this week NEED FOR RECOVERY page 213 • SECOND WAVE page 214 • NW NIGHTINGALE page 216 KING/PA JACOB Mass covid testing rolled out in Liverpool

Liverpool has become the fi rst city in of a new national lockdown starting on Army personnel will be sent England to roll out mass testing of its 5 November. to the city to help process the population for covid-19. Prime minister said the mass testing, as they did in Since 6 November all people living or pilot testing scheme, which has been Leicester over the summer working in Liverpool can take a covid- backed by local leaders, would help to 19 test regardless of whether they have identify many asymptomatic people who symptoms, under a government pilot could still infect others without knowing. scheme that will screen as many as half a “Dependent on their success in Liverpool, million people in the city. we will aim to distribute millions of these The pilot will test the feasibility of new rapid tests between now and Christmas the government’s ambitious plans for and empower local communities to use mass population screening throughout them to drive down transmission,” he said. England, as The BMJ fi rst revealed in the “It is early days, but this kind of mass testing leaked documents in has the potential to be a powerful new LATEST ONLINE September. The army will provide logistical weapon in our fi ght against covid-19.” support, with 2000 deployed personnel. People will be able to book tests online, Covid-19: Study Several types of tests will be used in the in person, or by invitation from the local fi ndings strongly pilot (see box, p 214), including existing authority, and testing will take place support use of polymerase chain reaction (PCR) swab at various sites, including hospitals, pooled testing, say tests, new lateral fl ow swab tests that can care homes, schools, universities, and researchers turn around results without the need to workplaces, or at home. Any positive test Training: BMA be processed in a laboratory, and LAMP results will be collected and published by expresses concern technology that will be used in Liverpool the national NHS Test and Trace system. over changes to specialty University Hospitals Trust for NHS staff . Commenting on the rollout, Alexander recruitment Liverpool has one of the highest numbers Edwards, associate professor in biomedical of cases of covid-19 in England (410.4 per technology at the University of Reading, US nutritionists call for dietary 100 000 for 18-25 October) and was the fi rst said, “As a pilot study, there are plenty of guideline limits area of England to be placed under very high potential benefi ts if we can learn about real on saturated fat alert last month, more than three weeks world performance of mass testing intake to be lifted before the government’s announcement (Continued on page 214) the bmj | 7 November 2020 211 SEVEN DAYS IN Government faces legal challenge over appointments during the pandemic The government is facing criticism over how it has fi lled key public sector roles during the pandemic. In a legal challenge, the Good Law Project and Runnymede Trust have accused the government of appointing people personally or politically connected with senior members of the Conservative Party without an open competition or proper process. This was indirect discrimination (contrary to the Equality Act 2010), they said, and a breach of the public sector equality duty. , appointed head of the NHS Test and Trace service and then interim head of the National Institute for Health Protection, is named in the claim. She is married to the Conservative MP (both left ). Mike Coupe, Gareth Williams, Ben Stimson, and Paul de Laat, all appointed to senior positions at NHS Test and Trace, have also been named. Halima Begum, Runnymede Trust director, said, “When a recruitment process is not open and fair, it discriminates against those who are not connected to the decision makers. This has a serious detrimental impact on equality and on the diversity of the people at the top of organisations. This is always important, but even more so now so many lives depend on it. We are calling on the government to ensure a proper process is followed and for NHS bodies to be truly representative of the people they protect.” Elisabeth Mahase, The BMJ Cite this as: BMJ 2020;371:m4254

Covid-19 in England. They found that Obesity antenatal appointments than Healthcare workers no routine data were collected NICE recommends new currently recommended could report rise in abuse on how well requests for 14 treatment option reduce the odds of stillbirth. Over a third (35%) of 1250 day isolation were adhered to, NICE issued draft guidance Jane Brewin, chief executive of UK healthcare professionals making it impossible to know how recommending liraglutide the charity Tommy’s, said, “The surveyed by the Medical effective NHS Test and Trace is in (Saxenda) for adults with non- complex relationships identified Protection Society said that reducing covid-19 transmission. diabetic hyperglycaemia who here between stillbirth and social they had experienced verbal or They also found a lack of data have a body stresses make it clear that the physical abuse from patients, on people who needed or were mass index of government’s prevention strategy or patients’ relatives, during receiving support. at least 35 and must extend beyond the NHS to the pandemic. A further 7% a high risk of tackle these deeper underlying had received verbal or physical Ethnic minorities need cardiovascular issues within society.” abuse from a member of the better protection disease, after public outside a medical setting, In a review commissioned by the a discount was FGM and some had been sworn at Labour Party, Doreen Lawrence negotiated with the manufacturer, Kenyan girls are paraded for using the NHS queue at the (below) called for a wider package Novo Nordisk. Prefilled injection as control collapses supermarket. Pallavi Bradshaw of immediate measures to tackle pens will be prescribed in About 2800 girls from of the Medical Protection the disproportionate effects secondary care by a specialist southwestern Kenya’s Kuria Society described the findings of the pandemic on the black multidisciplinary tier 3 weight community who recently as “deplorable” and called for and minority ethnic population, management service. Treatment underwent female genital more concrete commitment to including further steps to protect should be discontinued if at least mutilation have been paraded implementing the NHS people frontline staff and improve 5% of body weight has not been through town centres, as plan, which sets out support communication. lost after 12 weeks, and for others reduced police vigilance during initiatives for staff. Lawrence, a life peer whose son it should not exceed two years. the covid-19 pandemic has died in a racist attack in 1993, allowed the practice to spike. Official data on England said that the government should Obstetrics Kenya is a regional leader in the found to be “patchy” confirm that employers have a Tackle social factors to cut fight against FGM, imposing Researchers developed an duty to report occupational stillbirth, say researchers prison sentences of up to three interactive dashboard, infections of, and Pregnant women who years since 2011 on people the i-sense COVID deaths from, covid-19 experience psychological stress, convicted of aiding in mutilation. Response Evaluation and should introduce domestic abuse, deprivation, “Covid-19 has taken us back,” Dashboard ( covid.i- a legal requirement or unemployment are more said Domtillah Chesang, an sense.org.uk), to for employers likely to have a stillborn baby, anti-FGM activist. “There is provide fuller data to publish their showed a study published in misinformation in villages that on how “find, test, covid-19 risk the British Journal of Obstetrics covid-19 will never end and [that] track, isolate, and assessments on & Gynaecology . Researchers people should cut their girls and support” is working a central portal. also found that attending more marry them off.”

212 7 November 2020 | the bmj SIXTY SECONDS MEDICINE ON . . . Climate crisis Trusts have NEED FOR Hospitals fail to act on been urged RECOVERY single use plastics to cut back on single More than half (57%) of hospital YAWN, POINT ME TO THE REST AREA use plastics trusts in England and 88% in You’re not the only medic in search of a Wales do not have a policy on how breather. A 2019 survey of 4000 British and Irish emergency department doctors found to reduce their consumption of their median need for recovery (NFR) score single use plastics, said a report was 70—against an average of between 36 from the BMA on how the NHS and 44 reported in the literature. The trainee can reduce its carbon footprint. led evaluation of inter-shift recovery in This is despite single use plastics the emergency department (TIRED study), making up about a quarter of all ill, mentally competent adults in published in BMJ Open on 2 November, is the NHS waste in England and Wales, the final months of life to request BIRTHS fi rst time the scale has been evaluated. and a pledge in NHS England’s assistance from a medical long term plan last year to cut professional to end their life. From 1 April THERE’S NO CHANCE OF SLEEP UNTIL back on such plastics. The BMA to 1 July 2020 I KNOW MORE. WHAT’S THE NFR? called for nine recommendations, General practice caesarean section It’s an indirect measure of work intensity including for trusts and boards Appointments are up one and fatigue that uses 11 statements with yes births in the or no answers to assess the time it takes to to publish consistent and million on a year ago North West of recover from the physical and psychological detailed reporting on their carbon Figures from NHS Digital showed eff ects of work, providing a score from 0 footprint and to have targets to 26.7 million appointments in England carried to 100. The statements include, “I fi nd it reduce single use plastic waste. general practices in England last out under general diffi cult to relax at the end of a working day,” month, a million more than in anaesthesia “By the end of the working day I feel really Paediatricians prioritise September 2019 and up from reduced from worn out,” and, “When I get home from work, climate and health 16 million in April. The data I need to be left in peace for a while.” The Royal College of Paediatrics showed 15 million face-to-face 7.7% to and Child Health declared appointments in general practice I DON’T HAVE TIME FOR THAT a climate emergency and is in September, up from 7.5 million 3.7%, Maybe you should make time. A higher NFR accelerating its work in the in April. Richard Vautrey is linked to increased risk of burnout and after advice to might serve as an “early warning” indicator area. It said the effects of (left), chair of the BMA’s use regional that you need to do something to protect the climate emergency were General Practitioners your wellbeing, say researchers Laura Cottey, especially detrimental to Committee, said, “These anaesthesia to reduce the risk trainee at the Peninsula Deanery, and Blair children and teenagers. figures show that GPs Graham, lecturer in urgent and emergency Stunted lung growth and are absolutely open and of infecting care at University. function from air pollution, for doing all they can for patients in healthcare staff WHAT ABOUT BURNOUT INVENTORIES? example, can lead to irreversible these most challenging of times.” with SARS-CoV-2 damage. The college called for NFR is diff erent, the authors say. They WHO’s air quality standards to Revalidation [Anaesthesia] note that higher NFR scores were most become legally binding targets GMC reschedules further signifi cantly associated with poor access and for the planned ban on the revalidation dates to annual leave and study leave and to the proportion of out-of-hours work sale of new petrol, diesel, and Revalidation dates of around undertaken. Given this, employers should hybrid vehicles to be brought 9000 doctors who were due to focus on “aspects of job forward by 10 years to 2030. revalidate from March to July sustainability such as 2021 have been postponed maintenance of rotas and Assisted dying for four months, said the GMC, work intensity to improve New Zealanders back law because of the ongoing demands wellbeing,” they say. for terminally ill adults of the pandemic. These doctors Nearly two thirds of New can revalidate at any time from AND TIME OFF, TOO? Zealanders (65.2%) supported now to their new date. All doctors Absolutely. “Ready access the End of Life Choice Act, which affected will be contacted to to annual and study leave will legalise assisted dying. The confirm their revised timetable. can have a positive impact act was passed in 2019, but its Earlier this year 50 000 doctors on staff recovery between shift s and this must therefore remain a implementation was delayed until who were due to revalidate from priority, even during challenging times,” the the public had had a say through March 2020 to March 2021 had authors add. the binding referendum. Due to their dates changed. come into effect in November Zosia Kmietowicz , The BMJ 2021, the law will allow terminally Cite this as: BMJ 2020;371:m4245 Cite this as: BMJ 2020;371:m4252

the bmj | 7 November 2020 213 (Continued from page 211) methodology. The underlying questions about accuracy, speed, and acceptability must be carefully measured alongside gaining technical and logistical experience.” Luke Allen, GP academic clinical fellow at the University of Oxford, said, “If it can be implemented smoothly then we will have a much clearer picture of how the virus is spreading. There are several big ‘ifs,’ though: people need to show up for testing, testing should happen repeatedly in order to track changes over time, and— “No alternative” to second most importantly—the track and trace system needs to function eff ectively.” England lockdown, says PM Gareth Iacobucci , The BMJ Cite this as: BMJ 2020;371:m4268 ew national measures , the UK’s chief scientifi c to try to stem the rising adviser, said, “By the beginning of WHICH TESTS WILL BE USED number of cases of covid- December we will see the level of deaths IN LIVERPOOL? 19 in England came into seen at the peak of the fi rst wave, if nothing RT-PCR swab tests N force on 5 November, as is done. That is a grim picture in the Reverse transcription polymerase the government conceded that the surge absence of action.” Hospital bed use would chain reaction tests, the default in cases and hospital admissions now be exceeded on 20 November, as would during the pandemic, involve taking threatened to breach NHS capacity. ventilator capacity, he said. a throat and nose swab. They look Several hospitals already have more Boris Johnson said no responsible prime for the RNA of the virus and have inpatients with covid-19 than in the spring minister could ignore the message of the been used to show whether a person surge, said , England’s chief fi gures. He added he still believed the local with symptoms currently has covid- medical offi cer, at a press briefi ng on tier based strategies introduced in the past 19. They can produce a result in 3-4 hours, but can takes longer if 31 October. By early December hospital few months had been the right approach samples have to be sent to external admissions will exceed the peak seen and there were signs that they had paid off . laboratories. in the fi rst wave of the pandemic, with He added that overwhelming the NHS Lateral flow tests deaths rising to 800 a day by 24 November, would be a “medical and moral disaster These detect whether the virus is modellers have estimated (see below). beyond the raw loss of life” as “doctors present by applying a nose and throat swab to a test kit. These small, portable tests display a point-of- Experts’ modelling suggests 85 000 care result like a pregnancy test in 15-30 minutes, without the need to deaths in second wave of covid-19 be processed in a laboratory. They detect the virus directly without The second covid-19 and 31 March 2021, with SAGE said 77 000 of the the amplification steps of RT-PCR or wave in the UK could last daily deaths exceeding direct covid deaths would be LAMP. An independent evaluation of until April and see 85 000 500 for at least 90 days. in England, 4400 in Wales, one test (the SD Biosensor test) found it had a clinical specificity of 99.3% people die, making it It also predicted 356 000 2600 in Scotland, and 1900 and a clinical sensitivity of 76.6%. more deadly than the fi rst cases requiring patients’ in Northern Ireland. But LAMP wave, concluded one of admission to hospital and the group also noted these Loop mediated isothermal the modelling studies that that the peak weeks would numbers did not include amplification is a new type of testing prompted the government to begin in early January and “additional covid-19 deaths technology that allows significant take action in England. continue “past the end of that could occur due to lack volumes of tests to be delivered in A report from the the scenario on 31 March.” of NHS capacity or other hospital laboratories. As with RT-PCR, Scientifi c Advisory Group The study’s assumptions excess deaths.” LAMP detects whether viral RNA is for Emergencies (SAGE) included that mortality in present. It also involves collecting outlined the worst case inpatients with covid and Current picture nose or throat swabs but can also use scenario of a second wave treated with dexamethasone The React-1 study, which samples from mucus produced by for the government on would be reduced by 17% is using swabs in a hard coughing. It can produce results 30 July. The document, (based on data from the representative sample of in 2-3 hours. The leaked Moonshot published by the Spectator , Recovery study) and that people to measure infection documents seen by The BMJ listed LAMP tests as having a “lower said that there could be any acquired immunity levels across England, has sensitivity” of 80-100%. 85 000 deaths across the would be maintained over reported in a preprint that UK between 1 July 2020 the course of the scenario. between 16 and 25 October

214 7 November 2020 | the bmj MEASURES ACROSS THE UK Scotland unveiled five tiers (0 to 4) of restrictions on and nurses would be forced to choose which Johnson said Christmas would be very 29 October that came into patients to treat, who would live and who diff erent this year, but added, “It is my sincere force on 2 November. Level would die.” He added that “the sheer weight hope and belief that, by taking tough action 3 areas include , Edinburgh, of covid demand would mean depriving tens now, we can allow families across the country East Lothian, West Lothian, Falkirk, of thousands, if not hundreds of thousands, if to be together.” Stirling, and Dundee. In these areas much of the hospitality sector closed not millions, of non-covid patients of the care Although health leaders welcomed the completely (though some restaurants they need.” plans, which were due to be approved by MPs remain open), people have been told to If covid cases were allowed to rise along on 4 November, some regretted that action make only essential journeys, and some the lines projected, he said, “then the risk is was not taken in September when SAGE senior school pupils have to wear face that for the fi rst time in our lives the NHS will recommended a two week “circuit breaker.” coverings in classrooms as well as in not be there for us and for our families. And Chaand Nagpaul, the BMA’s chair of communal areas. so now is the time to take action, because council, called for a clear exit strategy. Wales introduced a 19 day there is no alternative.” “We cannot aff ord to have a repeat of the “fire breaker” on 23 September People were told to stay at home and leave fi rst lockdown—which was followed by a that ends on 9 November, after only for work (if working from home were not rebound surge in infection and by impacts which people will be asked to possible), exercise, medical reasons, food on mental health—where the economy take responsibility for helping to keep and essential items, or to care for vulnerable is made even more fragile and where the levels of the virus down. people. Non-essential shops will close, as NHS and its workers teeter on the verge of Northern Ireland has had restrictions will leisure venues, pubs, and restaurants, collapse,” he said. in place since 16 October that ban although takeaways can continue. Childcare, “This lockdown must be used to ensure households from mixing except for early years settings, schools, colleges, and we develop a fi t-for-purpose test and essential services, although up to universities will remain open. trace programme with the capacity and six people can meet in gardens. Two Single adult households can still form responsiveness to promptly isolate those households can form a bubble, and exclusive support bubbles with one other with infections. This will need investment in a maximum of 10 people can meet household, and people who are extremely local public health teams and an end to the indoors, although overnight stays clinically vulnerable would not be asked fragmented outsourcing arrangements that are banned. Schools reopened on 2 November after closing on 19 October. to shield, although they are asked to keep have failed to deliver, at scandalous cost.” Half of the region’s schools have recorded contact with others to a minimum. Zosia Kmietowicz , The BMJ cases of covid-19. The measures will be in force until a review Cite this as: BMJ 2020;371:m4247 on 2 December, when the tiered system could be reintroduced according to local conditions, said Johnson. He urged people to MODELS suggest hospital admissions will exceed the peak seen continue to use the NHS for scans and other appointments as usual. in the first wave, with deaths rising to 800 a day by 24 November

the overall prevalence was way. It will inevitably lead the group said daily deaths 1.28% (128 infected people to a very large number of were “almost certain to per 10 000). The samples infections, severe episodes, exceed [the predicted (863 of which were positive) and deaths in the coming deaths of no more than 100 were taken from more than weeks and months. Eff orts until the end of November] 85 000 volunteers, and will be required to reduce within the next two weeks.” the fi ndings indicate that the national reproduction Across the UK more than infections were doubling number below 1.0.” 60 000 covid related deaths every nine days. The overall Meanwhile, the Scientifi c have been registered, and R number had increased Pandemic Infl uenza since 10 October the daily from 1.16 in the previous Group on Modelling has number has once again round (18 September to warned that England exceeded 100. The React-1 study preprint found prevalence 5 October) to 1.6. was “breaching the Other European countries to be highest in the North West (2.3%) Igor Rudan, joint number of infections and experiencing a second wave and in Yorkshire and the Humber (2.7%). director of the Centre for hospital admissions in have also imposed new Global Health and WHO the Reasonable Worst lockdown measures. Prevalence increased across all age groups, but Collaborating Centre at the Case planning scenario” Elisabeth Mahase, the largest rise was seen in people aged 55-64 , as outlined in the SAGE The BMJ (1.2%), and an increasing trend was also said, “This study should be document. In a consensus Cite this as: BMJ considered very accurate statement from 14 October 2020;371:m4242 seen in primary and secondary schoolchildren. and reliable scientifi c Despite this, prevalence remained the highest in evidence that shows a very This is accurate and reliable scientific 18-24 year olds at 2.2% large second wave of the evidence shows a very large second wave covid-19 pandemic is under of the pandemic is under way Igor Rudan the bmj | 7 November 2020 215 COVID-19

Manchester’s Nightingale hospital reopens to treat non-covid patients

he Nightingale hospital designed to take patients with covid- NHS Foundation Trust, but the It doesn’t in is open 19 requiring critical care. During the hospital will provide step-down care make sense and ready to admit fi rst wave, all patients in the North for the whole of the North West region. for Liverpool patients from across the West who needed to be on a ventilator Rob Barnett, chair of Liverpool Local residents to be T North West of England. were treated in existing hospitals. Medical Committee, branded this a trekking out to But, unlike how these hospitals were Although Manchester admitted the “hare brained idea.” He said, “This used in the fi rst wave, it is admitting most patients with covid-19 of all the might be fi ne for people who live in Manchester only patients without covid-19. Nightingales, at around 100, it did Manchester and the surrounding Rob Barnett The facility, at the Manchester not off er respiratory support beyond area, but it really doesn’t make sense Central Convention Complex (formerly continuous positive airway pressure. for Liverpool residents to be trekking known as G-MEX), is the fi rst of the out there.” Nightingale hospitals to reopen to Step-down facility The transfer of patients who are fi t help take pressure off local hospitals. This time, NHS Nightingale Hospital for discharge from hospital into the Sunderland and Harrogate are North West will act as a step-down community is a persistent problem expected to be next, and all the others facility for patients without covid-19 that needs to be resolved more are on standby. discharged from general and surgical locally, he said. Many such patients in A spokesperson for the NHS in the wards to free up beds in existing Liverpool were from deprived areas, North West confi rmed the hospital hospitals. It will house patients so their family and friends might not was open, was expecting its fi rst awaiting social care assessments and have the means to visit if they were patients, and would “provide care for provide support and rehabilitation sent to another city. “It beggars belief those who do not have covid-19 but do services. Over the summer, day room that anyone thought it was a sensible need further support before they are facilities at the Nightingale were idea,” Barnett said. able to go home, such as therapy and expanded, and a kitchen for use in As in the fi rst wave, staff will be social care assessments.” the rehabilitation and enablement of drafted in from a variety of places The facility has 750 beds, but patients has been installed. to work at the Nightingale. Some unlike the fi rst Nightingale hospital, The fi rst patients are expected to will be deployed from other NHS which opened in London, it was never arrive from Manchester University services, and NHS Professionals is

Scottish hospitals sent 338 patients with covid to care homes

Scottish hospitals discharged more likely to be aff ected. Ninety statistical analysis is only part 338 patients with a diagnosis per cent of homes with more than of the story. “What is missing is of covid-19 to care homes in the 90 residents had an outbreak, the story of those who cared for three months from March this compared with under 4% of those residents. I hope the researchers year, says a report from Public with fewer than 20 residents. can take some time to listen to Health Scotland. The report said that hospital staff in care homes where there The discharges freed up space discharge is associated with a have been signifi cant outbreaks.” in hospitals for covid patients, Subsequently, 93% of people higher risk of an outbreak when The Scottish health secretary, but some owners claimed the were tested but the report says 45 considered on its own, but “after , said, “We will move introduced the virus into patients were transferred despite accounting for care home size continue to adapt our guidance their care homes, causing almost not having two negative tests. and other characteristics, the and the steps we are taking 2000 deaths across Scotland. PHS’s analysis showed that estimated risk reduces and is not to protect care homes in line PHS says most of the 3599 338 patients with a diagnosis of statistically signifi cant.” with the latest data, scientifi c discharges in the busiest month covid on their discharge record Donald Macaskill, chief offi cer evidence, and clinical advice.” of March were people who had were moved into a care home. Not of Scottish Care, which represents Bryan Christie , Edinburgh never been tested. Of the 650 who all cases were confi rmed by a test care home providers, said the Cite this as: BMJ 2020;371:m4225 were tested, 78 were positive, but and may include suspected cases. the discharges still went ahead. The PHS recorded 1915 A report published in August found that of overall deaths in S cottish government guidance covid related deaths in care 47% on 21 April said people being homes between March and May. Scotland linked to covid were in care homes, compared with 42% discharged into care homes Almost a third of homes had an in Northern Ireland, 30% in England, and 28% in Wales needed two negative tests. outbreak, and larger ones were

216 7 November 2020 | the bmj “VIPs” given special criteria for PPE contracts, suggest emails

Documents leaked to the Good company, Prospermill, which was Law Project appear to show special set up in 2019 with share capital pathways through which “VIPs” of £100 and two directors, had and Cabinet Office contacts were secured production in China. But able to win contracts to supply he requested the government sign personal protective equipment at the contract with Ayanda because the height of the pandemic. it could arrange overseas payments The non-profit organisation, more quickly. Mills and Ayanda along with the campaign group told the Times in August that his

PETER BYRNE/PA EveryDoctor, is mounting a position as a government adviser High Court challenge to the had played no part in the award of THE FACILITY has 750 government’s decision to award the contract. beds, but unlike the first Nightingale hospital lucrative contracts to companies it was never designed to take patients with with little or no experience in the “Enormous margins” covid-19 requiring critical care supply of such equipment, some The Good Law Project said that it with links to the Conservative Party. was aware from emails that Ayanda, also advertising positions. As well In the emergency caused by which was awarded £252m for as medical, nursing, and pharmacy the pandemic earlier this year, two types of masks, “were guided vacancies, a range of allied health contracts totalling billions of through the process by the Cabinet professional roles to support patient pounds for medical supplies and Office.” A document headed “Terms rehabilitation are needed, including hospital equipment were awarded and conditions inc price” appears physiotherapists, speech and to private companies without the to state that no questions would be language therapists, and dietitians, usual competitive tender. Contracts asked about value for money unless the advertisement says, and all for the supply of PPE were prices were more than 25% above applicants need to commit for a given to, among others, a average unit prices. minimum of four weeks. pest control company, an , director Ingrid Torjesen, London employment agency, and of the Good Law Project, said, Cite this as: BMJ 2020;371:m4224 a confectioner. “The leaked documents reveal One company—Ayanda Capital, that Cabinet Office contacts and a private family fund specialising others were helping ‘VIPs’ sell PPE BMA reiterates call for in currency trading, offshore to government outside normal property, and private equity—won a procurement channels. The extra support for GPs £150m contract for 50 million FFP2 information that government would masks, which in the event were buy at 25% above the price paid to The BMA has asked NHS until 30 September through not used because the government regular suppliers was a licence to England to provide more primary care networks. decided their fastenings were not make enormous margins (35-45%) fi nancial support for The BMA has called for safe enough. Ayanda has said the on contracts sometimes worth general practices dealing an extension of the covid masks met safety specifications. hundreds of millions of pounds.” with a growing workload support fund until March Court papers disclosed that the A government spokesperson as hospitals cancel routine and for other measures, original approach to sell the masks said, “We have been working procedures and GPs have including free personal came from Andrew Mills, an adviser tirelessly to deliver PPE to protect to pick up the slack. protective equipment. to the UK Board of Trade and a our health and social care staff At the same time GPs are Krishna Kasaraneni, senior board adviser at Ayanda. His throughout the pandemic, with providing covid secure care of the BMA’s General more than 4.4 billion items while also facing workforce Practitioners Committee, The information that the delivered so far and 32 billion shortages as staff test said, “Nobody should government would buy at items ordered to provide a positive or take time off for doubt the commitment 25% above the price paid continuous supply over the caring responsibilities or of GPs to serve their to regular suppliers was coming months. Proper due self-isolation. communities, but to do this diligence is carried out for a licence to make A NHS England covid eff ectively in a time of crisis all government contracts support fund set up they need more support— enormous margins and we take these checks during the fi rst wave of and for this support to be (35-45%) on contracts extremely seriously.” sometimes worth millions the pandemic ran until 31 delivered without delay.” Clare Dyer, The BMJ July. Some extra funding Ingrid Torjesen, London of pounds Jolyon Cite this as: BMJ was then made available Cite this as: BMJ 2020;371:m4240 Maugham (right) 2020;371:m4180

the bmj | 7 November 2020 217 BEATA ZAWRZEL/NURPHOTO/PA 218 7 November 2020 | the bmj THE BIG PICTURE Poles march against tighter abortion law

A pro-choice protester in Krakow holds a coat hanger as a symbol of the dangers to women of the near total ban on abortions imposed by Poland’s Constitutional Tribunal last month. The tribunal ruled that abortion on the grounds of fetal abnormality was unconstitutional, further restricting the already stringent 1993 law. The ruling means termination remains valid only when the pregnancy poses a serious risk to the mother’s health, or when it is a result of a criminal act. On BMJ Opinion Maria Lewandowska , researcher in abortion provision at the London School of Hygiene and Tropical Medicine, writes: “It is crucial the international medical community condemns this ruling and advocates for Polish women’s reproductive rights. That could include campaigns for free or subsidised abortion provision abroad. “Unless the nationwide protests triumph and bring about a dramatic change, women in Poland will face fear and isolation, being forced to risk their health and life carrying ill pregnancies to term, or to seek abortion care online or abroad, suff ering the social, fi nancial, mental and physical consequences of the tribunal’s sadistic ruling.” See bmj.com for the full Opinion article Alison Shepherd, The BMJ Cite this as: BMJ 2020;371:m4253

the bmj | 7 November 2020 219 EDITORIAL Neuropsychiatric complications of covid-19 From acute delirium to long term fatigue, the virus has serious eff ects

iral infections of the (coronerve.com).17 The precise respiratory tract can incidence of these conditions and have multisystemic whether they are also associated eff ects, including on with milder forms of covid-19 are V the central nervous still unclear. system (CNS), and thus may High rates of anxiety, precipitate a spectrum of psychiatric depression, and post-traumatic and neurological disorders. 1 Some stress disorder have been reported patients with covid-19 are now in people who recover after hospital known to develop various CNS admission for covid-19. 18 Some abnormalities with potentially patients experience disabling serious and long term consequences, fatigue19 and cognitive diffi culties20 including stroke and isolated after discharge. psychiatric syndromes.2 GETTYIMAGES In laboratory studies, SARS- Long covid CoV-2 is neurotropic (replicating Long covid is and may be the sole presenting A diverse group of presentations, in neurons) and has the potential likely to result feature of covid-19 in older increasingly referred to as “long 11 to enter the CNS via angiotensin in substantial adults and those with dementia. covid,” is also being described in converting enzyme 2 receptors in Delirium is associated with poorer patients who did not require hospital 3 population 10 the olfactory bulb. Whether this morbidity outcomes and is especially treatment. These patients report a happens in clinical populations is prevalent among patients requiring wide variety of symptoms, persisting unclear. Postmortem studies show with serious intensive care,12 where cognitive for many months after acute evidence of cerebral infl ammation, implications and behavioural abnormalities infection. To date, most research on and neuroimaging studies for health and have been reported in one third of has been led by patients, detect leucoencephalopathy and social care patients after discharge.13 and it suggests this is a common and microbleeds in critically ill patients.4 Screening for delirium should disabling disorder.21 While viral RNA is typically absent be considered in acute cases, Long covid is likely to result in from the cerebrospinal fl uid5 particularly in older adults or substantial population morbidity and postmortem brain samples, 6 Matthew Butl er, those with pre-existing dementia, with serious implications for health antibodies to SARS-CoV-2 have NIHR academic along with close monitoring for and social care. Urgent research is clinical fellow been identifi ed in cerebrospinal longer term adverse outcomes needed to characterise this disorder, neuropsychiatry fl uid.7 Other mechanisms causing such as cognitive impairment.15 defi ne disease mechanisms, Thomas A Pollak, CNS dysfunction include cytokine Eff orts should also be made to direct the use of either existing 8 NIHR clinical lecturer driven infl ammatory responses in neuropsychiatry identify patients with alterations in therapeutics or the development of and wider systemic eff ects such as mental state that are not explained novel treatments, and direct health Timothy R endotheliopathy, breakdown of the Nicholson, clinical by delirium, as they may need and social care support. 7 blood-brain barrier, and clotting senior lecturer in more advanced diagnostic and Clinical scientists must work 6 abnormalities. neuropsychiatry , therapeutic approaches. closely with patient groups Additional biological mechanisms, King’s College and national and international including autoimmunity, may be London timothy. Surveillance organisations such as the WHO relevant to psychiatric disorders, as nicholson@ The UK based CoroNerve group is Brain Health Unit. Collaboration will well as the psychological trauma of kcl.ac.uk gathering surveillance data through help to translate research fi ndings life threatening illness and pandemic Alasdair G Rooney, clinician reports of neurological and into meaningful improvements related socioeconomic stressors. clinical lecturer in neuropsychiatric disorders among in managing the acute and long Neuropsychiatric symptoms, neuropsychiatry , inpatients with covid-19. Reports term neuropsychiatry of covid- University of particularly delirium, were common so far include covid-19 associated 19. We strongly support public Edinburgh in previous coronavirus outbreaks psychosis, mood disorders, and health messaging emphasising Benedict D Michael, of severe acute respiratory disease catatonia as well as encephalopathy, longer term morbidity, including senior clinician (SARS) and Middle East respiratory scientist fellow encephalitis, and other neurological neuropsychiatric complications, 9 syndrome (MERS). So far, covid-19 in neurology, disorders in those admitted with associated with covid-19. 16 seems to follow a similar pattern: Walton Centre NHS covid-19. We encourage clinicians Cite this as: BMJ 2020;371:m3871 delirium is the most common encountering such cases to report Foundation Trust, Find the full version with references at 10 acute neuropsychiatric syndrome Liverpool them through the study website http://dx.doi.org/10.1136/bmj.m3871

220 7 November 2020 | the bmj EDITORIAL Vaccine trial protocols released A rare opportunity for public scrutiny of these key studies

he ongoing phase III trials for covid-19 vaccines are some of the most consequential T randomised trials ever done. In September, following months of campaigning,1 2 four manufacturers made their full study protocols publicly available.3 - 6 The publications create a rare opportunity for “real time transparency” in which the conduct of clinical trials is opened to public scrutiny while the studies are still under way. FELIX DLANGAMANDLA/BEELD/GALLO/GETTY IMAGES Whatever the results ultimately show, public release of these protocols—each We still 1% a year for some trials. If these their design and conduct. These include over 110 pages containing far greater have time predictions are accurate, 99% of why children, immunocompromised detail than was previously available— to advocate control participants will not develop people, and pregnant women have enables a more scientifi c, deliberative, for changes symptomatic covid-19 over the been excluded from most trials; and inclusive trial process. While to ensure next year, leading to large “number whether the right primary endpoint protocol transparency is not new, needed to treat to benefi t” estimates. has been chosen; whether safety is transparency in real time is an these trials Presumably, these were conservative being adequately evaluated; and important development providing an investigate planning estimates that justify larger whether gaps in our understanding of unprecedented space for translating the questions trials capable of delivering effi cacy the clinical implications of pre-existing critique into action to improve trial that most results fast. The focus on speed fi ts T cell responses to SARS-CoV-2 are design mid-stream. And there is much need answers with the prespecifi ed fi nal “event being addressed . 11 to critique. driven” analyses at roughly 150 total The fi rst question is whether the right events, with many interim analyses Adding value endpoints are being studied. Contrary specifi ed even earlier. We still have time to advocate for to prevailing assumptions, none of the But the low event rate assumptions changes to ensure these trials vaccine trials are designed to detect foster an impression that vaccines investigate the questions that most a signifi cant reduction in hospital are being tested on people at low risk need answers. While the notion admissions, admission to intensive of getting covid-19—and even lower of “moving the goalposts” during care, or death.9 Rather than studying risk of severe disease—who may be ongoing trials may raise concerns, severe disease, these mega-trials all unrepresentative of populations meaningful, scientifi cally valid, set a primary endpoint of symptomatic prioritised to receive an approved transparently reported amendments covid-19 of essentially any severity: vaccine. Manufacturers should be to protocols that are made to improve a laboratory positive result plus mild encouraged to provide real time data the value of trial results should symptoms such as cough and fever on the baseline characteristics of always be welcomed. count as outcome events. recruited participants. Critical appraisal of clinical These studies seem designed to Sixty years after infl uenza evidence traditionally occurs after the answer the easiest question in the least vaccination became routinely publication of studies, and generally amount of time, not the most clinically recommended for people aged 65 or fi nds much to criticise. Early release relevant questions. older in the US, we still don’t know of full trial protocols off ers a historic if vaccination lowers mortality. opportunity for the democratisation Built for speed Randomised trials with this outcome of science. The covid-19 vaccine trials The second question is whether the have never been done.9 Unless we act may not have been designed with our trials are recruiting people at high now, we risk repeating this sorry state input, but it is not too late to have our risk. The study protocols suggest of aff airs with covid-19 vaccines. say and adjust their course. With stakes this intention, but sample size Peter Doshi, The covid-19 vaccine protocols this high, we need all eyes on deck. calculations were apparently based associate editor, should be scrutinised by the widest Cite this as: BMJ 2020;371:m4058 on the expectation of very low event The BMJ possible readership, to open a critical Find the full version with references at rates in the control arm—around [email protected] discussion of many questions about http://dx.doi.org/10.1136/bmj.m4058 the bmj | 7 November 2020 221 THE BMJ INTERVIEW Whether it’s economy v health or politics v science, it’s all about balance, says Chris Whitty In a rare interview, England’s chief medical offi cer speaks to The BMJ’s editor in chief, Fiona Godlee , about the pandemic and being a physician in Whitehall

How are you, Chris? WHITTY ON TRANSPARENCY I’m fi ne. To be honest, I’m much more concerned about everybody who’s working on the front line I’m very much in favour of transparency because that’s the really hard work. in all areas. I was really pleased that, And as we look forward to what’s going to be an for example, the SAGE minutes were extremely diffi cult winter for the NHS—one that I published—I think that’s exactly as it suspect, unfortunately, will be unlike any we’ve should be. I can see no disadvantage to seen in recent memory—I’m really concerned openness. about the welfare and the morale of all the medical It’s important that people making very, professionals who are working on this, because this very diffi cult political decisions have the is going to be a long and diffi cult slog. I think all of us time and space to be able to do that before have huge admiration for what people did in the fi rst this constant commentary on it. But I do wave. It was really extraordinary. And we’re going to think that transparency, wherever possible, have to do that again. is a good thing. And certainly on the science side, we’ve What do you think is likely to happen as we head tried to be very open about what our advice into winter? is and how it’s given. This is a new virus. It may behave in ways we’re not expecting. From an epidemiological point of view, mortality. First, there’s the direct eff ects of covid. there’s minimal evidence of signifi cant immunity at And as we know, there are signifi cant morbidity this stage. So, unfortunately, a lot of people could eff ects as well as mortality eff ects. become infected. Second is where we have an over-running of the I think we have to assume that this virus will emergency services such that all emergency care benefi t from the winter season, just as most other stops. We fortunately avoided that in the fi rst wave, respiratory viruses like fl u and adenovirus that we but it’s not a given if we don’t take strong action. come across every winter in the NHS do. So, my Third, some people need urgent but not expectation is that, even if we do exactly the same emergency care—elective care—which will be things as we did two or three months ago, rates of delayed further because the health service is under infection will be higher. considerable strain. Even in a typical fl u season about 7000 people And fourth, we all know that deprivation leads to a year in the UK die of seasonal fl u. And in a bad serious long term ill health eff ects, lifelong in some fl u year, which often goes quite unremarked, it can cases, and generational impacts. The things we have be north of 20 000 people dying. SARS-CoV-2 is to do to keep the virus under control have signifi cant In every signifi cantly more lethal than fl u is, in every age social and economic impacts. direction we group apart from maybe children. It’s extremely We’re faced by all of these. Making things better go there are transmissible, as we’ve seen with these explosive for one of them can have a negative impact on the harms, and outbreaks around the world. So, I think we have others. For example, freeing up bed space to ensure we’re trying to assume that there will be signifi cant outbreaks that we have emergency care puts greater pressure and, as a result, signifi cant numbers of people in on the elective care system. Bringing in more societal to find the hospital, some of whom, sadly, will die. I don’t think measures will have a bigger impact on the economic least harmful I’m saying anything that will come as a surprise to eff ect while it brings down the covid numbers. combination anybody in the NHS. We’re in this very diffi cult tension where in every of things we In every winter season some hospitals come under direction we go there are harms, and we’re trying to can do very substantial pressure, and some even have to fi nd the least harmful combination of things we can call for mutual support. And that’s even without do. But this is going to be tricky to manage, and the covid. So, I anticipate signifi cant pressures this year. health eff ects are going to spill well beyond those There are four ways this virus is going to kill who get covid directly, although obviously there will people and cause long term morbidity, as well as be signifi cant numbers of those.

222 7 November 2020 | the bmj WHITTY ON HERD IMMUNITY AND ERADICATION

There’s an extremely heated I have an absolute international debate on how belief in the ability countries should manage of science to get us the pandemic. Where do you out of this hole sit on the spectrum between suppression of the virus and realises that this is extremely population immunity? impractical as a solution. Let’s start with “herd SAGE has looked at this immunity,” as it’s sometimes twice and came to the same called in the press, conclusion both times. which was perhaps most The third reason I represented by the Great personally have problems Barrington Declaration. with it is that, ethically, it My view is that it’s wrong would lead to a signifi cant scientifi cally, practically, number of people dying and probably ethically. who otherwise would not It’s really a pretty minority have died of this virus. view, but it’s been seen as And it almost certainly a much wider view. It’s a would lead to much higher perfectly respectable one— pressure on the NHS and but the reason it’s wrong therefore some of the scientifi cally is that it starts indirect damage. from the assumption that As for the other end of you will get herd immunity the spectrum—which is, and that this is how you why can’t we just eradicate control epidemics. this virus?—that’s also For the great majority impractical for a variety of of the infections I’ve dealt reasons. There are reasons with—and I’m an infectious why we have, to date, only disease epidemiologist—you managed to eradicate one never get herd immunity. human disease—smallpox— You don’t get it for malaria, with two or three others you don’t get it for HIV, you that have been just on the don’t get it for Ebola. You edge for a long time. It’s just don’t get it ever. very, very diffi cult to do. Second, it makes an What we’ve got to do assumption that immunity is get this virus down will be maintained, at least as low as is practical at for a period of time. And any point in time, using this is not clear yet with the tools we’ve got, and covid. We certainly know, expect that we will get for example, that antibodies medical countermeasures. wane quite quickly. So, I It might come in the form think scientifi cally it’s on of vaccines. It might come WHITTY ON CIRCUIT BREAKERS very, very weak foundations. in the form of drugs, as Then there’s the practical happened with HIV, for The concept of a circuit breaker is that you buy time; question. Let’s say that it example: we don’t have an you wind back the clock from wherever you are by a was possible to achieve HIV vaccine, but we’ve got few weeks, and that helps to slow down the rate of rise. immunity. It works on the very good control in the UK But you still have to do things after you come out of assumption you can identify on that. it. It’s not something where you do it and then that’s all of the people who come to There are other possible a substitute for all the other things you have to do. harm and completely exclude technical solutions. So, we Rather, it’s a way of trying to slow stuff down. But it them for the remainder of shouldn’t see that we’ll be comes obviously with a very signifi cant impact on other the time that this virus is in in the current state for an societal things. So, it’s not a panacea. circulation, or at least in high indefi nite period. I have an What SAGE was saying is that this is one of the tools circulation. absolute belief in the ability that needs to be considered. I think it was slightly Anyone who’s thought of science to get us out of overwritten [in the media] as saying that you’ve got to about this with this this hole. But it is going to do this or nothing else will work. We need to do quite a particular virus, which is take a while before we get to lot of things, and this is one of the tools to think about. incredibly easy to transmit, that point. the bmj | 7 November 2020 223 How do you respond when it doesn’t seem as if the I have a lot What can you say to local public health professionals government is going to follow what you consider to of sympathy who feel left out of the approach in terms of track and be important advice? with the trace and other public health measures, who believe The thing to understand is that I’m only presenting the view that that it would be better with their involvement? health advice. I passionately believe in the health side of there should When I go to places like Harlow or Blackpool or so on, things, and I strongly believe that good science leads to you see remarkable public health leaders doing the day good political decisions. But the economic side [and] the be local job, [working on] all the other areas of public health on societal issues are also important. The political leaders leadership top of all the covid activity. who have to represent the public have to balance all these and local Particularly in this second wave, which is much less of diff erent elements together. ownership of a national picture and where we have a lot more tools at Whenever I look at a problem, I generally decide many of the our disposal, I have a lot of sympathy with the view that whether it’s primarily technical, political, or a bit of decisions there should be local leadership and local ownership of both. If it’s primarily technical I’ll say, look, in my view, many of the decisions. We’re very fortunate to have such there’s only one technically correct solution. So: which good directors of public health—there’s a long tradition kind of drugs should we be using to treat covid? That’s a of that in the UK. And I think that trusting them to make technical decision. Politics should play no part in that. good local judgments is very sensible. Equally, prioritisation or balance between elements of the The fi rst wave was a slightly diff erent situation response—for example, health against education against because, fi rst, the whole of the UK went through the wave wider societal aims—those are political questions. almost the same way: it was very, very similar across the country, and we were starting out from an incredibly What’s your sense of the likelihood of a vaccine standing start with very few tools. But as we go through in the next year? this second wave we have a much more varied picture, There’s the biggest eff ort to get vaccines that’s ever been which is actually much more typical of what other seen. I think there’s a reasonably good chance that we countries, in Europe for example, had in the fi rst wave. will get a vaccine in the next year. But nobody should I think that this makes the argument for local assume that, and nobody should put a date on it. You leadership and local decisions where possible. You can’t never know which one is defi nitely going to cross the do it across the board, because the health system will fi nishing line fi rst. Obviously, we would all hope that the be criticised for having a very confusing picture if we do fi rst two or three vaccines that are leading will work, and things too diff erently and for being too monoculture if we if every single one of the vaccines worked that would be do things all the same. There’s a balance between having an outstanding result. But let’s see. some degree of a national approach and some degree of local. And I think that inevitably in the second wave the Recent data published by the Financial Times show ratio is slightly diff erent and should be slightly diff erent. that countries that have done worse in terms of covid deaths have also done worse economically, with the The UK government seems to have preferred a more UK scoring badly on both counts. This suggests that centralised approach, with commercial companies it’s a false dichotomy to talk about health versus delivering many of the measures. Do you envisage wealth and that we have to control the virus to a larger role for the public sector and local public restore our economy. Is that how you see things? health teams in the second wave? That is absolutely how I see things. I don’t think I’m saying anything about the public sector

224 7 November 2020 | the bmj versus private sector, which is a debate I consider to Whitty (above it doesn’t mean having to be bought into other people’s be in the political delivery end rather than the public left) pictured in decisions, but you help infl uence how this goes, and I health end. February with think that’s important. We see ourselves as a profession Boris Johnson, Mine was more to do with local authorities, local with a collective leadership, of which I am one, and many , directors of public health, and their considerable and Downing people who might be reading this are also leaders. contribution. It’s basically about using both. They don’t Street aides Lee have the degree of specialisation, they don’t have the Cain (centre) As a civil servant you’re accountable to the resources that you have centrally—but they do have local and Dominic government, but how do you guard your own knowledge. They have local experience. They understand Cummings; and credibility, when that’s where your authority comes what’s happening locally. delivering a from among your colleagues and the wider world? public advice The CMO role is diff erent from most civil service roles, message in March I had always understood that the CMO was head of in that I’m statutorily independent while being in public health in the UK. But people are confused government. And so I feel that, no, I’m not bound by what about where oversight or leadership of public the government’s view is. I give my own view straight. I health sits, given what’s happened with the hope people realise that I give my own view and I don’t dissolution of and the new feel constrained. Joint Biosecurity Centre. People see you as head of Where being a civil servant matters is that there’s an public health in the UK. Is that right? absolute statutory requirement, rightly, for impartiality I felt quite strongly when I came into this role, not just and to stay out of party politics. So, if I think something is for public health, but for the medical profession as a a political issue, I am not going to engage publicly in it. whole, that we ought to have a collective leadership. I am No one [in government] has ever said to me, “Gosh, defi nitely part of that collective leadership. you went a bit far there” or “I want you to say this, and if But there are the royal colleges and, in the case of you don’t there’s going to be trouble.” They have always public health, obviously the Faculty of Public Health, accepted that this role is an independent role, and it and there are all the various NHS organisations in NHS ceases to have use if people like me are having to cut our England. There are the devolved nations, which have jibs just to suit the situation. It would no longer be helpful pretty well complete control over health decisions. And to the government. That’s the way it works, that’s the way local authorities which have very signifi cant infl uence. it has always worked, and the way in my view it always It’s neither right nor sensible that anybody says, “I am should work. the person who just leads the whole thing.” I see this as a This is an collective leadership, but the CMO role is and always has independent After the Dominic Cummings incident you were been a senior leader within that system. role, and it asked at the press conference in May what your views Particularly going through this crisis at the moment, ceases to were. It could seem that Boris Johnson rather quickly it’s been really important that the leaders talk very stepped in to stop you commenting . . . regularly to the presidents of the royal colleges, to the have use if I did think it was a party political issue at that point in directors of public health, to the leaders of NHS England people like time. I’ve been very careful across the board never to and PHE. It’s important that we see ourselves as a me are having comment on individual people. At its extreme collective leadership. to cut our jibs I really strongly push back against journalists asking I would actually see the editors of the major journals just to suit about individual patients, which they did near the as part of that collective leadership of the profession: the situation beginning. the bmj | 7 November 2020 225 WHITTY THE PHYSICIAN I identify primarily as a doctor, done on-calls on a rota for I’ve been a clinician so to me that role matters a acute medicine, because I throughout that time—I lot. It’s also helpful to talk to didn’t think I could stay up have to do it at times when colleagues all the way through to date with all the acute parliament’s not sitting, in the system—doctors, nurses, medical guidelines. I’ve kind holiday times, but I really all of the other professionals. It of restricted it to infectious enjoy it, as well as thinking it’s I’ve hugely benefited grounds you in how the system diseases, which is my own something I should do. It is a is. So, there’s a win for the specialist area. But I’ve hugely real privilege to be a doctor. from working as a wider role. benefi ted from doing it all the And I think that anyone who’s doctor all the way This is the fi rst job I’ve way through the time I’ve been a clinician doesn’t realise quite through the 10 years done where I haven’t actually working in government, which how lucky they are until they I’ve been working done weekly clinics and is now around about a decade. try to do something else. in government

The UK lacks an independent organisation such as that’s what they report back. That’s what it feels like to me the Robert Koch Institute in Germany, which provides sometimes as a medical practitioner in the system. information, data, and analysis to the public. Do you What I said, I hope, was reasonably clear, and I would think this is something the UK should establish? invite people to go back and listen to my words, which were In this kind of pandemic, I don’t think it makes much carefully chosen and were pretty accurate. diff erence where the advice is situated. I think it’s very important that public health advice is seen to be free of What do you think we’ve learnt from this pandemic political interference. We can agonise rather a lot about that we’ll need to apply in the next one? exactly what form that should take. Some of those who Unfortunately, we always say this at the end of every major were very exercised about the fact that PHE was no longer epidemic: what this demonstrates is the need to get proper to be PHE were very exercised about PHE being created in diagnostic capacity, proper public health systems properly the fi rst place, saying it was disgraceful that it was being rooted locally, because that’s what stands you in good stead created out of otherwise independent organisations. when you have an emergency. That’s very easy to say during The general principle should be—as with all medical an emergency. Immediately afterwards, everyone will say advice, so this is true for clinicians as well—you should it. And then the enthusiasm gradually wanes. And then you give the advice you gave professionally, independently, get to a situation where the next wave hits. This is a lesson and without any sense that you’re cutting the advice you could have rewritten after several previous pandemics. according to what the person who you’re talking to wants to hear. Any doctor who doesn’t abide by that general How will the pandemic end? principle is not doing them, their patients, or the wider I don’t think the virus is going to disappear. We’ll get public if they’re in public health, any favours at all. medical countermeasures—drugs, vaccines, or other So independence is, in my view, a state of mind and a things—and they’ll help us de-risk it signifi cantly. But I tradition that should be fi rmly adhered to. Organisational think we’ll have covid circulating, and it may become like structures strike me as less important. seasonal fl u. It may become like seasonal adenovirus. It might become something which is rather less seasonal; At the beginning of the pandemic politicians made it there are a variety of ways it could play out. clear they would follow the science, and presented a But I think its impact on society, its impact on mortality, very united front with you and Patrick Vallance, the and its existential threat to medical practice—the stopping chief scientifi c offi cer. This seems to have faltered us from doing all the other elements of health—will fade, as recently, such as when you said the three tier system we get on top of it with the medical countermeasures. wouldn’t be enough. Does the loss of unity worry you? Medical countermeasures will make this a manageable What I said was, if an area of the country has got such a problem, just as HIV is now a manageable problem. When I high level of transmission already and is rising such that was a doctor in southern Africa a third of people my age had it needs to go into the tier 3 areas, the very base case of it, and it was 100% mortality. Now HIV is still a very serious tier 3 would probably not be suffi cient on its own to allow threat, but it is much, much less a threat than it was. that area to turn the curve down. But within tier 3 there are I’m not equating HIV and covid as diseases—they’re very multiple options on top of that. There will be some degree diff erent—but they are two infectious diseases that have of local discretion as to what the right ones are. But if you had a massive impact on society, where medical science think that you’ve got tier 3 and can just do the base case, and medical practice will reduce the risk such that the that will be insuffi cient. impact on society will be much smaller—without being What was reported was that I was saying tier 3 was no Fiona Godlee, editor able to say that it’ll be completely gone. Because I don’t good. Quite often I give a very precise answer, and people in chief, The BMJ think “completely gone” is a realistic goal for this or most cut out the bit that they want to hear and just narrowly Mun-Keat Looi, other infections. report that. It’s just like if you’re talking to a patient and international features This interview was conducted on 28 October and has been edited for length you’re giving a long talk about all the pros and cons of the editor , The BMJ and clarity. Listen to the full interview here: https://t. co/2S35dhU3Po?amp=1. treatment and they choose to only hear one bit of it, and [email protected] Cite this as: BMJ 2020;371:m4235

226 7 November 2020 | the bmj