this week CONTAGION page 213 • VACCINE SAFETY page 214 • COVID VARIANTS Q&A page 216 DAVID CLIFF/NURPHOTO/PA DAVID NHS shake-up to reverse Lansley reforms

Key elements of the Health and Social Care the health secretary will have a new duty to , the health Act 2012 are to be reversed in the biggest publish a report every parliament that “will secretary for , legislative shake-up of the English health support greater clarity around workforce will oversee a major service in a decade. planning responsibilities.” reorganisation of the health services in the country A draft white paper, leaked to the The Care Quality Commission will be website Health Policy Insight, outlines given direction to assess local authorities’ proposals to reverse major parts of former delivery of adult social care, and the health health secretary ’s secretary will be able to intervene if there is controversial reorganisation, including a risk these duties will not be met. But there formally abolishing requirements to do with are no details for social care changes. competition and competitive tendering in The Medicines and Healthcare Products the NHS, and shifting control and decision Regulatory Agency will be able to set up new making power back to Whitehall. national medicines registries and work with As The BMJ reported in December, the NHS to maintain them “where there is LATEST ONLINE clinical commissioning groups, created in a clear patient safety or other important 2012, will be replaced by larger statutory clinical interest,” the draft paper adds. Increase in medical “integrated care systems” that will manage Danny Mortimer, NHS Confederation school applicants local health systems. But the government chief executive, said, “There is often anxiety will not equal more also intends to shift substantial power from about ‘another NHS reorganisation,’ but the doctors, says BMA NHS England to the secretary of state for NHS and the partners we work with have NHS agrees to health and social care, who will be given been on this journey now for several years. pay £13m for boy direct control over local integrated care This is the logical next step.” who was left brain systems, NHS England, and NHS foundation However, he added, “There is concern that damaged from lack of nutrition trusts, which will lose their independence. in an overly centralised system the reforms after birth Ministers will also be able to intervene “at need to better empower local NHS and care any point” of a reconfi guration process and leaders to lead—they are best placed to run McKinsey agrees to pay $574m be given powers over arm’s length bodies to services for their communities.” to US states to stipulate their functions and abolish them. bmj.com See Andy Cowper BMJ 2021;372:n384 settle opioid The document does not include a specifi c Gareth Iacobucci , The BMJ claims plan to tackle workforce shortages but says Cite this as: BMJ 2021;372:n377 the bmj | 13 February 2021 211 SEVEN DAYS IN BMA welcomes decision to enable doctors to make deferred choice on pensions The BMA has backed the government’s decision to allow doctors to make a deferred choice on their pension contributions, in response to a Court of Appeal ruling that changes made in 2015 unlawfully discriminated against younger members of public service pension schemes. The changes meant that only older members—those within 10 years of retirement in April 2012—were allowed to remain in the older and more favourable fi nal salary scheme. Aft er consulting on two options, the government said it had decided to proceed with the deferred choice rather than the immediate choice option. “This means that members will make their decision between scheme benefi ts shortly before benefi ts are paid from the scheme,” it said. “In the meantime, members will be deemed to have accrued benefi ts in their legacy schemes, rather than reformed schemes, for the remedy period, until they make that choice.” Most respondents to the consultation backed the deferred choice option, as it would give greater certainty on benefi t entitlements at the point at which they made a decision, while the immediate choice would have forced them to make a decision now, on the basis of assumptions about factors such as future earnings. Vishal Sharma (left ), chair of the BMA pensions committee, said the government had listened to “common sense.” Gareth Iacobucci , The BMJ Cite this as: BMJ 2021;372:n362

Covid-19 covid reported side effects more International news of Health figures, reported by No classic symptoms in frequently after the first dose. South Africa pauses the BBC, found that only 531 of 40% with past infections A second small study from the use of Oxford vaccine almost 750 000 fully vaccinated Around a quarter of people University of Maryland, also Rollout of the Oxford- people aged over 60 tested with evidence of past covid- published as a preprint, reported AstraZeneca covid-19 vaccine in positive for SARS-CoV-2 (0.07%). 19 infection were completely similar findings. South Africa was paused after a Of these, just 38 were admitted asymptomatic, a UK study found, study in 2000 healthy and young to hospital with moderate, while 40% did not have any of the Data for Oxford vaccine volunteers reported that it did severe, or critical disease. three typical symptoms—fever, support 12 week dose gap not protect against mild and persistent dry cough, or loss of moderate disease caused by Vaccine hesitancy taste or smell. The UK Biobank the new variant (501Y.V2) that Bishops and church leaders SARS-CoV-2 Serology study emerged there. The unpublished tackle misinformation analysed monthly blood samples study, seen by the Financial The NHS joined forces with of nearly 19 000 people from 27 Times, examined the efficacy of cross denominational leaders May to 4 December. Some 99% of the vaccine against the 501Y.V2 of the Christian faith to launch participants who tested positive variant—which accounts for a campaign aimed at tackling for previous infection retained The UK’s approach of leaving a around 90% of cases in South misinformation that has antibodies for three months after three month interval between Africa—in HIV negative people. caused distrust about the being infected, and 88% did so doses of the Oxford-AstraZeneca No data have been made covid-19 vaccine, particularly for at least six months. vaccine was backed by new available to the public. in black majority communities data, and Oxford University and churches. Supporters Past infection may mean researchers said the vaccine N ew infections in Israel of the Give Hope campaign only single mRNA dose “may have a substantial drop after vaccinations organised by YourNeighbour, a People who have already had impact on transmission.” The Early findings from Israel’s network of more than 1000 confirmed covid-19 may need paper, a preprint under review covid-19 vaccination churches from over 40 only a single dose of an mRNA by the Lancet , is an analysis programme suggested denominations in the UK, vaccine, two small studies of additional data from trials that the rollout of the include Paul Butler, bishop indicated. The first, from Mount involving 17 177 participants in -BioNTech vaccine of Durham; Agu Irukwu of Sinai in New York and Paris and the UK, Brazil, and South Africa. was leading to fewer the Jesus House; Rose published as a preprint, found A single standard dose of vaccine new infections and Hudson-Wilkin (left), that seropositive people had a provided 76% protection overall was at least 50% bishop of Dover; rapid antibody response after one against covid-19 symptoms in effective 13 to Anthony Cotterill of dose of either the Pfizer-BioNTech the first 90 days after vaccination, 24 days after the Salvation Army; or the Moderna vaccine. It also and protection did not wane in the first dose. and other senior found that people who had had that time frame. Israeli Ministry church leaders.

212 13 February 2021 | the bmj SIXTY SECONDS MEDICINE ON . . . Research CONTAGION Russian vaccine efficacy is 91.6%, results show AS IN, WHEN A DISEASE IS SPREAD BY The covid vaccine developed by TOUCHING SOMEONE OR SOMETHING? the Gamaleya Research Institute, Well, yes. But the term contagion can also part of the Russian Ministry refer to situations in which ideas spread from of Health, has an efficacy of one place to another. Which brings us neatly 91.6%, interim results from a on to Matt Hancock. phase III trial showed. Findings HAS HE BEEN SPREADING THE GOSPEL published in the Lancet showed ABOUT TECHNOLOGY AGAIN? the two dose regimen of the viral The viral vector No, not this time. England’s health secretary vector vaccine was generally well “Sputnik V” vaccine has in fact revealed that the UK’s swift tolerated, with no associated response to rolling out a vaccine for covid- serious adverse events and a good enough excuse” for 19 was influenced by Contagion , the 2011 similar efficacy in people aged “painfully slow” progress, MPs CYBER Steven Soderbergh fi lm starring Gwyneth over and under 60. The Gam- argued. The committee chair, Paltrow and Matt Damon, which is about COVID-Vac, also known as Sputnik Meg Hillier, said, “Government CRIME the spread of a deadly virus and the ensuing V, was given to 15 000 volunteers must move on from aspirational global response. NHS staff (of whom 1611 were over 60), and words and start taking the hard SOUNDS EERILY FAMILIAR 4902 received a placebo. decisions required to deliver real in England Indeed. There was a surge in interest in results—time is running out.” received a total of the fi lm last year because of covid-19, Climate change and Hancock clearly picked something “Millions” face potential Alcohol 137 476 up aft er watching it. He told LBC Radio health risks in UK Numbers of deaths malicious emails that aft er observing the fi lm’s portrayal of hit record high in 2020 the huge scramble for the vaccine once it last year, official Deaths from alcohol reached became available, he insisted the UK order record numbers in England and figures from NHS 100 million doses of the Oxford-AstraZeneca Wales in the first nine months Digital showed vaccine, rather than 30 million. of 2020, showed provisional [FOI request from HOW DOES THIS FIT IN WITH data from the Office for National the Parliament “FOLLOWING THE SCIENCE”? Statistics. Some 5460 deaths Hancock insisted that the Hollywood Almost a third of people report related to alcohol specific causes Street think tank] blockbuster was not his “primary” source of experiencing post-traumatic were registered from January to advice, but he said it did open his eyes to the stress disorder after their September—a 16.4% increase on “huge” demand for a vaccine once approved. house flooded, highlighting the same nine month period in “He would keep referring to the end of the the potential health risks from 2019 (4689 deaths). A peak rate fi lm,” one former Department of Health climate change for millions of of 12.8 deaths in 100 000 people adviser told . UK residents, warned a report was reached in the first three WOW! IS HANCOCK AFTER A by the Climate Coalition and the months of 2020—the highest PART IN CONTAGION 2? Priestley International Centre for since records started in 2001. Well, Soderbergh has revealed that Climate. Experts estimated that he is working on what he described more than 12 million people in Staff wellbeing as a “philosophical sequel” to the UK were vulnerable to adverse Call to support doctors Contagion but set in a diff erent health because of events made and drop “hero narrative” context. If that context requires an more likely by climate change, The mental health charity Mind enthusiastic go getting individual such as heatwaves and flooding. launched guidance for NHS with a love of apps, then maybe leaders on creating cultures where Hancock could be the new Damon. Progress on air quality mental health and wellbeing DOES HE HAVE ANY ACTING is “painfully slow” are prioritised and talked about EXPERIENCE? The government is failing to openly. The guidance, funded Based on a recent TV clip in which he cried at deliver on its 2011 pledge to by the BMA, aims to help the news of the fi rst covid-19 vaccine being improve the natural environment tackle the stigma that has been delivered, a mid-career transition from the “within a generation” and must do compounded by the pandemic’s green benches to the silver screen might not more to tackle critical issues such “ongoing hero narrative.” be out of the question. as air and water quality, an inquiry OPINION, p238 by the Public Accounts Committee Gareth Iacobucci , The BMJ concluded. Complexity “is not Cite this as: BMJ 2021;372:n374 Cite this as: BMJ 2021;372:n350

the bmj | 13 February 2021 213

what is seen with, for example, the First UK vaccine safety data fl u vaccine, so this provides us with a great deal of reassurance.” “reassuring,” says regulator Most reported side eff ects were mild; a sore arm was the most common, and others included headache, tiredness, he UK’s medicines The number By 24 January an estimated and a mild fl u-like illness. regulator has described of yellow card 5.4 million fi rst doses of the Pfi zer- the fi rst safety data reports we BioNTech vaccine and 1.5 million Allergic reactions related to covid-19 are receiving doses of the AstraZeneca-Oxford Severe allergic reactions were reported T vaccines as “reassuring,” is very similar vaccine had been administered, and after administration of the fi rst doses with most side eff ects reported being around 500 000 second doses, mostly of the Pfi zer-BioNTech vaccine on mild and in line with those seen with to what is of the Pfi zer-BioNTech vaccine. Overall, 9 December. The MHRA then advised other types of vaccine. “The benefi ts seen with, for the data show around three yellow against its use for people with a history continue to far outweigh the risks,” example, the card reports per 1000 doses—a smaller of severe allergic reactions to any of its said June Raine, chief executive of the flu vaccine proportion than the 10% of patients ingredients and said recipients should Medicines and Healthcare Products Munir reporting them in clinical trials. be monitored for at least 15 minutes. Regulatory Agency (MHRA). Pirmohamed “We don’t expect everybody A total of 101 anaphylaxis or The agency published yellow card who gets a side eff ect to report anaphylactoid reactions after the data for vaccines given between on yellow cards,” said Munir Pfi zer-BioNTech vaccination (1-2 cases 9 December and 24 January, which Pirmohamed, chairman of the expert per 100 000 doses) have been reported comprise 22 820 reports from working group of the Independent to the MHRA up to 24 January, and 7 164 387 fi rst doses and 474 156 Commission on Human Medicines. 13 anaphylaxis reactions after the second doses. Most (16 756) are “The number of yellow card reports AstraZeneca-Oxford vaccine. from people who received the we are receiving is very similar to Bell’s palsy is listed as a possible Pfi zer-BioNTech vaccine, and these side eff ect of the Pfi zer-BioNTech list 49 472 suspected reactions. vaccine, and facial paralysis or paresis Administration of the AstraZeneca- MHRA received 107 reports of after this vaccine was mentioned in 69 Oxford vaccine began on 4 January, yellow card reports; facial paralysis and 6014 yellow cards were reported death after the Pfizer-BioNTech vaccine, 34 was mentioned in six reports after the up to 24 January, detailing 21 032 AstraZeneca-Oxford vaccine. Philip suspected reactions. A further 50 after the AstraZeneca-Oxford vaccine, and 2 in Bryan, vaccine safety lead at the reports did not name the brand. which the brand of vaccine was unspecified MHRA, said, “Bell’s palsy is something School worry as more children infected in Israel and Italy

Experts have warned that schools rise was due to the emergence of Cohen urged caution over San Raffaele Hospital in Milan, must be reopened with caution, the more contagious UK variant, schools reopening. “Though I am tweeted, “The much more amid emerging evidence from which spreads more easily convinced that education should contagious English variant calls Israel and Italy that more young among younger age groups. be the first sector to open up, it is for much greater precautions.” children are being infected with Cyrille Cohen, head of the my opinion we should still reopen new variants of covid-19. laboratory of immunotherapy at gradually . . . until we understand Safer schooling consultation Bar-Ilan University and a member better the infection pattern of this On 5 February the UK Sharp rise of the national covid-19 vaccine new variant,” he said. Independent Scientific Advisory Paediatricians in Israel, which clinical trial advisory committee, He said no evidence yet Group for Emergencies called for has surged ahead in vaccinating told The BMJ his figures indicated showed the new variant to be safer schooling to be prioritised its adult population, reported that, since the emergence of the more dangerous to children, but as it launched a consultation a sharp rise in SARS-CoV-2 UK variant B.1.1.7 in Israel in he noted that in January Israel document. Stephen Reicher of infections in children and mid-December, the proportion of had opened its first special covid the University of St Andrews, teenagers, with more than 50 000 new daily cases accounted for by intensive care unit for children. and an iSAGE member, said, “For testing positive in January—more children aged under 10 had risen Italy saw similar warnings after now, we must restrict all non- than seen in any month during by nearly a quarter (23%). a spike in cases in the northern essential activities to bring down the first and second waves. village of Corzano. On 3 February infections as fast as possible Yuli Edelstein, health minister, 10% of its total population of and reopen schools as soon as told the Jerusalem Post , “The 1400 (140) was reported to have the level is low enough for us to Israeli Association of Paediatrics tested positive for the virus, 60% start doing so without driving the are very worried about the rate of whom were children of primary pandemic back out of control.” of disease in younger students.” or infant school age. Roberto Michael Day, London Some experts in Israel said the Burioni, professor of virology at Cite this as: 2021;372:n383 H LEVINE/SHUTTERSTOCK BMJ

214 13 February 2021 | the bmj The UK was the fi rst country Covid aerosol risk may in the world to approve and start administrating the Pfi zer-BioNTech be higher than thought vaccine, but it is certainly not the fi rst in the world to report its adverse Pressure is mounting on the government and NHS trusts reaction data. The MHRA has been to adopt a more precautionary approach to personal

S AND R GREENHILL/ALAMY criticised for its lack of transparency protective equipment for NHS staff working outside Bell’s palsy is listed as a possible side in not publishing the data or its risk intensive care after the results of a study indicated they effect of the Pfizer-BioNTech vaccine management plan for monitoring the may be at greater risk of SARS-CoV-2 infection through that can also happen naturally, so its vaccines until almost two months after aerosol transmission than previously thought. association with the vaccine hasn’t they began being given. Raine said, The study, funded by the National Institute for Health been established.” The MHRA is “We’re committed to transparency Research and available as a preprint, found the risk of investigating the association more with the data, [and] we’ll be publishing aerosolisation was likely to be high in departments where thoroughly using the Clinical Practice our analysis weekly moving forward.” infected patients were coughing, such as emergency Research Datalink—a database of But advice from the Commission on departments and general wards. These are places where anonymised GP records covering about Human Medicines Expert Working staff generally wear face masks only. 20% of the population. Group to ministers regarding the The MHRA received 107 reports vaccines and the working group’s Intensive care settings of death after the Pfi zer-BioNTech minutes remain unpublished. In contrast, the risks of SARS-CoV-2 aerosolisation vaccine, 34 after the AstraZeneca- seemed to be lower than expected in situations where Oxford, and two in which the brand “Seemingly positive news” patients receive continuous positive airways pressure was unspecifi ed. Most reports Peter Roderick, principal research (CPAP) and high flow nasal oxygen (HFNO)—procedures concerned older people or those with associate at the Population Health that have been presumed to carry a high risk of aerosol underlying illness, the MHRA said, Sciences Institute at Newcastle generation and are and a review of individual reports and University, said, “It’s good to see these delivered by intensive care patterns of reporting did not indicate data coming out, with seemingly staff wearing the more that the vaccine had a role in the death. positive news for now. I’m pleased as protective FFP3 respirators. “We know, for instance, based on well to hear that there will be weekly R esearchers in Bristol data from [the Offi ce for National reporting.” But he added, “MHRA still assessed aerosol emissions Statistics], that for every 100 000 has some way to go before it can be from 25 healthy volunteers doses given to people aged 80 or over, regarded as a transparent regulator.” when breathing, speaking, around 200 people die of natural Ingrid Torjesen, London and coughing and also KING/PA

causes within a week,” Bryan said. Cite this as: BMJ 2021;372:n363 when using oxygen and JACOB respiratory support CPAP produced fewer Puberty b lockers do not stop systems. CPAP (with aerosols than breathing, exhalation port filters) was speaking, and coughing negative thoughts in children found to produce fewer aerosols than breathing, speaking, and coughing, and Puberty blockers used to treat The study followed children who while HFNO did emit aerosols, most of the particles were children aged 12 to 15 who have began treatment between June 2011 generated by the HFNO machine, not the patient. Coughing severe and persistent gender and April 2015. Inclusion criteria was associated with the highest aerosol emissions. dysphoria had no signifi cant eff ect on included the ability to give informed their psychological function, thoughts consent. PPE policy of self-harm, or body image, a study The High Court case was brought “Policy around PPE should be updated to reflect these has found. by Keira Bell, a former patient, and adjusted risks,” said James Dodd, study lead and a The fi ndings, from a study of Mrs A, the mother of a patient on consultant senior lecturer in respiratory medicine at 44 children treated by the Gender the waiting list. University College Bristol University’s Academic Respiratory Unit. Identity Development Service London Hospitals and Leeds Teaching Emergency department and acute medicine staff are (GIDS) run by the Tavistock and Hospitals trusts, who provide the more than twice as likely to be seropositive for anti-SARS- Portman NHS Foundation Trust in puberty blockers, intervened in the CoV-2 IgG than those working in intensive care units and London, have emerged as the trust case to provide submissions. anaesthetics. Dodd said exposure to patients who may be prepares its appeal against a High The court has also agreed to hear coughing and are earlier in the disease course could have Court ruling that led NHS England from David Bell, an adult psychiatrist a bearing on this, as could lower level PPE. More attention to pause referrals of under 16s for who worked at the Tavistock for should also be paid to building ventilation, he said, along puberty blockers. 24 years. He did not appear in the with reinforcing the need for patients to wear masks. The appeal, expected to be heard original case but told The BMJ that he A Department of Health spokesperson said, “The between May and July, will challenge was able to speak more freely since UK Infection Prevention Control Cell conducted a the ruling by three senior judges that retiring from the trust on 15 January. comprehensive review of evidence and concluded current guidance and PPE recommendations remain appropriate.” children under 16 are unlikely to be Clare Dyer , The BMJ able to give informed consent. Cite this as: BMJ 2021;372:n356 Ingrid Torjesen, London Cite this as: BMJ 2021;372:n354 the bmj | 13 February 2021 215 NEWS ANALYSIS Will vaccines work against these emerging variants? How big a threat is the E484K R esearch shows the current vaccines work against the UK B.1.1.7 variant without the E484K mutation. mutation to pandemic control? However, recent clinical trials by Novavax and Johnson & Johnson First identifi ed in the South African variant, the mutation has also been showed that their vaccines were less found in the UK and Brazilian variants, prompting fears the virus could eff ective in South Africa than in the UK become resistant to vaccines. Jacqui Wise looks at what we know so far or US, which is presumably because of the high proportion of virus carrying the E484K mutation. Even so, Novavax reported a 60% effi cacy of their vaccine in South Africa, which is still a fairly good response, similar to that of the infl uenza vaccine. Scientists say vaccines can be redesigned and tweaked to be a better match for the new variants in a matter of months. The Oxford-AstraZeneca team, for example, announced they were already looking at updating their vaccine to make it more eff ective against the mutations that are being seen and it could be available by the BEN BIRCHALL/PA autumn. It is possible it could take What do we know about the Is this mutation something to the form of a one dose booster that is E484K mutation? worry about? updated and rolled out every year. E484K is a mutation that occurs in E484K is called an escape mutation diff erent variants of SARS-CoV-2 and because it helps the virus slip What is the UK doing to has already been found in the South past the body’s immune defences. the spread of variants? African (B.1.351) and Brazilian Ravindra Gupta at the University The UK has identifi ed 105 cases of (B.1.1.28) variants. The mutation of and colleagues have the South African variant B.1.351, is in the spike protein and seems to confi rmed that the new B.1.1.7 so far. Most could be linked to travel, have an eff ect on the body’s immune plus E484K variant substantially but 11 cases could not, meaning it is response and, possibly, on vaccine increases the amount of serum spreading within the local community. eff ectiveness. antibody needed to prevent infection As a result the government announced On 1 February Public Health of cells. We already know the B.1.1.7 it would carry out additional surge England (PHE) announced that variant is more transmissible, so testing and sequencing in eight the Covid-19 Genomics (COG-UK) a combination of a more rapidly postcode areas in England. This is consortium had identifi ed the spreading virus that is also better at B.1.1.7 variants likely to be the tip of the iceberg, mutation in 11 samples carrying the evading immunity is worrying. If it carrying however, as less than 10% of samples UK variant B.1.1.7 (sometimes called isn’t stopped it would outcompete the E484K from people who test positive are the Kent variant), after analysing the older B.1.1.7 variant. mutation sequenced, and many people never get 214 159 sequences. Another concern is that the South may be more tested in the fi rst place. African variant might be able to more efficient at Where in the UK has it been effi ciently reinfect people who have reinfection Is monitoring good enough? identified? previously been infected with the Lawrence Young The UK has carried out nearly confi rmed to original form of the virus. Lawrence half of all SARS-CoV-2 genome The BMJ that it has now identifi ed Young, a virologist and professor sequences deposited to the global 11 cases of the B.1.1.7 variant of molecular oncology at Warwick database, GISAID. A spokesperson carrying the E484K mutation University, said, “This is likely to be, for the COG-UK consortium said that around the Bristol area and 40 in part, because the E484K mutation since the start of the pandemic it has cases of the original SARS-C0V-2 may weaken the immune response conducted genome sequencing on virus carrying the same E484K and also impact the longevity of about 7% of positive test samples mutation in the Liverpool area. the neutralising antibody and this proportion is rising as case Public health offi cials are carrying response. So B.1.1.7 variants numbers fall and capacity increases. out enhanced , carrying the E484K This is the highest in Europe, additional laboratory analysis, and mutation may be more apart from Denmark, which testing in these areas. effi cient at reinfection.” announced it will soon test

216 13 February 2021 | the bmj all positive covid-19 test swabs for Black people aged over 80 are the presence of variants. Globally, however, genomic surveillance of half as likely as white people SARS-CoV-2 remains patchy. For to be vaccinated in England example, the US sequences less than 1% of new samples, and many Targeted activity may be needed to countries, especially in Africa, have tackle the disparities in access to While 42.5% of white covid-19 vaccines, the authors of a no sequencing data at all. people were vaccinated, only B.1.1.7 plus the large study have said after finding Is the UK sharing its capacity to E484K variant that ethnic minorities, people living 20.5% of black people carry out genomic testing? substantially in areas of high deprivation, and and 27% to 29.5% On 26 January the UK government increases the those with severe mental health of people of mixed, other, and announced it was launching the illness or learning disabilities seem amount of South Asian ethnicities were. New Variant Assessment Platform to serum antibody less likely to have been vaccinated. off er genomics expertise to identify needed to Between 8 December and The other 39.7% were of new variants of the virus to countries prevent cell 13 January 41% of people aged 80 unknown ethnicity or over in England who do not live that do not have the resources to do infection so. This will be led by Public Health in care homes were vaccinated. only describing the disparity in Ravindra Gupta England working with academic But the researchers, from the vaccination rates between different partners and WHO’s SARS-CoV-2 University of Oxford and the London groups, and we cannot explain global laboratory working group. School of Hygiene and Tropical them. Nonetheless, it’s fair to say Medicine, found much divergence this is either vaccine hesitancy How can we stop any more in vaccination rates by ethnicity or issues around the logistics of variants emerging? within this group of 476 375 people how the vaccination programme The SARS-CoV-2 virus makes around (of a total of 1 160 062 aged over is rolled out, or a mixture of the one or two mutations a month. This 80). While 42.5% of white people two. The ethnicity gap that we are sounds quite a low number and is were vaccinated, only 20.5% of seeing is consistent with the gap in fact lower than for other viruses, Even the most black people and 27% to 29.5% of that has been observed in previous including infl uenza. The more stringent of people of mixed, other, and South vaccination campaigns of different the virus circulates, however, the border controls Asian ethnicities were. The other vaccines for different diseases.” more opportunity it has to change. are unlikely 39.7% were of unknown ethnicity. The authors said that live data So anything that can be done to to prevent the Another disparity was seen in monitoring could help healthcare deprivation: 44.7% of people living workers make operational suppress spread of the virus will appearance of in the wealthiest areas had been decisions about vaccine rollout. help to limit new variants emerging, new variants including distancing, mask wearing, vaccinated but only 37.9% of those They said that targeted activity and handwashing. Jonathan Stoye in the poorest areas. Patients with might be needed to tackle lower pre-existing medical conditions vaccination rates in certain groups. Will closing the UK borders help? were equally likely, or more likely, Goldacre said, “We are providing From 15 February UK residents to have received a vaccine across these data as a service to help and Irish nationals travelling to the most comorbidity groups, with people and to identify problems UK from 33 “red list” countries will two exceptions: severe mental and fix them early in a very fast have to quarantine in a hotel for 10 illness and learning disability. The moving vaccination programme. days. Non-UK travellers are currently analysis, carried out on behalf of We are happy in principle to banned from entry. However, the NHS England, was published as a consider giving local teams access Labour Party, which complained non-peer reviewed preprint. to local summary data.” that the government took 50 days to The principal investigator, Ben Adrian O’Dowd, London introduce the measure after the fi rst Goldacre, told The BMJ, “We are Cite this as: BMJ 2021;372:n357 South African variant was identifi ed in the UK, is calling for the scheme to be extended to all international travellers. Jonathan Stoye, from the Francis Crick Institute, said, “Under conditions of very high levels of virus replication even the most stringent of border controls, although they may delay spread, are unlikely to prevent the appearance of new variants.” Jacqui Wise, The BMJ Cite this as: BMJ 2021;372:n359 DAN CHARITY/PA DAN the bmj | 13 February 2021 217 THE BIG PICTURPICTUREE MyanmarMyanmar medicsmedics resist resist military militar ycoup cou p

Medical staff at Yangon General Hospital aft er losing the election in November and join the nationwide protest against the claiming the vote was fraudulent. military coup in Myanmar. Making the three Two days later staff at 70 hospitals and fi nger salute and wearing the red ribbons clinics in 30 towns went on strike. In a that symbolise resistance, the staff echoed statement the organisers of the medical calls to shut hospitals across the country as resistance said, “We refuse to obey any a gesture of defi ance. order from the illegitimate military regime On 1 February Myanmar’s military who demonstrated they do not have any arrested the leader of the National League regards for our poor patients.” for Democracy, Aung San Suu Kyi, and Alison Shepherd, The BMJ declared a year long state of emergency Cite this as: BMJ 2021;372:n368

218 13 February 2021 | the bmj the bmj

| 13 February 2021 219

ANADOLU AGENCY/ GETTY IMAGES EDITORIAL Universal basic income and covid-19 pandemic Evidence backs up health benefi ts and may show the way forward

he gulf between the 14 474 Kenyan households from wealthiest and poorest 295 villages, rates of physical had been increasing illness, mental health issues, and even before the covid-19 hunger were signifi cantly lower in destroyed the globe’s households receiving payments.15 T 1 health and economies. Recent A review of studies, focusing on research indicates a growing depth the eff ects of universal basic income of poverty, and women and children on health, was published in 2020.16 are the biggest casualties of this Twenty seven studies reported deepening divide.2 The World Bank health benefi ts, including reduced predicts the number of people in mortality, improved adult health, extreme poverty will increase by and increased provision of nutrients 70-100 million in 2021 alone.3 for low birthweight infants. Welfare programmes were often criticised as unable to deal with Costs economic changes, such as the threat One common counterargument of automation and rise in fl exible NEIL HALL/EPA-EFE/SHUTTERSTOCK to basic income is the cost. work. However, since March 2020, Poverty and sub-Saharan Africa, all eight Sophisticated estimates value the rising inequality and changes stagnant studies examining the fi nancial cost of universal basic income in the to the labour market have forced income eff ect found that short term UK at £65bn-£75bn.17 This is less governments to implement economic growth are poverty was reduced. Nine of 11 than 10% of the UK government’s initiatives, such as basic income inextricably trials looking at healthcare use total spending. The net cost is, at programmes, that previously would entwined reported a positive eff ect, including most, the same as the most optimistic have been politically untenable. an increased likelihood to seek estimates of the total costs of Brexit.18 Spain, for example, has given with poorer healthcare when seriously unwell. Another criticism is that universal €1015 (£900) a month to 850 000 health Pre-pandemic evidence from fi ve basic income does not reach those households most in need,4 and the outcomes out of six trials in Latin America most in need. Some people who US paid $1200 to all adults earning reported a considerable reduction currently receive multiple social less than $99 000 annually.5 Evidence in short term poverty with universal security benefi ts might lose out. from the many pre-existing universal basic income.10 In Brazil, poverty has However, this depends on the level of basic income schemes6 suggests they fallen to its lowest level in 40 years the basic income, and short term steps may be a valuable addition to other as about a quarter of the population to ensure people are not worse off initiatives to alleviate poverty and have been receiving monthly cash would be relatively low cost.17 improve health outcomes globally. payments of $110 since March Finally, there is a fear that universal 2020. 11 basic income disincentivises work. A Safety net Poverty and stagnant income review of several unconditional cash Universal basic income programmes growth are inextricably entwined with transfers has found little evidence for aim to provide a net through which poorer health outcomes. Evidence this concern, however, with minimal individuals cannot fall by providing suggests reducing poverty improves eff ects on labour supply.19 unconditional payments to a given mental health and access to suffi cient Poverty is increasing, and this population. In practice, many existing nutrition. In the recent OpenSafely damages the health of the most schemes have been guaranteed basic study of over 17 million adults in the vulnerable members of society. income, which is a means tested Salil B Patel, clinical UK, deprivation status was strongly Fiscally conservative governments approach, as governments have research fellow, associated with covid-19 mortality. 12 are backtracking on previously John Radcliffe dipped their toes in the water. Childhood poverty is inversely inconceivable economic spending Hospital, University The fi rst nationwide randomised of Oxford related to working memory in because of ballooning unemployment 13 trial of basic income started in salil.patel1@ young adults. Children in the rates and shrinking economies. Finland in 2017, where 2000 nhs.net lowest 20% income bracket are 4.5 Universal basic income, or a variant, unemployed recipients were paid Joel Kariel, DPhil times more likely to develop severe may help economic and health 8 €560 monthly over two years. candidate, mental health problems than those outcomes once normality resumes. 14 But most evidence comes from Department in the highest bracket. Cite this as: BMJ 2021;372:n193 of Economics, less developed countries. In a In a randomised controlled trial Find the full version with references at review of 24 cash transfer trials in University of Oxford of universal basic income across http://dx.doi.org/10.1136/bmj.n193

220 13 February 2021 | the bmj EDITORIAL Protecting the envir onment from plastic PPE Greener manufacture, use, and disposal are urgent priorities

lthough measures Governments PPE waste overwhelmed waste Although vaccines are expected to to control covid-19 in the UK, management systems during the reduce the spread of covid-19, roll- 10 11 have been associated Portugal, and fi rst wave of the pandemic. out across the global population faces with some positive Capacity for local incineration, the multiple logistic challenges and is some US states 17 A environmental have reversed mainstay of clinical waste disposal, likely to be slow. The increased use eff ects, including decreases was exceeded, increasing use of of disposable PPE is likely to persist. in global emissions of carbon or delayed landfi ll and potentially contributing Strategies to reduce unnecessary dioxide,1 the pandemic has policies to improper PPE disposal.10 11 exposure to potential pathogens, exacerbated plastic pollution restricting Although incinerators have adverse such as physical distancing and through high use of personal single use environmental consequences, source isolation, should be the fi rst protective equipment (PPE). plastics including greenhouse gas emissions line of defence, before PPE is needed, In England alone, 2.3 billion items and release of hazardous compounds to reduce infection risk in healthcare of single use PPE were distributed such as dioxins, their overall harm settings and among the public.18 to health and social care services Elissa J Zhang, is less than landfi ll if appropriate Rational and evidence based use of between February and July 2020, the clinical academic, pollution controls and technologies PPE will help reduce risk of shortages same amount distributed throughout Westmead Hospital, are used.8 - 12 Capacity strains on waste and control unnecessary waste.18 the whole of 2019.2 Globally, 129 Westmead, New management systems have highlighted billion face masks and 65 billion South Wales the need to consider surge capacity Policy reversal gloves are estimated to have been Lucy P Aitchison, and the environmental impact of waste Aside from PPE related waste, used every month during the covid- University of New in disaster management plans.13 the pandemic has increased 19 pandemic.3 South Wales, Another challenge to waste consumption of single-use plastic The disposable face mask market Randwick, NSW management is that contaminated more broadly. 3 8 This has been was estimated to have increased Nicole Phillips, PPE could transmit disease.14 This driven by what is likely to be a director of medical from $800m in 2019 to $166bn in potential risk, combined with the permanent shift towards industries services 2020.4 If usual patterns of disposal complex composition of some that require more single use plastics Ramon Z Shaban, continue, around 75% of plastic PPE types of single use PPE, make waste (eg, e-commerce and takeaway food clinical chair of waste related to covid-19 will end up recycling challenging. Research into providers) and a public perception 4 infection prevention in landfi lls or ocean environments. and disease control better methods of recycling PPE is that single use plastics are more Evidence of improper disposal Andrew W Kam, ongoing, exploring methods such hygienic. Governments in the UK, of PPE is emerging, with plastic registrar, University as feedstock recycling—breaking Portugal, and some US states have masks and gloves found on of Sydney polymers into smaller molecules that reversed or delayed environmental beaches, ocean beds, and urban andrewkam@ can be used to create new products— policies restricting single use plastics environments globally.5 6 ranzco.edu or conversion into liquid fuels. 11 - 15 during the pandemic.3 - 19 Although justifi ed by the public Microplastics health crisis, these policy changes Surgical face masks, gloves, and have slowed hard won progress gowns are commonly manufactured towards reducing the global impact from plastics that break down slowly, of plastic pollution.11 13 It is now even such as polypropylene, polyurethane, more important that governments polyacrylonitrile, polyethylene, and non-governmental organisations and polyethylene terephthalate.3 5 design and implement policies A surgical mask made from these to reduce use of plastics; develop materials could take 450 years to alternative materials; promote a fully decompose.5 6 These plastics circular plastic economy where are dispersed globally by wind and plastic products are recycled, refi ned, ocean currents and may persist as or reused at the end of their lifecycle; microplastics (fragments <5 mm).5 - 7 and educate the public. Together, Plastic pollution has substantial these changes would help reduce the adverse environmental eff ects, and grave environmental threat caused by growing evidence suggests that plastic pollution. microplastics enter human food Cite this as: BMJ 2021;372:n109 chains, where they may adversely Find the full version with references at aff ect health.5 9 http://dx.doi.org/10.1136/bmj.n109 the bmj | 13 February 2021 221 FEATURE Why test and trace will fail without support for people told to self-isolate

The spread of SARS-CoV-2 will only slow if those who test positive are able to stay at home. But experts fear that this is not as easy as the government appears to think. Chris Stokel-Walker reports

arina Marquez was depending on the country, support It’s not just those needing to self-isolate who have surprised to see the for people forced to self-isolate financial tested positive or have been in contact Latino man return to the has universally lagged. “What’s support that is with a positive case, as well as for test site she was running driving the majority of background needed, many NHS staff and other key workers who C in San Francisco. He’d community transmission is non- people cannot want to protect their families from received a positive test result but had modifi able by individual choices,” potential exposure. Or indeed those come back seeking advice. says Müge Çevik, co-author of a self-isolate who live in accommodation too small “I think he was probably recent editorial in The BMJ , who properly from or unsuitable to isolate properly from undocumented and still had to go researches infectious diseases at the the rest of their the rest of the household. to work,” says Marquez, associate University of St Andrews. household Just one in eight people in the UK professor in the school of medicine “Economically marginalised live alone, according to the Offi ce for at the University of California, San communities generally cannot simply National Statistics. In London, 6.2% Francisco, and an infectious disease choose to modify their transmission of households contain two or more expert. “He was very nervous to tell networks through changes to their unrelated adults. Within-household his boss and was totally confl icted.” living or working contexts in the transmission is “very common,” Presenting only mild symptoms, absence of specifi c support.” according to the Scientifi c Pandemic he reasoned he couldn’t be that Covid-19 is known to have Infl uenza Group on Modelling (SPI-M), infectious. The patient was torn disproportionately aff ected the which advises the government, but between going to work to earn poorest in society, often in jobs that can be mitigated in part by off ering money for his family and doing right either cannot be done from home or a “comprehensive package of by his community by isolating. are unstable, or in industries such as information and support.” For millions worldwide, a positive hospitality that are not stable enough Yet government systems put in test isn’t just a medical blow but a to survive the closures that lockdowns place to support those asked to self- fi nancial one too. UK government and have wrought. isolate do not match what SPI-M says polling suggests just 17% of people To stop working and isolate is to cut off is needed. with symptoms are taking a test for fear your livelihood with immediate eff ect. that a positive result and the ensuing It’s not that they aren’t reaching out Hotels to the rescue self-isolation will lose them money. for help either: the UK Labour party Self-isolation can be diffi cult even with It’s the same quandary Marquez’s says nearly three quarters of people fi nancial support, not least for those patient faced—until she gave him who applied for discretionary grants living in the mixed, multi-generational a $500 (£366) gift card to support from local councils were denied the households that have proved to be one his family. It’s part of a Californian funding despite being asked to self- Some UK hotel of the main vectors of transmission of system implemented by primary care isolate by the NHS Test and Trace app. chains are ready to SARS-CoV-2. Which is why some UK doctors and politicians, called the And it’s not only fi nancial support house people who doctors have been working with the Right to Recover Act, to encourage the to stop working that’s needed. would struggle to hospitality industry to try and provide self-isolate at home state’s least wealthy to come forward People also need help to prevent space for those who don’t have it, to but the government for testing, funded mostly through spreading the virus to others in their has not embraced slow the spread of the virus. philanthropy. In a paper for Plos One households. This is a concern for the idea “There are people who need to last October, Marquez and colleagues isolate but are struggling to do so evaluated the scheme’s success. “All because of a number of factors, such of a sudden he relaxed,” she says of as living in shared accommodation,” her visitor. “He said: ‘Okay, I can do says Akbar de’ Medici, honorary it.’ Before that he was like, ‘I don’t associate professor at University know.’ It was a powerful thing to see.” College London, and medical director of Cavendish Health Concierge. Test, trace, isolate De’ Medici has been working with While functioning test and trace the hotel chain Best Western to train systems have stuttered into life hotel staff in infection control and

with diff ering degrees of speed, WESTERN BEST prevention, should they be asked

222 13 February 2021 | the bmj to step in to support hospitals. The partnership sprang up during the fi rst wave of the pandemic, with two or three hotels around London working with local hospitals to off er NHS staff quarantine space, and another housing the homeless to try and prevent street spread. But in the second wave there has been minimal action from the government to repeat the experiment, despite a third national lockdown. “Everyone’s concentrating on the vaccine, test and trace is not as proactive as it was before, and the government’s focus has shifted away from these simple, short term solutions,” says de’ Medici. The hotel industry has 20-30 000 diseases,” says Annelies Wilder- Covid is known even in their own home. It is almost unused hotel beds that could be Smith, professor of emerging to have most impossible to adhere fully to social converted into isolation hubs. infectious diseases at the London affected the distancing if you’re living in crowded “We’ve got 10 months of learning School of Hygiene and Tropical poorest in or inadequate accommodation. and putting together structures and Medicine. “But the true decline to society, often With colleagues, Wilder-Smith protocols to manage covid positive zero was because they also isolated in jobs that modelled what impact facility based patients,” says Rob Paterson of all mild cases. Every case that tested isolation for all cases could have on cannot be done BWH Hotel Group, which runs Best positive was isolated.” the spread of disease. Off ering fi ve Western hotels. The stories of China building from home isolation beds per 10 000 people Paterson likens the eff ort to hospitals from scratch reported in could reduce new infections by 57%, Dunkirk, where a fl otilla of small the early stages of the pandemic were and deaths by more than a third. boats helped evacuate Allied troops a misconception: while they were But even if they were off ered a from France during the second called hospitals, they were largely place to stay away from family, the world war. More than 500 hotels are makeshift shelters. Just last month, potential loss in income would be waiting to accept homeless, covid the country built a quarantine camp such that many might reject the positive patients needing step-down for 4000 people on the outskirts of off er, which is why it needs to be care, NHS staff looking to distance Shijiazhuang, the provincial capital of coupled with fi nancial support. “The safely from their family while the province that surrounds Beijing. problems that happen during the working, and those who have been period of isolation don’t go away, so asked to self-isolate but would fi nd it Hospital beds being able to link to other fi nancial diffi cult to do so from home, he says. China and other Asian countries support or mental health support is He reckons 5000 rooms could be such as Singapore have managed important,” says Marquez. prepared within 72 hours of being to control the spread of the virus by It’s a model that other cities in the asked. The hotels are fully insured to doing similar and admitting positive US have also followed, including New handle patients and staff , and hotel cases to hospital. That costs money, York which also has a city government workers have been trained to clean “but they do it, because they know run programme off ering a hotel and work in a way that minimises risk nobody is totally capable of isolating room, free of charge, for up to 14 of spread (only cleaning whole fl oors themselves from other household days if they do not have a safe place and only when empty, for instance). members,” says Wilder-Smith. to self-isolate (for instance if they The whole enterprise is charged at And that say the experts is the share a bathroom, live with someone cost with no profi t made. reality the UK and other European considered vulnerable, or do not The government’s response has countries—lurching from one have space to stay six feet distanced). been muted, however. Hotel isolation lockdown to another while never “The fi nancial support, the is being implemented but only for really stemming the spread of the wraparound services, and the a small number of international virus—need to wake up to. Closing human connection can convince travellers arriving from certain schools, shops, and workplaces people to do things that are really countries where cases are high. is only solving half the problem. hard,” she says, “because a lot of The reticence to the proposal goes People with mild symptoms shed times that three days of lost wages against evidence that institutional the same amount of virus as severe can tip you over the edge.” self-isolation works. “In Wuhan, cases, with some variation, and Chris Stokel-Walker, freelance journalist, they pulled out every single weapon people aren’t perfect in adhering to Newcastle-upon-Tyne [email protected] in the armoury against respiratory social distancing and isolation rules, Cite this as: BMJ 2021;372:n327 the bmj | 13 February 2021 223 THE BMJ INTERVIEW : I was too slow to boost the NHS workforce. Action can and must be taken now

The former health secretary tells Gareth Iacobucci of his regrets from his time in charge, how they have made the pandemic worse, and why this has fuelled him to be so outspoken against the current government CHRISTOPHER PLEDGER/EYEVINE CHRISTOPHER

224 13 February 2021 | the bmj wish I’d known about it doesn’t mean that the NHS does have If you don’t “That’s why, for the sake of from the outset,” says the capacity it needs, and that’s why plan the morale, with all that pressure Jeremy Hunt. “I was very I concluded during my time as health workforce ahead of us, we need that long term proud to push through secretary that we need many more strategically, workforce plan.” “ Ivery large increases [in doctors and nurses.” it ends up “If you don’t plan for the NHS recruitment] in 2016. But the truth Though generally relaxed and workforce strategically, it ends up is that not a single doctor has yet refl ective as he talks to The BMJ on costing the costing the taxpayer much more entered the workforce as a result of video link, Hunt is unable to mask taxpayer because the NHS then recruits those changes.” his frustration when he mentions much more locum doctors and agency nurses This is a big concession for a this glaring aberration in workforce because the who are much more expensive,” former health secretary, who admits planning. He argues that the current NHS recruits he adds. “This is actually the best that he was too slow to grasp the short term approach—where staffi ng locum doctors bet in the long term if you want importance of workforce planning in increases are negotiated between and agency good cost control as well as a happy the early part of his tenure (2012 to the Treasury and the Department of nurses workforce.” 2018). Hunt’s changes expanded the Health around spending reviews—is who are number of medical student places to blame and needs urgent reform. much more Holding government to account by 25%, from 6000 to 7500 from “We need a much longer time frame expensive If things had gone diff erently in 2018 onwards, costing an estimated [for planning] to get the capacity into 2019, Hunt himself could now be £100m. But this came after several the NHS that we need,” he says. ordering this as prime minister. But years of intake plateauing and didn’t “We should ask the Offi ce for he lost out to in the solve the immediate workforce crisis. National Statistics to work with NHS Conservative leadership race. The With the covid-19 pandemic England every year and publish what rest, as they say, is history. exposing an already stretched NHS the 5, 10, 15, [and] 20 year workforce Some might have expected a workforce to new levels of stress, requirements for the NHS are going quiet retreat to the backbenches for burnout, and trauma, Hunt, who now to be, so that we can make absolutely the man who once said that health chairs the House of Commons health sure that we are training enough would be his last big job in politics and social care select committee, is in doctors, nurses, endoscopists, (it wasn’t—he later became foreign no doubt that action is needed, and oncologists. All those diff erent secretary). Instead, a liberated now. “We’re in the rather ridiculous specialties,” says Hunt. He is sure Hunt has reinvented himself as a situation that three years after the that such numbers already exist. “We parliamentary inquisitor-in-chief, NHS 10 year plan was published, we could easily publish them this year, forensically holding offi cials and still don’t have the 10 year workforce and we should.” ministers to account leading the select plan,” he says. On 26 January, , committee. The incumbent health “This has been the most chief executive of NHS England, secretary, Matt Hancock, among challenging year for the NHS in told MPs that the number of people others, has looked uncomfortable its history. We should be asking waiting more than a year for an being grilled by his predecessor. ourselves, what do we need to do operation had risen from about 2000 The BMJ spoke to Hunt in the now to turn this into a 1948 moment to 200 000. Given this and strained week that the UK passed the grim [when the NHS was founded] and public fi nances, how does the NHS milestone of 100 000 deaths from give the workforce the confi dence bolster a healthcare workforce that covid-19—“a horrifying number and that there is a long term strategic is in dire need of a break? Hunt says it’s genuinely heart breaking for us plan in place that will ultimately deal the circumstances demand boldness as a country to go through this,” he with the rota gaps, the pressures, and from the government. says. Where does he think the biggest the shortages?” “The NHS was set up in 1948 mistakes were made? “We’ve talked when we were bankrupt as a about test and trace, we’ve talked Lack of workforce planning country, exhausted after the second about the timing of lockdown, which Hunt is considered in the way world war, and yet we still found is often debated,” he says. “The he makes his criticism, perhaps the imagination and vision to do biggest mistakes in the social care conscious that he ran the NHS for something truly wonderful,” he says. sector were around the discharging six years in a period of austerity that “It’s going to be all hands on deck to of patients who were covid positive led to the biggest ever NHS funding try and bring those waiting lists back into care homes.” squeeze, staff shortages, reductions down. That is going to expose the “We have a lot to learn from in bed capacity, and a junior doctors’ gaps in our workforce even more. countries like Germany that said that strike over new contracts. “The question a lot of people ask is, does the NHS have enough HUNT’S CHANGES expanded the number of medical capacity [and] resilience to handle a pandemic?” he says. “I would say student places by 25%, from 6000 to 7500 from 2018 onwards, costing an that actually it has been surprisingly eff ective in the last year. But that estimated £100m the bmj | 13 February 2021 225 care homes were not allowed to take covid positive patients unless they were able to quarantine them for two weeks, and they were very strict about that. That may be the single reason why their death rate has been so much lower.” More recently, Hunt has been calling for more fi nancial support for people who are asked to self-isolate by NHS Test and Trace, noting that Hunt as health secretary gives evidence on the spending review to the Health Select Committee in May 2016 many people are not complying because of fears over loss of income. than the methods that you would use We should big lessons of the future is to have “We should just off er a blanket salary for SARS and MERS [surveillance and just offer a localised contact tracing capability.” backfi ll promise that if you’re asked containment, community testing, blanket salary Trust, he says, is the reason— people to self-isolate, we will refund any contact tracing and isolation, and backfill are more likely to comply with advice salary you lose,” he affi rms. “Frankly, stockpiling personal protective promise if called by someone from their local that would be cheaper than having to equipment, and ventilators]. that if you’re council “than someone in a call extend lockdown continuously.” “That was not unique to the UK. centre 300 miles away.” That was shared in the US and across asked to He supports the call for a public Pandemic groupthink Europe. But it’s why there is this stark self-isolate, inquiry into the UK’s handling of the Hunt acknowledges that decisions diff erence in the eff ectiveness of our we will refund pandemic and suggests that this could he made while in offi ce have responses compared with countries any salary begin as soon as the autumn, though aff ected the UK’s ability to respond in East Asia. That meant that we you lose not until the pandemic is under to the pandemic. “We’ve really didn’t have test and trace capability control. “Having given evidence to been on the back foot from the at the outset, but also that we spent public inquiries myself as a cabinet start on test and trace, and in some much too long deciding to do it.” minister, they are immensely time ways it dates back to the period This spring, the select committee consuming,” he says, “I don’t when I was health secretary,” he will publish its report into lessons think we would want to tie up Matt says. In 2016, the UK government learnt from the UK’s pandemic Hancock, Boris Johnson, or [vaccine undertook the response. As well as pandemic deployment minister] simulation to test our preparedness preparedness, it will examine in that kind of process at this stage.” for a pandemic. Hunt insists that the the importance of domestic He insists that any inquiry should government implemented all of the manufacturing of personal consider successes, such as vaccine recommendations from the report, protective equipment and assess development and distribution, but concedes that, in hindsight, the whether the UK got the right balance as well as failings. “We have UK and other western countries were between central and local testing had probably the most eff ective too focused on infl uenza. and contact tracing. vaccination programme anywhere “We did exhaustive pandemic Hunt was one of the most vocal in the world, in terms of the speed of preparations; we were lauded by critics of the government’s decision approving and distributing vaccines, Johns Hopkins University as being to initially stop community testing but also this is the country that the second best prepared country and tracing last March, before it developed one of the vaccines that in the world. But we were sadly also later reintroduced it with a new, has been approved for use,” he says. part of a groupthink that said that centralised system in May. “Because “The UK has punched well above the primary way that you respond we had to set up our capacity very its weight in terms of helping the to a pandemic is the fl u pandemic quickly in May [2020], we opted world fi nd a solution to this terrible playbook [with a focus on areas for a centralised solution, which nightmare.” like vaccination and boosting is certainly quicker to get up in a Gareth Iacobucci , The BMJ hospital capacity], rather hurry,” he says. “But one of the Cite this as: BMJ 2021;372:n335

“THE EXTREMELY BITTER JUNIOR DOCTORS’ DISPUTE WAS A SOURCE OF GREAT SADNESS TO ME” For Hunt the positive years, around 3.4% a a proposed new contract. that is that you can aspects of his legacy year on average. “It made it much harder quickly get sucked into include his focus on But he says that he for me to communicate a very bitter dispute patient safety after the particularly regrets the my core priorities around that neither side really Mid Staffordshire inquiry failure to reach a similar patient safety to an wants—much more and the 2018 long funding settlement for absolutely vital and very quickly than you might term NHS funding deal, social care, and the hardworking part of the imagine. And it was a which provided an extra “extremely bitter” dispute workforce,” he says. source of great sadness £20.5bn spread over five with junior doctors over “What I learnt from to me that it happened.”

226 13 February 2021 | the bmj