insiders say has been feature of process - causing many NHS trusts to act unilaterally. /19

@SarahNev @FT @Jeremy_Hunt @patcp66 @MattHancock It looks like UK efforts only really started to ramp up early/mid March (Sir Simon Stevens told March 17 select cmme that needed to happen) and the UK Fashion and Textile Association, representing 2,500 cos engages on 18th. But is is slow going /20

@SarahNev @FT @Jeremy_Hunt @patcp66 @MattHancock Here's how the boss Adam Mansell @UKTF_Adam describes it - slow to understand supply chains and access industry expertise. It's now happening - which is the 'right strategy' - "just four weeks too late" /21

@SarahNev @FT @Jeremy_Hunt @patcp66 @MattHancock The result of all this? A savage assault on the trust of careworkers in the government. Having said Mar 17 there was "adequate supply", by April 17 @MattHancock admits we are "tight on gowns" and issuing emergency guidance on alternatives - lab coats and industrial coveralls./22

It is a sorry tale. If I had a pound for every time a doctor friend said "I'd rather have a gown than a clap" (polite version) I'd be a rich man.

Part of this is force majeure - there's a war on, other countries are short too - part of this is being slow off the mark, BUT.../23

There is another fundamental issue, which explains why SIX heads of the august Royal Colleges of medicine (and this is not BMA) wrote this letter to PPE Tsar warning the govt of it's "duty of candour" to doctors and the public on PPE /24

rcplondon.ac.uk/news/joint-let…

That is not an idle phrase. 'Duty of Candour' is the statutory and ethical obligation of doctors to be honest with patients. To be "to be open and honest when things go wrong".

When those doctors write that, it's surely time to reflect. ENDS

themdu.com/guidance-and-a…