Lilian Macer looks back on a year of failings and flaws in the battle against COVID-19.
Novel coronavirus (COVID-19) is a new strain of coronavirus first identified in Wuhan, China towards the end of 2019. Clinical presentation may range from mild-to-moderate illness to pneumonia or severe acute respiratory infection. COVID-19 was declared a pandemic by the World Health Organization (WHO) on 12 March by which time it had arrived in Europe with shocking scenes from Italy relayed across Europe. Lockdown in the UK began in the UK on 23 March but only after the Cheltenham race meet and other mass events were allowed to proceed with potentially lethal consequences. By December, over 60,000 people in the UK had died.
From March, public services rapidly changed priorities and previously insurmountable barriers to change fell away. The NHS transformed almost overnight to cope with unprecedented demands, pausing many services, discharging patients back home or into residential and nursing home care and setting up new crisis services to cope with the anticipated demands. Councils closed down many services but within days created new ones to care for the kids of key workers and provide support for hundreds of thousands of vulnerable people who were told to stay at home.
Those who argue that radical change cannot happen overnight, or even in the lifetime of a parliament, should acknowledge how much was achieved at pace when people were united by a common purpose. However, it is recognised that this was achieved at a cost to ‘normal’ services and with huge demands on key frontline staff and managers. Public health departments, that had suffered years of cuts to budgets and staffing levels and so had little capacity, became the centre for expert advice and support on the unprecedented crisis.
From March, extensive measures were implemented across many countries to try and slow the spread of COVID-19. Whilst this was referred to as ‘following the science’, the main purpose of lockdown, social distancing, public messages about hand hygiene and appeals for people to stay away from A&E departments was to stop the NHS being overwhelmed by patients and staff contracting COVID-19. There was a much publicised shortage of PPE and ventilators but, arguably more important, also a shortage of nurses to care for the Covid and non-Covid sick. Numbers of registered nurses in the NHS has for many years failed to keep pace with the increasing need for their skills. Whilst PPE and ventilators, and even new hospital buildings, could be sourced in a matter of weeks or months, nurses take three years to train.
From the beginning the WHO advised governments to ‘Test, Test, Test’ in order to track the virus, understand epidemiology and suppress transmission through self-isolating those who had the virus. However, testing the population was never really started in the UK with only those who were symptomatic getting access to testing. This was not a failure of the NHS but of a 40-year long failure of industrial and scientific policy and of funding the NHS that left the UK with limited testing facilities and no manufacturing capacity to rapidly produce the reagents needed for testing.
NHS systems could cope with testing of patients but the UK government had to set up from scratch the Nightingale Labs to cope with the demand for testing people in the community. The option of commandeering the research facilities of private industry for testing or for the manufacturing of the reagents was not considered.
Acute hospitals quickly became COVID-19 hot zones so the priority to protect the vulnerable elderly and the capacity of the NHS led to a rapid discharge of patients into care/nursing homes and to the community. Without a testing regime in place, this was a major mistake and something which will no doubt come under intense scrutiny through the judicial review agreed by Parliament. At the same time, the failure of many of the mostly privately-run care homes to apply strict infection control measures or to ensure staff were paid whilst needing to isolate compounded the situation leading to the huge number of deaths in those establishments. Neither the staff nor residents in the care homes or those coming out of hospital were being tested, nor was the virus being tracked in these settings, until someone was symptomatic by which time it was too late to stop it spreading.
Suddenly, as we all clapped for carers, the nation realised the importance of these staff, putting themselves at risk, saving lives and caring for elderly within the community as well as in care homes, but not getting tested.
In June, lockdown was ended and we moved to the recovery phase for the country, remobilising paused NHS services, and opening up industry, office buildings, retail, education and leisure. A proper functional test and track system which the UK government boasted would be world class was still not in place. It is clear that the end of lockdown was taken for economic and public spending reasons and not because the virus had been beaten or that the necessary testing systems were in place. The UK Tory government put its faith in the private sector, at huge costs, to deliver. It failed.
Its efforts to create an app that could track people who were in contact with the virus had to be scrapped and eventually arrived after a similar one was delivered in Ireland and Scotland. In England the, again hugely expensive, private test and track system was still not fully in place till around November.
In Scotland, setting up the test, trace and isolate system was a public health imperative for the NHS. Recruiting the experienced staff needed was a challenge but that was achieved with assistance from councils. The importance of isolation was critical, and the actions of unions, with the support of Directors of Public Health, winning the fight to ensure private sector care staff received their pay when they needed to isolate was crucial.
However, 10 months after the WHO declared the pandemic and called for ‘Test Test Test’ to be implemented, we remain still far short of this objective. Care home staff and residents have only been tested on a weekly basis for a few months. Care at home staff who visit up to a dozen homes of service users each day were told in November that they would be tested but now know that it could be February or even March before that happens. Union pressure which won the initial commitment for this cannot, unfortunately, produce the significant additional capacity needed any sooner.
The return of students to university accommodation in September was a disaster as, without testing, asymptomatic students infected others and thousands of new cases were reported. Testing before they went home for Christmas may help prevent something similar happening in reverse and testing again in early 2020 may prevent a repeat.
Schools, where up to 2,000 pupils and staff congregate each day without the recommended social distancing, do not have testing offered. The UK government’s announcement in late December, as English schools closed, that secondary schools would have testing facilities available in January has been met with incredulity by the education unions who, understandably, ask ‘where are the staff who will administer these tests’?
Despite the introduction of tiers and levels of restrictions lasting months, including a return to almost full lockdown in Wales, the virus has not been controlled. The failure to regularly test in sufficient numbers has meant that the gains achieved in lockdown, such as reducing the ‘R’ number and numbers of hospital admissions, has been wasted with each lockdown or greater restriction being followed by rises in cases. Just as in February, people still pass on the virus when they don’t know they have it as they don’t, and sometimes never, have symptoms.
There were concerns earlier that testing people who were not symptomatic would be ineffective as the test would often return a false negative result. There remain concerns about the efficacy of the available tests but experience has shown that without testing along WHO recommended lines, the UK’s response to Covid-19 has been much poorer that it could have been.
This was further emphasised when the announcement was made a week before Christmas that, due to a new strain spreading up to 70% faster than the original virus, restrictions would be increased across all of the country and, as the media reported it, Christmas would be cancelled. Testing would not have stopped the mutation of a new variant but higher levels of testing would have allowed for greater suppression from the start.
NHS services are again struggling. As of December, Scotland was in a better position than London and the south east of England but the NHS was still coping with significant Covid demands on top of trying to restore other services and the annual winter pressures. Staff are exhausted and resources are stretched. In addition, they are starting to deliver the Covid vaccine. This is initially to be prioritised to the frontline NHS staff and in-patients over 80 years of age, then care home residents and staff. The priorities beyond that have still to be decided with people with underlying health problems, home carers and school staff justifiably seeking a place high up the queue. Given the higher incidence of deaths among the BAME and poorer communities, demands for prioritisation are being raised here also.
As the spring approaches, the NHS will be delivering vaccinations to millions of people. The shortage of nurses, which was a feature earlier and throughout the pandemic is also an issue with the vaccination programme and will be more so if there is an increase in Covid-19 cases going into hospitals along the lines experienced in the south east of England. The demand for other NHS services, with a backlog of cases from before Covid-19 struck, will be immense.
WHO level testing must be put in place at the same time as all of these pressures in order that public services are not overwhelmed and the virus can finally be stopped from causing even more harm than it already has.
It is clear that, along with the scientific lessons learned from the pandemic, there are important political ones too. The NHS needs better funding to train and employ more nurses and specialist staff. Care homes need to be properly funded within a national care service. Councils who have responded well to the crisis but been further financially weakened need their long-term funding issues resolved to recover and rebuild community services. Industry and science need to be resourced and re-directed in order to build the capacity for the benefit of society as a whole so that in times of crisis like pandemics vulnerable people and the key institutions like the NHS, care and education can be protected.
Lilian Macer is the Convenor of UNISON Scotland