Written evidence submitted by the Royal College of Physicians (COR0003)
The Royal College of Physicians (RCP) welcomes this Health and Social Care Committee inquiry on ‘The management of the Coronavirus outbreak’. The RCP is tracking the effect of COVID-19 on frontline clinicians. The first nationwide survey of c.2,000 members about the impact of Coronavirus was carried out on 1-2 April and the second on 22-23 April. This submission is based on the data from these two surveys, plus additional consultation with members working on the NHS frontline. A third survey is planned for the 13-14 May which will be published on our website shortly afterwards.
How well the NHS is dealing with the outbreak of Coronavirus
1. Response of local NHS Trusts dealing with COVID-19
1.1 Largely members have been impressed at how quickly and efficiently their local Trusts re-organised their hospitals to manage the outbreak of COVID-19. Strong local leadership and empowering local systems to decide their own approach has been key to this. While there have been some teething issues around rotas, there generally has been a positive team spirit of ‘everyone mucking in’ to give the best quality treatment care to patients with COVID-19. Intensive care units have been rapidly expanded, specialty staff have been redeployed to acute and general and some senior consultants have taken charge of wards and patients they would never usually manage in order to support and protect junior colleagues. In some areas, hospitals have collaborated to create regional centres for intensive care patients. The outbreak of COVID-19 has presented huge challenges to the system but it has forced it to manage departments and patient flow differently.
1.2 The innovation seen during this period should be evaluated as plans to begin to return to a ‘business as usual’ NHS are developed. Health Education England (HEE) and its devolved equivalents will need to give consideration to trainee doctors who were redeployed from their usual specialty training and will need to return to it. While some things - like redeployment of staff - are not sustainable in the long term, other solutions for managing the outbreak of COVID-19 like virtual appointments and digital consultations could have equal benefit as we restart and reset. In December 2019 a survey of RCP members found that fewer than 10% of respondents had conducted more than 4% of their outpatient consultations by video in the last week. Yet social distancing has forced more clinicians to rapidly incorporate digital communication into their practice – with largely positive response from staff. New ways of working could be a positive to take from the pandemic so considered evaluation must take place.
2. Testing has increased for NHS workers, but not their household members
2.1 Over the last month there have been improvements in the management of COVID-19. More NHS frontline workers are able to access tests for COVID-19, with 91% of those with symptoms now able to access testing for themselves compared to just 31% three weeks’ before. This is a welcome improvement and we hope that number will continue to rise. Where tests are available, the turnaround for results has varied from 24 hours to a week for members. It is crucial that we continue to work towards routine testing with timely results for 100% of NHS workers. The new NHS testing portal will be key in achieving this and the RCP will continue to speak with members about ease of accessing tests through this new system.
2.2 More needs to be done to increase the availability of tests for people who live with frontline NHS workers. 29% said they were still unable to access testing for a symptomatic member of their household. Knowing whether household members have COVID-19 could be the difference between an NHS frontline worker returning to work or potentially needlessly self-isolating for 14 days. One member told us that in the early days of the outbreak, they were told that testing was not available for under 18s – meaning they had to self-isolate for two weeks because of a coughing child. In the earlier stages of the response it is clear that more could have been done to ensure that the NHS workforce was at full-strength with everyone available to work, working.. Those with symptoms or a symptomatic household member need to know as soon as possible whether they should rest or return to work.
2.3 Increased testing may have reduced the number of people off sick due to suspected COVID-19 over April. Nationally less than 8% of RCP members reported ‘being currently off work’, compared to 21.5% in London and 18.3% in the rest of England three weeks ago. Many members said that the potential negative effects of staff absence in their teams had been mitigated by re-deploying staff. Over a quarter (29%) of clinicians told us that they were working in an area of medicine that is different to their usual specialty. Annual leave has been cancelled or postponed in some Trusts. These short-term fixes are not sustainable as the NHS begins to re-open and encourage the public to come forward for treatment for cancer, heart attacks, strokes or mental health conditions. Although every area made preparations for a COVID-19 surge, the virus has hit different parts of the country harder than others. That means in some areas, where core services are reduced but the number of COVID-19 patients has been relatively low, staff resource is stronger than usual. As we begin to restart and reset non-COVID-19 services, we must not only build in the time and space for staff to recuperate, restore and reflect, but also plan for how staffing levels will be affected by a surge in non-COVID-19 patients while the need to treat the virus continues.
2.4 Although staffing levels have been a problem in hard hit areas, one of the other big impacts of staff absence has been on team morale, as frontline NHS workers worry about whether their friends and colleagues who are off work unwell, with confirmed or suspected COVID-19, will recover. One member told us that in the early weeks of the outbreak, a high proportion of consultants off sick and the tragic death of a colleague had resulted in ‘palpable fear’ among the team. Many respondents said that the absence of staff members threw into sharp relief the importance of consistent access to PPE as the best protection against contracting the virus in the first place - ‘critically unwell staff members…probably made people, including managers, take issues of PPE seriously’. This toll on the physical and mental health of the workforce must not be forgotten and will require dedicated support for the months and years to come.
3. Personal Protective Equipment
3.1 It is therefore a concern that access to PPE appears to have declined over April, with over a quarter (27%) of RCP members saying they couldn’t access the necessary PPE to manage COVID-19 patients at the end of April, compared to 22% at the start of the month. Only half of doctors surveyed had consistent access to protective goggles. 37% said they could not always access a full-face visor and 31% could not always access a long-sleeved gown if working in high risk aerosol generating procedure (AGP) areas. Some members have begun sourcing their own items of PPE such as masks or scrubs because they are concerned about official stocks running out, with 27% reusing PPE because of shortages. This chimes with findings from the British Medical Association (BMA) that just over a third of hospital doctors reported sourcing their own PPE for personal or departmental use, or had relied upon donations. Doctors must be able to focus on treating patients with COVID-19 safe in the knowledge that the PPE they need will be there when they need it.
3.2 PPE is only effective when it is properly fitted, so it is concerning to see that 31% either had not been fit tested or were unable to access fit testing for their PPE. One member told us that they failed fit testing twice but were not given an alternative mask – ‘and now I have Covid [sic], which I figured was inevitable’. No clinician should have to choose between protecting their own health or that of their patients. Fit testing and fit checking must take place to properly protect staff. Trusts must follow the Health and Safety Executive guidance on fit testing and we welcome the communication from the National Medical Director and Chief Nursing Officer emphasising the importance of fit checking. The RCP echoes this guidance. If masks are being reused it becomes even more important that fit checking takes place is crucial to protect staff. The RCP has been encouraging our members to have a PPE partner when donning and doffing PPE to ensure that this is undertaken correctly to minimise risk.
3.3 While PPE is potentially life-saving, it is not without issue. The BMA has raised concerns about the additional problems faced by women trying to get a secure fit for their PPE masks. Despite the high proportion of female clinicians working in the NHS, PPE masks are largely designed for male frames. One RCP member told us that they only passed fit testing when the mask was tied very tightly – something that they worried might not be replicable in an emergency situation. Opaque PPE masks also present problems for healthcare workers, patients and carers who are deaf or have a hearing loss, whereas hoods with respirators which are transparent have been used with positive feedback from both wearers and patients in some hospitals. The RCP encourages Government procurement teams to expand the selection of PPE equipment that they are purchasing with the aim of ensuring that all members of the NHS workforce have the PPE that they need.
3.4 We welcomed the appointment of Lord Deighton to ‘bolster the production of PPE’. The pandemic has placed considerable strain on global supply chains and we know dedicated procurement specialists are facing fresh challenges in trying to boost the availability of protective equipment. Yet for professionals on the frontline, supplies of general PPE are ‘a daily uncertainty’. Government must urgently increase access to PPE, underpinned by clear guidance from Public Health England (PHE) about what to use when. In a joint letter to Lord Deighton the RCP alongside 5 other Medical Royal Colleges urged him to be open about the procurement challenges “Just as clinicians have a duty of candour with patients and their families, the government must observe the same principle with the profession. We encourage you to be open and frank in your new role about the challenges you face, while doing everything possible to get the supplies to where they are needed.”
3.5 While the RCP supports the current PHE guidance, two points should be made. Firstly, the RCP and the Resus Council have outstanding concerns about PHE guidance that says starting CPR (specifically chest compressions) does not require Aerosol Generating Procedure (AGP) PPE. Secondly, free-text comments in our survey from members show that much needs to be done to restore confidence in the scientific basis of the guidance. PHE and the Government’s approach to involving the professions in the development of PPE guidance has been varied. At times they have worked extremely closely with the RCP and other Royal Colleges to develop the updated guidance published on the 2 April. At other times they have surprised the professions by putting out new advice on what to do in the event of PPE shortages without consultation. Working with the sector is vital for consistency of message and to maintain clinical confidence in guidance that is there to protect their own and patients’ safety.
3.6 Without adequate PPE, doctors and other clinicians are putting their lives at risk. Teams across the country are coping with the sudden, tragic loss of friends and colleagues. Overpromising and underdelivering risks further damaging the trust of frontline professionals in plans to boost the availability of protective equipment. Government must be open and transparent with NHS workers about the challenges faced in sourcing PPE – while doing everything it can to direct supplies to where they are needed to prevent further loss of life.
Patient and staff safety
4. The impact of the deaths of health and social care workers
4.1 At least 119 number of health and social care workers are known to have died with COVID-19. The initial data shows that many of the people who have died are health and social care staff from a Black Asian and Minority Ethnic (BAME) background. While nationally less than 8% of members reported being off work, 23% of locally employed doctors and 15% of SAS doctors said they were currently taking time off. Of those, 42% were ill with COVID-19. While the total number of SAS and locally employed doctors was just over 5% of the total respondents, a large proportion of these doctors are BAME.
4.2 The RCP welcomes the UK government announcement that Public Health England will lead an inquiry to understand why such a disproportionately high number of people from BAME backgrounds are dying from the virus. It is vital this work progresses at speed and issues interim recommendations/findings if needed. Given that a BAME background is an emerging risk factor for COVID-19 – alongside being male, age or having pre-existing health conditions – national guidance must be developed and issued as soon as possible for employers to carry out workplace risk assessments. Risk assessments must be individual in order to avoid further deaths of NHS staff.
4.3 We welcome the steps taken so far to support the mental health and wellbeing of frontline health workers. It is important not to underestimate the toll of COVID-19 on doctors’ mental health and wellbeing and the subsequent impact on the NHS’ ability to deal with the outbreak. Although staff may not yet be absent from work as a result, many will be experiencing understandable mental health difficulties. 41% of those working in a different clinical area to normal felt they had not been given sufficient psychological or emotional support. Other polling for IPPR revealed 50% of healthcare workers surveyed said their mental health had deteriorated since the virus began. Time off for NHS and social care staff to rest and recuperate must be part of any Government plan to ‘restart’ core NHS services.
About the RCP
The RCP plays a leading role in the delivery of high-quality patient care by setting standards of medical practice and promoting clinical excellence. We provide physicians in the UK and overseas with education, training and support throughout their careers. As an independent body representing over 37,000 fellows and members worldwide, we advise and work with government, the public, patients and other professions to improve health and healthcare. Our primary interest is in building a health system that delivers high-quality care for patients.
 RCP (2020) first survey of members about impact of Coronavirus.
 RCP (2020) second survey of members about impact of Coronavirus.
 RCP (2019) https://www.rcplondon.ac.uk/news/survey-reveals-barriers-providing-good-care-and-confidence-new-solutions
 BMA (2020) https://www.bma.org.uk/media/2407/bma-covid-19-survey-results-for-hospital-doctors-4-may-2020.pdf p12.
 RCNI (2019) ‘PPE one size fits all design is a fallacy that’s putting female health staff at risk’.
 NHS Employers (2019) Gender in the NHS.
 TUC (2016) ‘Personal protective equipment and women’ p4; Dr Helen Fidler in the Guardian, April 2019.
 RCP (2020) https://www.rcplondon.ac.uk/news/joint-letter-lord-deighton-ongoing-ppe-supply-challenges
 RCP (2020) Statement on PHE advice on managing PPE shortages, 18 April 2020.
 HSJ (2020) Deaths of NHS staff from COVID-19 analysed, 22 April.
 GMC (2020) Unfair treatment affecting many SAS and LE doctors.
 IPPR (2020) Care Fit for Carers, p12.