8

Written evidence submitted by Geoff Snell (CLL0041)

• The UK government was unprepared for the covid-19 pandemic.
• If previous warnings from significant organizations, individuals, recent outbreaks of zoonoses and public health exercises had been heeded the UK might have had the same level of preparation, including testing and tracing contacts, as South Korea with similar outcomes in numbers of cases and deaths.
• Potential preparations against further epidemics/pandemics are listed (Paragraph 9), which, if adopted should lead to the UK being better prepared in future.
• With increasing population pressure forcing contact with wildlife in wilderness areas and increasing interconnectedness through air travel, further zoonotic pandemics  are extremely likely. The UK government needs to be better prepared for them.
• Key to future UK preparedness will be a change of government and societal attitudes away from efficiency and leanness towards resilience.
• The World Bank’s cost/benefit analysis is in favour of preparation.

Background

1 From 1969 to 1986 I was a laboratory scientist at the Ministry of Agriculture, Fisheries & Food’s (MAFF) Central Veterinary Laboratory, in parasitology and then microbiology for 12 years. Attendant learning included an applied zoology degree. I developed a good understanding of zoonoses (diseases of animals transmissible to people). In 1986 I moved to MAFF’s Internal Audit Division and retrained as an internal auditor. Soon after moving to the Manpower Services Commission (MSC)  in 1989, I became a senior auditor. Internal audit is concerned with the adequacy and effectiveness of internal control systems in every area of an organisation’s business, not only finance. I was involved in auditing a wide range of systems in both MAFF and MSC and its successors. I became a counter-fraud specialist in 1996 and led the Learning & Skills Council’s counter-fraud activities from 2001, retiring in 2008. I am writing because I want the country to be better prepared for the next epidemic than it was for Covid-19.

Our preparedness for Covid-19

2 Lockdown with the messages ‘stay at home’, ‘flatten the curve’, ‘protect the NHS’ was imposed on 23rd March 2020. Within days I realised this was because we were totally unprepared for Covid-19. This realisation was substantiated by later statements in the news media (e.g. Sir David King, Government Chief Scientific Adviser, 2000-2007, “Britain was better placed to face a pandemic in 2008/9” and “since 2010 things have been run down.” ;[1] Sir Paul Nurse, Head of the Francis Crick Institute, “the government was unprepared”;[2] Matt Hancock, Secretary of State for Health, admitting that the government had moved away from a ‘test & track’ strategy on the 12th March because of a lack of capacity.[3])

The warnings missed

3 Successive governments failed to act on warnings from significant people (e.g. Larry Brilliant, 2006, epidemiologist on the smallpox eradication team;[4] Bill Gates (2015)[5] on his foundation’s observations.) and events. These events are:

• Ebola (multiple outbreaks since 1976),
• bird flu (multiple outbreaks since 1997),
• Severe Acute Respiratory Syndrome (SARS, 2003),
• swine flu (2009),
• Middle East Respiratory Syndrome (MERS, 2012),
• Exercise Cygnus in England (2016) and
• Exercise Iris in Scotland (2018).

Jose Manuel Barroso, former president of the European Commission and previously prime minister of Portugal, said on 22nd May 2020 that pandemic was top of the world risk list, but western countries did not prepare.[6]

4 By contrast, South Korea experienced MERS in 2015 with 200 cases, 38 deaths and a cost of US$8 billion. They therefore prepared for the next outbreak, covid-19.[7] A key part of their preparations was a system which enabled them to implement test and trace quickly. The outcome to 26th November was: 32,318 cases and 515 deaths from a population of 51.5 million. On the same date the UK outcome was: 1.65 million cases and 56,533 deaths from a population of 66.65 million.

The result

5 The result of these missed warnings was that the UK was unprepared.

6 From the start, there were shortages of everything: laboratory facilities, testing equipment and reagents, Personal Protective Equipment (PPE), intensive care unit beds, and ventilators. Government procurement was forced to compete with other countries in international markets for everything and was unable to acquire what was needed. Scientific advice was constrained by lack of resources. “A lack of capacity drove strategy rather than strategy driving capacity.”[8]

7 Matt Hancock, the Secretary of Health & Social Care’s position was summed up in a profile broadcast on 26th April, ‘He’s pulling all the right levers, but there’s nothing there’.[9] There was nothing there because preparations were not made.

8 The UK was unable to follow the South Korean example.

What could have been in place

9 When I realised our lack of preparation, I made the following list of preparatory actions applicable to any pandemic. I amended the detail in the light of further information. Many of the arrangements that the current government has had to make under pressure, and thus poorly, could have been made calmly by previous governments before the pandemic and therefore better. Preparations should include:

1. A permanent independent expert commission charged with keeping up to date with potential threats, overseeing planning, and maintaining response arrangements, such as those below, in line with advances in technology. What is needed is a single organisation responsible for all aspects of pandemic preparation. All of this should be the responsibility of the new National Institute for Health Protection, which should absorb the New & Emerging Respiratory Virus Threats Advisory Group (NERVTAG). The remit of Public Health England (PHE) has been too broad. Its emphasis was not on pandemic preparation. Its Strategic Plan for 2020 to 2025 refers briefly only to pandemic flu.[10] Jeremy Hunt, Health & Social Care Committee, confirmed that PHE had the wrong structure and concentrated too much on ‘flu virus types, and not enough on SARS virus types. BUT PHE was focusing on the areas the government told it to.[11]
2. Dedicated isolation hospitals for infectious diseases This is also advocated by Carl Heneghan, Professor of Evidence-based Medicine, Oxford University.[12] He suggests a return to fever (isolation) hospitals; fully equipped beds reserved for infectious disease outbreaks. However, the NHS faces the same pressure towards ‘leanness’ as all government departments. In the financial year 2018/19 the NHS bed stock was 141,000 (down from 289,000 in 1988). Overnight, general, and acute bed occupancy averages 90.2% and regularly exceeds 95% in winter. This is  well above the level considered safe by many.[13] There is little slack for emergencies.  Dedicated isolation hospitals (including mothballed Nightingale Hospitals) would avoid closing many NHS routine services. Saffron Cordray, (NHS Providers), said  the cost of reconfiguring the NHS for covid-19 would be a slow return to routine treatment.[14] The NHS Confederation said  returning to normal service would be difficult and predicted waiting lists would double to 10 million by the end of the year.[15] Excess non covid deaths (e.g. from cancer) due to ceasing normal operations were reported.[16] It may not have been the best decision to treat Covid-19 patients in ordinary hospital wards having created capacity by stopping all non-urgent treatment. This left the Nightingales under-used. Neil Mortensen, President, Royal College of Surgeons, pointed out the need to split covid-19 hospital provision from other provision.[17] Belatedly hospitals were split between covid and non-covid wards to enable a semblance of normal service.[18] Apart from a permanent core, emergency staffing of isolation hospitals might come from volunteer NHS staff, recent NHS leavers and retirees; medically trained military personnel (including bandspeople) and as was suggested this time, furloughed flight attendants. Since doctors and nurses are required to undergo continuous revalidation adequate retraining time would be needed. Perhaps this might be provided by a period of annual recall like that of the army reserve forces.
3. Stockpiled PPE, ventilators, and testing and other equipment. Lack of PPE was cited multiple times in interviews of medical staff, including a consultant doctor interviewed on 12th May.[19] Robert White, National Audit Office (NAO), reported that PPE stockpiles were inadequate; there was the wrong mix of items which ran out quickly. Needing to buy scarce items on the international market resulted in excess expenditure of £10 billion.[20] Mark Roscrow, Health Care Supply Association, said that a review after the 2009 flu pandemic highlighted holding cost and volume issues. The result was a mixed ‘just in case’ and ‘just in time’ solution of stockpiles and contracts for delivery triggered by notification of a pandemic. Such contracts failed.[21] The result was insufficient PPE for both the NHS and Care sectors. Care staff and patients were left exposed. Ventilators were also in short supply. At the start of the outbreak the NHS had less than 8,000. Despite the Government strategy to increase this number by buying proven devices from the few small UK firms that made them, importing from abroad, and using innovative outcomes from a “ventilator challenge” issued to manufacturers on the 16th March 2020, only 10,000 were available by the 15th April 2020 against a revised target of 18,000 machines. The situation was only mitigated by the discovery that only half of covid-19 patients needed ventilators. Also, Italian doctors had found that in the absence of ventilators, which required intubation, [22] continuous positive airway pressure (CPAP) and anaesthetic machines could be used. Kim Trautman, of NSF International (a US company with a UK subsidiary involved in product testing, inspection and certification in many areas including ventilators and other medical devices), formerly of the US Food & Drug Administration, wrote on the US and UK situations, “We may have become too efficient from a manufacturing and government perspective. Because we haven’t stockpiled we’ve lost a lot of the mentality of the First and Second World Wars. Therefore, we’ve gone too lean and efficient – which is great from a business perspective, but not when something like this happens. This is where stockpiling, and those warehouses full of emergency products, come into play.”.[23] As part of our preparations for nuclear war there were, until 1995, depots managed by the large haulage and warehousing companies with food stockpiles, field kitchens and lorries. They were also useful backup for civil emergencies like dock strikes. Stockpiling would avoid the need for competition for scarce resources on international markets.
4. The rehoming from abroad of contracts for essential, high volume, low profit items, such as PPE. British companies do not usually make PPE, which is a high volume, low profit product most profitably made in countries with lower labour costs such as China, Myanmar and Turkey.[24] The government was therefore forced to buy on the crowded international market from countries that may not share the UK’s safety standards. It has been admitted that much heralded PPE brought by the RAF from Turkey on 22nd April does not meet UK safety standards and is unused in a warehouse.[25] It was not until 27th May that  Robert Jenrick, Secretary of State for Housing, Communities & Local Government, was able to say that a British company had been contracted to make billions of PPE items in the UK.[26] The UK government now says 70% of PPE needs are now made in the UK.[27] UK manufacture by expert companies would avoid the need for competition for scarce resources on international markets. It would also help ensure quality and safety standards are met. Both Mark Roscrow, Health Care Supply Association, and Robert White, NAO, say UK manufacturing should supply all PPE.[28] More broadly I believe there is a need to recognise that there are strategic sectors, such as public health, which, wherever possible, should not be dependent on overseas supply chains. This could have a positive effect on UK employment.
5. Properly tendered call-off contracts with drug and chemical companies both for drugs and test reagents. Suppliers would be required to sell preferentially to the NHS, again avoiding the need for competition for scarce resources on international markets. Besides a lack of laboratory facilities, testing capacity was restricted by a shortage of test reagents because the British company making them was selling them abroad.[29] As late as 1st October 2020, Jeremy Hunt, Health & Social Care Committee, was reporting that testing of NHS staff was restricted by shortage of test reagents.[30]
6. Properly tendered call-off contracts with competent companies to adjust their production to make necessary equipment As was learned in this outbreak, these would be with experienced companies, or consortia including them, making equipment based on proven models that meet regulations. This would avoid the waste of time and resources of the ventilator challenge. Evidence of panic is that two weeks were given for companies to submit designs. Also, manufacturers with no previous experience in making sophisticated, highly regulated, medical devices were included in the challenge. In the end the government contracted with experienced companies, or consortia including them, making models based on proven machines.[31] Similarly, panic buying led to contracting with companies with no experience of making PPE, e.g. Ayanda Capital and Pestfix. 50 million masks bought in April costing £150 million were unusable.[32]
7. Properly tendered call-off contracts with transport companies to ensure distribution.
8. A list of laboratories (state, university, commercial, medical, and veterinary) with trained people and equipment able to take on testing  in an emergency. This would avoid the lack of testing capacity experienced this time. The Commons Science & Technology Committee criticized the government’s decision to choose the progressive increase of PHE laboratory capacity over a surge in capacity using other laboratories.[33] The central Public Health Laboratory at Colindale was supplemented by initially 3, and ultimately 9[34] Lighthouse laboratories (partnerships of commercial companies, university staff and others). NHS laboratories were underused or not used. It was believed that centralisation was the only way to build capacity.[35] The Head of NHS Providers admitted that they were ‘over-dependant on centralised laboratories for testing’.[36] Centralised systems are not resilient. Problems have a high impact; handling 30,000 or more samples gives a high risk of things going wrong.[37] Other problems included: decreasing capacity as university staff returned to teaching ;[38] inefficiencies caused by people trying to work across multiple organisations without the appropriate infrastructure, standardisation, or communications;[39] and a chaotic environment in test centres. For example, 20 different types of sample tubes were in use, which makes handling complicated and causes error and inefficiency.[40] In complaining of the Government’s unpreparedness on the 1st May Sir Paul Nurse, Head of the Francis Crick Institute, said that laboratories like his were not used until late.[41] He said that the UK is always playing catch-up in relation to testing because of the bad decision to concentrate on large laboratories and not use small ones. Using smaller ones would have given the necessary capacity.[42] The Head of PHE admitted, ‘We were late coming to realise that veterinary laboratories are identifying viruses all the time’.[43] Belatedly Jeremy Hunt admitted the need to decentralize testing to hospital laboratories for resilience.[44] The government was wrong to waste money contracting with companies without their own relevant experience and expertise. The technique for identifying viruses of whatever origin is a standard which uses the same reagents and equipment, therefore all laboratories using the same technique and having adequate biosecurity should be used.
9. A list of designated post holders in the NHS and other organisations at strategic and operational levels who would be required to act in an emergency. It would include those responsible for ensuring safe conduct of business in a pandemic and those with suitable customer service and interviewing skills who would undergo appropriate regular training as contact tracers to join local public health teams as needed. They have been successful, centralised contracted Test & Trace has not. Local public health teams must be adequately resourced. The House of Commons Science & Technology Committee criticized the government for moving from the test and trace strategy on 3rd March due to lack of capacity.[45] The Government set a launch date of the 1st June for centralised test and trace, using commercial contractors, which was brought forward to the 28th May. On the 28th May Baroness Dido Harding, Head of NHS Test & Trace, [46] and others including Chris Hobson, NHS Providers[47], and four members of the government’s Scientific Advisory Group on Emergencies (SAGE)[48] agreed that Test & Trace would not be fully operational until the end of June. However, centralized Test & Trace’s effectiveness is still questioned continually (26th November 2020). The contract with SERCO was reduced from 18,000 to 12,000 tracers (too many were employed to do too little). The call was for resource to go to local depleted public health teams.[49] As late as October it was still being complained that effective local provision was being underused.[50] Test & Trace only reached 62.6% of contacts in the week ending 7th October, its worst performance. Local public health protection teams traced 97.7%. James Naismith, Professor of Structural Biology at Oxford, said Test & Trace has failed; it cannot achieve the large numbers needed. It takes years to build a good system like South Korea’s.[51] In late October Greg Clark, Science & Technology Committee, admitted that use of local test and trace had increased in the previous few days, but it was too late.[52]

The likelihood of further outbreaks

10 Further outbreaks of zoonoses are highly likely.

11 Peter Daszak, of the Eco Health Alliance estimates there are 1.7 million undiscovered viruses. 70% of new infectious diseases are zoonoses.[53] Zoonotic viral outbreaks are increasing in frequency.[54] In the last 50 years there has been a fourfold increase in virus spill-overs from animals to people.[55]

12 With increasing pressure on wilderness and interaction with wildlife and our interconnectedness through air travel, pandemics are bound to happen again. The UK government needs to be better prepared for them.

Government attitude change needed

13 Over the past 50 years the UK government has over-concentrated on leanness and efficiency. This has created aversion across the public sector to redundancy of any sort in public services. However, the transferring of a ‘just in time’ mindset from car production into the public sector does not work in overwhelming emergencies.

14 Regarding both stockpiling and the ventilator challenge, Carl Heneghan, Professor of Evidence-based Medicine, Oxford University, said, “A strategy that relied on firms cobbling together life-saving devices in a matter of weeks should teach us more enduring lessons. When we look back there will be serious questions to answer about all the decisions made. What’s been very noticeable is that we always seem to be one step behind on the policy. If it’s not ventilators, it’s tests, if it’s not tests, it’s PPE. It’s an important lesson that we have to invest to create overcapacity for these moments. We’ve really cut to the bone in this country far too much.”[56] General Sir Nick Carter, Chief of the Defence Staff, interviewed on the armed forces’ part in the response to covid-19, commented that, although boring, resilience is needed rather than leanness and efficiency.[57]

15 Key to future UK pandemic preparedness will be a change of government and societal attitudes away from efficiency and leanness towards resilience.

The cost/benefits of pandemic preparation

16 Before it wound up its pandemic unit in 2012 the World Bank had calculated the cost/benefits of preparing for pandemics for developed countries: spending of US$3.4 billion spread over 3 or 4 years would save US$80 billion.[58]