this week ROTATIONS page 254 • HOSPITAL ACQUIRED COVID-19 page 256 • AFTER ICU page 259

MPs demand evidence for testing policy

A cross party group of MPs has said that inadequate for most of the so far, A letter to from ’s failure to publish arguing that “capacity drove strategy rather the Science and Technology the evidence behind its decision to than strategy driving capacity.” Committee calls the lack discontinue community testing at the start The letter detailed 10 key lessons the of transparency over the decision to stop community of the covid-19 outbreak is “unacceptable.” government should learn from the fi rst testing “unacceptable” In a 19 page letter to the prime minister, months of the epidemic, on the basis the Science and Technology Committee of evidence given to the committee by called for publication of the evidence base scientists and other experts. informing PHE’s decision to concentrate The MPs urged the government to testing for covid-19 in a limited number of regularly update the public list of members its own laboratories and to expand testing of the Scientifi c Advisory Group for gradually, rather than surging capacity Emergencies (SAGE) and to publish the through a large number of laboratories in papers on which the group draws its advice, research institutes and universities. as well as the scientifi c advice that has This led to the government announcing informed government decisions. They also on 12 March that testing would stop in the called on the government to “urgently” LATEST ONLINE community and would occur principally build up capacity for contact tracing and set US food and drink in hospitals—a decision that was “one out a clear approach for managing the risks industry sought to of the most consequential made during around asymptomatic transmission. infl uence scientists, [the] crisis,” the MPs said. “It meant that The committee chair, Greg Clark, said, emails show residents in care homes—even those with “Greater transparency around scientifi c Alarm bells ring symptoms—and care home workers could advice; putting capacity in place in advance for patient data not be tested at a time when the virus was at of need, such as in testing and vaccines; and privacy in the its most rampant.” collecting more data earlier; and learning covid-19 goldrush The letter continued, “The failure of PHE from other countries’ approaches are some Rest and PPE to publish the evidence on which its testing of the early lessons that are relevant to reassurance are policy was based is unacceptable for a further decisions that will need to be taken needed before decision that may have had such signifi cant during the weeks and months ahead.” NHS services can consequences.” Jacqui Wise, London restart, MPs hear It said that testing capacity had been Cite this as: BMJ 2020;369:m2022 the bmj | 23 May 2020 253 SEVEN DAYS IN Rotation of foundation an d medical training posts to restart in August Health Education England has announced that all trainees in foundation and core medical training posts will rotate as usual at the start of August. Planned rotations have been cancelled for May, June, and July as a result of covid-19. In England, 19 medical specialties involving more than 40 000 trainees will rotate in August. But HEE said that, because of covid-19, other programmes would have later start dates, though trainees and employers would have at least eight weeks’ notice. It added it was working with the devolved nations, GMC, and royal colleges to enable trainees to progress by increasing the flexibility of training programmes. Guidance is being developed to inform progression decisions being made by annual review of competency progression (ARCP) panels, HEE said. Sheona Macleod, HEE’s acting medical director, said it wanted to minimise any disadvantages for trainees. “Our priorities are to protect the education and training of our future workforce, to enable junior doctors and others to ensure the continued delivery of services, and to maintain the quality and safety of patient care during a summer period that is likely to be busier than usual.”

Abi Rimmer , The BMJ Cite this as: BMJ 2020;369:m1998

Convalescent plasma we are now confident enough to A&E criteria for ending lockdowns No evidence that treatment recommend this new measure. Drop in numbers is a such as falling rates of infection. is safe or effective The individual’s household “ticking time bomb” As the US passes 85 000 reported A Cochrane review found much should also self-isolate for 14 Attendances at emergency deaths, Fauci warned that uncertainty as to whether days as per the current guidelines departments in England totalled “needless suffering and death” convalescent plasma was and the individual should stay at 917 000 in April, down 56.6% would ensue if lockdowns were effective in people admitted to home for seven days, or longer on the same month last year and lifted prematurely. hospital with covid-19, because if they still have symptoms other the lowest since data collection all eight studies, with a total of 32 than cough or loss of sense of began in 2010, NHS figures Schools patients, had a high risk of bias smell or taste.” showed. Nick Scriven, immediate and the reporting quality was low. past president of the Society Lise Estcourt, head of NHS Blood Testing for Acute Medicine, described and Transplant’s clinical trials RCGP calls for joined-up the drop in attendances as a unit, said a trial of convalescent testing strategy “time bomb” that would be plasma for adults Martin Marshall, chair of the exacerbated by other pressures admitted to Royal College of General as hospitals tried to resume intensive care in Practitioners, wrote to normal services. Keeping people England (REMAP- England’s health and with covid-19 separate from other BMA: keep schools closed CAP) was ongoing social care secreatary, patients would be a challenge, he to avoid second spike and that researchers hoped to , to demand a said, as would the resilience of The BMA warned that the open a trial in all inpatients, in joined-up strategy throughout staff who had been “working flat number of coronavirus infections collaboration with the RECOVERY the NHS and social care to ensure out with little time for recovery.” remained too high to allow trial, for people of all ages. “the right people are tested at children back to school safely the right time.” He called for Overseas news and backed teaching unions in Symptom update pathology labs to update GP Trump fumes at adviser urging caution and prioritising Anosmia is added to records with results to help trace over lockdowns testing before reopening schools symptoms for self-isolating positive covid-19 cases, for test Tension between the White on 1 June. In a letter to Kevin The UK’s four chief medical kits to be readily available for House and US public health Courtney, chair of the National officers advised adding anosmia patients with symptoms, officials escalated this week Education Union, Chaand to continuous cough and fever and for clear guidance on after President Donald Nagpaul, BMA chair of council, as a symptom for which people how GPs can help patients Trump openly criticised highlighted the “relatively small should self-isolate because of access tests. He warned his top infectious disease amount of research available” probable covid-19 infection. In that clarity had not been specialist, on “the uncharted territory we a statement issued on 18 May sufficient to prevent (left), for testifying in find ourselves in.” Nagpaul they said, “We have been closely a second wave of Congress against the concluded, “Until we have got monitoring the emerging data infections or secure reopening of states case numbers much lower, we and evidence on covid-19 and the overall health of that had not met the should not consider reopening after thorough consideration the population. administration’s schools.”

254 23 May 2020 | the bmj SIXTY SECONDS MEDICINE ON . . . Global health FOLLOWING Pandemic derails UN’s THE SCIENCE development progress WHO fears that the world’s focus on Progress towards the UN’s SOUNDS LIKE A SENSIBLE APPROACH covid-19 will undo the sustainable development goals Evidence based policy does seem rather progress made against is too slow and is being further important during a pandemic. But malaria in recent years “thrown off track” by covid-19, government ministers’ recent parroting of WHO warned. Its World Health the phrase “we’re following the science” has Statistics report showed that raised some concerns. immunisation coverage has SURELY THIS IS AN IMPROVEMENT ON barely increased in recent “WE’VE HAD ENOUGH OF EXPERTS”? years, and malaria gains may be True. But there’s growing concern that the reversed. In 2017 only a third to 16.5% of respondents said they mantra is being used by ministers to deflect a half of the world’s population had been unable to get the PPE NHS 111 scrutiny of their handling of the covid-19 had access to essential health recommended by Public Health Between 18 March pandemic, rather than as a meaningful services. Over half (55%) lacked England in the past two weeks. and 18 May explanation of policy making. access to safely managed sanitation services, and over Research POLITICS’ VERSION OF “NOT ME, GUV”? That’s the nub. At a Science Media Centre a quarter (29%) lacked safely Human genome study to 2 531 228 briefi ng on 18 May the broadcaster and managed drinking water. sequence 20 000 people assessments conducted Brian Cox (below) said that, while A study of the genetic basis for science should inform policy, it’s not its job Digital NHS the varied outcomes of covid-19 through NHS 111 to decide it. “It almost seems like a defence Plan “will fall short” infection was launched, aiming online received a that some ministers have been coached to without extra investment to recruit and sequence the entire potential covid-19 deploy when asked a diffi cult question,” he Ambitious plans to transform genomes of 20 000 people who said, with a metaphorical stroke of the chin. digital services in the NHS in have been in intensive care, as final disposition England over the next decade are well as control participants who [NHS Digital] THINGS CAN ONLY GET BETTER likely to fail without substantial have experienced milder disease. Scientists are worried that if the current approach continues “the science” might extra funding, the National Understanding the increased be blamed if things go awry and that the Audit Office warned. It said burden of covid-19 disease in public’s trust in it could be damaged as a that NHS England and NHS ethnic minority populations is result. Cox called for politicians to embrace Improvement had one of its key aims. A new covid- the “uncertainty and humility” inherent in acknowledged 19 genomics UK consortium will scientifi c discovery and to communicate that the £4.7bn build on the existing Edinburgh this with transparency to the public. committed by the based GenOMICC study of government to critical illness and BUT WHAT ABOUT VA CUOUS SLOGANS? deliver its plan the UK’s genomics Alas, they would suff er. But Cox argues that from 2016 to infrastructure. a straightforward response to a diffi cult 2021 was “not question is too simplistic and does science a disservice by characterising it as enough to deliver the ambition” Antibody testing will help a homogeneous blob rather than a but could be used “to make a reveal immunity nuanced and constantly evolving significant start and demonstrate A study of as many as 20 000 body of evidence. the value of more funding in people by UK Biobank and future.” developed with the Wellcome SO, WHAT SHOULD MINISTERS Trust aims to track covid-19’s BE SAYING? Medical profession spread throughout England, According to Cox, they could try: Doctors’ concerns about Scotland, and Wales. Over six “We listened to the science and personal health rise months it will ask volunteers to the advice carefully—some of Almost half (48%) of doctors provide a blood sample every which may have been necessarily working during the covid month and answer questions contradictory because nobody knows everything about this virus and how pandemic said they were about any relevant symptoms. it spreads—and then we took responsibility concerned or very concerned The de-identified samples will and made a decision that was based on those for their health, found a Royal be sent for validated antibody discussions and other considerations.” Let’s College of Physicians survey, testing at the , hope Hancock and company are taking notes. with 1582 respondents. This and the first results are expected rose to 76% among members in early June. Gareth Iacobucci, The BMJ from ethnic minorities. Some Cite this as: BMJ 2020;369:m2006 Cite this as: BMJ 2020;369:m2014

the bmj | 23 May 2020 255 COVID 19

Surveys indicate low NEWS ANALYSIS infection level Doctors sound alarm over in the community transmission on wards Just 0.27% of people (one in 370) are thought With the pandemic continuing, the risk of hospital to have had covid-19 outside hospitals and care acquired infection is worrying medics, Gareth Iacobucci homes in England in the past two weeks, say the preliminary results of a snapshot survey of swab testing for presence of the virus published by octors have told The BMJ wards with people awaiting swab results the Offi ce for National Statistics. they are deeply concerned don’t have very good ventilation, and so Studies from Spain and France indicate at the number of patients they are kind of dangerous places.” that just 5% and 4.4% of their populations, becoming infected with Coebergh called for more aggressive, respectively, have ever contracted covid- D covid-19 in NHS hospitals timely, and regular testing of all hospital 19, indicating that most people may still be and have called for more stringent patients and for stricter separation to susceptible to infection. infection control measures. reduce the risk of infection spreading. They cite limited capacity for testing Tullie Yeghen, a consultant “Totally inadequate for ” and retesting as a barrier to keeping haematologist in south London, said Nicholas Beeching, consultant in infectious covid and non-covid patients separated she had seen cases of vulnerable diseases at the Liverpool School of Tropical in so called “green” and “red” zones. patients who had died as a result of Medicine, told The BMJ, “We need dependable They also have concerns about the nosocomial transmission of covid-19 antibody testing of a representative sample availability of side rooms and cubicles in hospital. She believes the infection of the population to to keep patients separate and believe was contracted either on a designated get a real picture of that poor ventilation in areas other than green ward for non-covid patients or the rates of infection. intensive care units may be contributing after admission to a “covid suspected” However, if it turns out to nosocomial infections. cohort bay pending swab results. that only 5-10% of the In a rapid response to The BMJ Yeghen population have been Distressing cases called for extra measures to protect infected with covid-19 Jan Coebergh, a consultant neurologist patients. She wrote, “Securing the then this would be totally inadequate to provide in Surrey who has worked on covid safety of our vulnerable patients would herd immunity as lockdown is released.” wards at several sites since the outbreak require, as a minimum, the allocation The ONS survey was based on self- began, told The BMJ he had seen of all shielded patients to a side room administered throat and nose swab tests from distressing cases of patients becoming in the appropriate colour coded ward 10 705 people in 5276 households during infected with the virus from other pending SARS-CoV-2 status, given the the two weeks to 10 May, of whom 33, in 30 patients while in hospital and who were difficulty in making or excluding the households, tested positive. This suggests that, likely to die as a result. diagnosis clinically and the potentially at any given time in those two weeks, an average “There clearly is intra-hospital patient devastating consequences of of 148 000 people in England had the virus. transmission,” he said. “In intensive nosocomial transmission. A more rapid The survey found that people who said they care and the respiratory wards they have turnaround time for tests would greatly worked in patient facing healthcare roles or special ventilation. But the other mixed facilitate this process. resident facing social care roles were more likely to test positive (1.33%) than people who reported working in other sectors (0.22%). Mental healthcare must be boosted No evidence of age difference The survey, carried out by Oxford and to deal with “tsunami” of cases universities, and Public Health England, found no evidence of diff erences in Mental health should be a “core A survey by the Royal College of the proportions testing positive by age. element” of the response to the Tom Wingfi eld, honorary consultant Psychiatrists of 1369 of its members at covid-19 pandemic, with greater physician at the LSTM, said, “It is not clear the beginning of May found 43% government investment to cope what the quality of these self-swabs was. In were seeing a rise in urgent and with a predicted surge in cases after addition, there is not yet enough data to help lockdown, say psychiatrists and WHO. emergency cases, including patients us to understand how confi dent we can be that After a survey of its members by a negative swab means that a person does not who had suicidal thoughts or were self- the Royal College of Psychiatrists currently have covid-19.” harming. At the same time 45% that showed a big rise in urgent Jacqui Wise, London reported a fall in routine appointments and emergency cases (see left), its Cite this as: BMJ 2020;369:m1992 president, Wendy Burn, said, “We

256 23 May 2020 | the bmj “In addition,” she wrote, “allocation to green areas of staff less likely to transmit SARS-CoV-2 needs urgent consideration and back up by national recommendations. Finally, urgent consideration is needed for the Urgent provision of additional side rooms and consideration isolation facilities in centres treating patients with covid-19.” is needed for STOPPING INFECTION BY HOSPITAL STAFF • Testing of staff is just as important as testing patients. University of the provision No official data of isolation Cambridge researchers found that hospital staff may be carrying SARS- Currently there are no official figures CoV-2 without realising it. Researchers swabbed and tested more than facilities on numbers of patients contracting 1200 NHS workers at Addenbrooke’s Hospital in Cambridge throughout Tullie Yeghen, covid-19 in hospitals. However, the April. Of more than 1000 staff reporting fi t for duty, 3% tested positive, consultant Guardian reported that the proportion signifi cantly greater than the estimated incidence in the local area. of covid-19 infections acquired in • Although patients admitted to NHS hospitals are now routinely screened hospital was between 10% and 20%, for covid-19 and isolated if necessary, NHS workers are tested and although NHS sources told the paper excluded from work only if they develop symptoms. The lead author, that the figures were skewed by poor Mike Weekes, told The BMJ that in light of the fi ndings this practice must infection control procedures at one change.“Test, test, test, and test again. That’s the absolute key,” he said. single trust and that the true rate was “We need to test all staff as frequently as we possibly can, irrespective of lower, at around 5% to 7%. symptoms, to prevent hospitals from becoming hubs of transmission.” Each trust Although lockdown was eased last • Hospitals should be vigilant in ensuring that areas such as staff rooms needs to tailor week, the prime minister admitted in don’t become hubs for spreading infection because of the diffi culty in infection parliament that further progress would enabling and the absence of PPE, Weekes added. control to local not be possible “unless we crack these twin epidemics both in care homes reduce it,’” he said. “We have a duty Chris Green, consultant physician circumstances and in the NHS.” to tell people if they’ve been possibly in infectious disease at University Chris Green, Coebergh said data on hospital harmed by our care.” of Birmingham and a consortium University of acquired covid-19 needed to be made The International Severe Acute investigator, said it was appropriate Birmingham readily available to ensure patients Respiratory and Emerging Infection for each trust to tailor its infection weren’t put off seeking care in acute Consortium is looking at data from control to local circumstances, noting settings. “Unless we have the data, around a third of trusts in England to try that larger hospitals may be able to set we can’t reassure patients and say, to assess the level of hospital acquired up separate “hot” and “cold” sites, ‘We have done this and this and to infection connected to covid-19. while smaller hospitals may have to settle for “hot and cold pathways.” As The BMJ went to press, NHS England reported that the proportion of covid-19 had not replied to a request for comment. Gareth Iacobucci , The BMJ infections acquired in hospital was between 10% and 20% Cite this as: BMJ 2020;369:m2013 are already seeing the devastating Ghebreyesus, and recovery from the covid-19 WHO says impact of covid-19 on mental health, the director general of WHO, said pandemic. the effects of with more people in crisis. at a recent policy briefi ng that the “A failure to take people’s the pandemic “But we are just as worried about eff ects of the pandemic on people’s emotional wellbeing seriously on people’s the people who need help now but mental health were already extremely will lead to long term social and mental health aren’t getting it. Our fear is that the worrying. economic costs to society.” is extremely lockdown is storing up problems An analysis by the UK charity the worrying which could then lead to a tsunami “Core element of our response” Centre for Mental Health, based on of referrals. He said, “Social isolation, fear data from previous epidemics and the “Mental health services will be at of contagion, and loss of family aftermath of the 2008 banking crisis, risk of being overwhelmed unless members are compounded by the suggests that around half a million we see continued investment. The distress caused by loss of income and more people in the UK will experience prevalence of mental health issues often employment. a mental health diffi culty over the is also expected to grow enormously “It is now crystal clear that mental next year as a result of the pandemic. due to the repercussions of the virus health needs must be treated as Ingrid Torjesen, London and the lockdown on mental health.” a core element of our response to Cite this as: BMJ 2020;369:m1994 the bmj | 23 May 2020 257 Hospitals treat surge in cases of inflammatory syndrome in children after urgent alert

here has been a surge in know what to look out for, the incidence of new cases was 0.3 a cases of an infl ammatory syndrome is rare and outcomes are month in the pre-pandemic group syndrome in children, generally good. and 10 a month in the post-pandemic believed to be linked to Kawasaki disease is a rare condition group. Among the covid-19 group T covid-19, after an alert to that mainly aff ects children under more children had cardiac symptoms, doctors in the UK at the end of April. 5 and is characterised by a high Kawasaki disease shock syndrome, The syndrome, which in the temperature that lasts for fi ve days macrophage activation syndrome, Is this is an UK is now being referred to as the or more, a rash, and swollen glands and a need for adjunctive steroid antibody “paediatric infl ammatory multisystem in the neck. It can cause the blood treatment (box). mediated syndrome which is temporarily vessels to become infl amed and Julia Kenny, a consultant in associated with SARS-CoV-2,” has swollen and can lead to complications paediatric infectious diseases and or delayed also been seen in Italy and the US and in the coronary arteries. immunology at Evelina London response to has been compared to both Kawasaki Children’s Hospital, said the Italian the virus? disease and toxic shock. Thirtyfold increase fi ndings seemed to be consistent Liz Whittaker, Experts have said the condition Researchers in hospitals in Bergamo, with cases seen in the south east of Imperial College may be an “antibody mediated or Italy (above right), have reported England. delayed response” to covid-19 that a 30-fold increased incidence of “Evelina has more than 50 children happens several weeks after the Kawasaki-like disease since the start with a similar syndrome, and while infection. They also emphasised, of the covid-19 outbreak. very few tested positive for the however, that while doctors must In a study published in the Lancet virus on swabs, the majority tested they said that between 18 February positive for covid-19 antibodies when Bergamo’s cases of inflammatory syndrome and 20 April the syndrome was subsequently tested, suggesting their diagnosed in 10 children, with an disease is associated with exposure to Cardiac symptoms 2 6 average age of 7.5 years, whereas the virus,” she said. in the fi ve years leading up to the At Great Ormond Street Hospital, Kawasaki disease shock syndrome 0 5 pandemic (1 January 2015 to 17 clinicians said they have seen a surge Macrophage activation syndrome 0 5 February 2020) the total was 19 in cases but emphasised that numbers Steroid treatment 3 8 children, with an average age of 3. were still small and that parents Pre-covid, n=19 (January 2015 to February 2020) Among the covid-19 group, eight of shouldn’t panic. Paediatric infectious Post-covid, n=10 (eight tested positive for SARS-CoV-2 the children tested positive for SARS- diseases consultant Karyn Moshal between 18 February and 20 April) CoV-2 antibodies IgG or IgM, or both. said, “There are a number of these The team reported that the children coming through to the district P atients should self-isolate before elective care, says guide

Patients should be admitted to should ensure social distancing those who are being discharged Consultants Committee, said hospital for planned or elective measures are in place. to a care home should be tested many trusts were still treating care only if they have self- The guidance says that up to 48 hours before they are large numbers of covid-19 isolated for 14 days beforehand outpatient appointments should due to leave. patients and staff needed time and tested negative for covid-19, be conducted remotely as much to recover “before beginning the says new guidance for trusts in as possible, and face-to-face Redesigning services huge task of redesigning their England designed to increase the consultations should not be Stephen Powis, NHS national services once more.” number of routine operations conducted with patients who medical director, said, “Now that He added, “We understand and treatments. have symptoms of covid-19. we are confi dent we have passed that the longer patients go People who need urgent Patients who stay in hospital the fi rst peak of coronavirus, it without [planned care] the or emergency care should be should be monitored for is important that we bring back greater the risk their conditions tested on arrival and streamed symptoms and retested for those services where we can, will worsen, putting more accordingly, with services split infection every fi ve but only where that can be done pressure on the NHS—but to make the risk of picking up and seven days after safely.” He encouraged the reintroducing routine services the virus in hospital as low as admission, and public to resume seeking help must be done safely and within possible, said NHS England. In when they needed it. NHS systems that can cope. emergency departments and Rob Harwood said staff However, Rob Harwood, “The government needs to other walk-in services trusts need time to recover chair of the BMA’s demonstrate it is able to procure

258 23 May 202 23 May 2020 | the bmj FIVE MINUTES WITH . . . Ron Daniels The consultant and UK Sepsis Trust founder on life after intensive care

general hospitals, and we’re getting of heart involvement.” She said that ne of the most rewarding calls to discuss them. Although some many patients were “presenting with parts of the job as an are well enough to be managed where suspected appendicitis.” intensivist has changed they are, we are erring on the side of Speaking at a press briefi ng on the over the years from acute caution and bringing them in, so we syndrome on 13 May, Liz Whittaker, “O care delivery to managing can treat them early.” clinical lecturer in paediatric infectious patients’ and relatives’ anxieties, and too oft en diseases and immunology at Imperial the dying process as well. With covid-19, this Distinct syndrome College London, pointed out that role has largely gone. She said many of the children the peak in these cases seemed to “Relatives aren’t around in the intensive care fell “between toxic shock and be several weeks behind the peak of unit to mentally record the patient’s journey to fill Kawasaki disease in terms of their covid-19 across the country. in the gaps when they recover—and aren’t always presentation,” but it did seem to be a “In London, the peak was estimated there during their passing. distinct syndrome. around the fi rst or second week of “ For patients who do survive, discharge home is Moshal added, “The age group is April, and we think we saw the peak traumatic, with little, disordered, or no memory of much older than the classic Kawasaki of these children this or last week. We what’s happened to them and difficulties returning patient group, who would be under wonder whether this is an antibody to function. Normally, a 5, with half of them under 2. The mediated or delayed response to the relative can advocate for population we are seeing are 7 or 8 virus that is happening several weeks the loved one. Covid-19 through to 17, with the majority in after the infection. That would explain survivors don’t have that. their teens, around 13 or 14. The why the children don’t test positive “Patients who’ve survived abdominal pain, the diarrhoea, for the virus using polymerase chain critical illness with covid- and the gastrointestinal symptoms reaction tests,” she said. 19 are likely to need many together with a persistent fever are Whittaker said that while they could months of rehabilitation. particularly prominent in this group.” not defi nitely say the syndrome was Early indications suggest Sophie Skellett, paediatric and related to covid-19, “it is happening in the neurocognitive and THE RECOVERY neonatal intensive care consultant the middle of a pandemic so it seems neuropsychiatric needs will PROFILE FROM at GOSH, said her department was reasonable to suggest they are related.” be huge. COVID-19 BEARS STARK SIMILARITY seeing more patients with toxic shock Elisabeth Mahase, The BMJ “The recovery profile TO SEPSIS type symptoms, but with “some sort Cite this as: BMJ 2020;369:m1990 from covid-19 bears stark similarity to that of sepsis, and bereavement is similarly sudden and indiscriminate. Sepsis is my suffi cient and appropriate PPE, specialist area; my team in Birmingham developed not only for patients needing the Sepsis 6, a treatment bundle intended to covid care but also to protect all empower juniors to act rapidly, in 2004-5. Now, patients needing elective care it’s used in almost all UK hospitals and in 34 other and to protect the staff looking countries. I also founded the UK Sepsis Trust, after them.” which has a specialist support service for patients On 15 May the government and relatives as one of its four pillars of activity. announced that more than “The trust just launched its Covid-19 Recovery 70 million face masks would Response with a new downloadable booklet. be manufactured: 4.5 million A. SPL BSIP / NOOR / It’s intended to help people understand what’s FFP2 and FFP3 masks each happened to them and why, and to share their month for the next 18 months. ON 15 MAY the likely recovery profile with their family, friends, Harwood welcomed the move but government announced that employers, and those caring for them at home. said, “Without evidence based “We’re now looking to bring specialist skills calculations showing how much more than 70 million face into our support team to supplement its intensive PPE is likely to be needed as masks would be manufactured, care and mental health nursing experience, demand rises, there’s no way of including skills in physiotherapy, nutrition, and knowing how eff ective it will be.” with 4.5 million FFP2 and neurocognitive and neuropsychiatric assessment Zosia Kmietowicz, The BMJ FFP3 masks being made each and rehabilitation.” Cite this as: BMJ 2020;369:m1991 month for the next 18 months Jacqui Thornton , London Cite this as: BMJ 2020;369:m1971 the bmj | 23 May 2020 259 THE BIG PICTURE Two hundred thank yous

Nathan Wyburn, an artist from Cardiff , created this collage during the covid-19 lockdown from hundreds of images sent to him by NHS staff . Wyburn put out a request on social media for selfi es from health workers and was taken aback by the number he received. “The response was overwhelming, with more than 200 photos sent in,” he says. He put the images together digitally to form the picture of a health worker wearing a mask. The collage has also been printed on T shirts and hoodies to raise money for the Cardiff and Vale University Health Board’s charity and has been displayed on 4 m high banners around the board’s sites. Wyburn says the collage is his way to show his appreciation for the work of NHS staff . “This is my thank you for your hard work, your courage, and your heart during this trying time,” he says. “It’s emotional to me, as this collage contains many of my best friends. You are all superheroes.” Tom Moberly, UK editor, The BMJ Cite this as: BMJ 2020;369:m2015

260 23 May 2020 | the bmj the bmj | 23 May 2020 261 EDITORIAL Developing a vaccine for covid-19 Old and new strategies are being investigated in an unprecedented worldwide eff ort

he rapidly developing protein”). Others are using just covid-19 epidemic has the tip domain of the spike protein stimulated an enormous as this is the part that targets the eff ort to develop receptors on human cells. Examples T vaccines against the of these approaches are likely to coronavirus SARS-CoV-2. At least enter phase I clinical trials this year. six vaccine candidates have entered clinical trials across the globe, with Repurposing other vaccines more than 80 others reported to be Repurposing existing vaccines is in preclinical stages.1 However, the being considered as an alternative road to successful vaccine licensure means of covid-19 control. is treacherous, and only a handful of The current frontrunner is the BCG these vaccines may make it. vaccine, normally directed against No vaccines are currently licensed tuberculosis. BCG vaccine can for any of the other coronaviruses stimulate broad, innate components aff ecting humans—SARS-CoV-1, of the immune system, off ering MERS-CoV, and minor cold viruses. some protection against a range of Economic reasons are undoubtedly diseases from infl uenza to bladder a major factor for the absence of cancer. 10 11 Several studies have now these vaccines, but vaccine design is proposed an epidemiological link also a challenge; immune responses between population BCG coverage to natural coronavirus infections and reduced covid-19 incidence can be short lived, and some trial at a country level.12 13 Although vaccines for SARS-CoV-1 raised several rebuttal studies have also safety concerns in animal models.2 No vaccines adenovirus vector to carry the spike been published, at least fi ve clinical The development of a SARS-CoV-2 are licensed protein gene. When the adenovirus trials are now recruiting healthcare vaccine may not be straightforward. for any of invades human cells, the spike workers to investigate whether BCG 14 The multiple strategies to the other protein will be produced, becoming protects them against covid-19. vaccine development for covid-19 coronaviruses a potential target for an immune Other potential repurposed include both traditional methods response. The clinical trial for this vaccines include the oral polio affecting and next generation techniques. vaccine started on 23 April and plans vaccine15 and the MMR vaccine.16 Live vaccines are not likely to be humans— to recruit over 1000 volunteers. 8 All these existing vaccines have the attempted for safety reasons, but SARS-CoV-1, The use of messenger RNA as a advantage that they can begin phase an inactivated whole virus vaccine MERS-CoV, vaccine is a relatively new strategy, III trials immediately as safety (phase has been tested in primates and a and minor cold and no licenced vaccines have yet I) and immunogenicity (phase II) phase I-II human trial is now under viruses used this method. The concept have already been established. way in China. 4 is simple though—inject mRNA However, evidence for their use must coding for the spike protein and be regarded as tenuous at this point. Spike protein let the host make the protein. One It’s too early to tell which vaccine Many other eff orts are currently advantage of this approach is a will make it successfully through focused on the spike protein in SARS- reasonably straightforward route to clinical trials fi rst. In an ideal world CoV-2. This protein is part of the manufacture, allowing rapid scaling we would have several safe and outer layer of the virus and is critical up of production. The fi rst mRNA eff ective vaccines. for entry into cells. Antibodies that vaccine entered clinical trials in the While fast tracking research target the spike protein can block US six weeks ago, and preliminary and development is an option in virus entry, potentially inhibiting results are eagerly awaited. Related all well resourced countries, the subsequent virus replication.5 The work is ongoing at Imperial College most realistic time frame for the S a r a h C a d d y , genetic sequence of the spike protein London, with promising results in production at scale of any safe and Wellcome Trust 9 was released internationally on 10 clinical research mice released at the end of April. eff ective vaccine against covid-19 January 2020, providing a blueprint career development Other vaccine strategies under still stands at more than a year. 6 7 for vaccine development. fellow , University of consideration include injecting DNA Cite this as: BMJ 2020;369:m1790 Scientists at the University of Cambridge coding for the spike protein or the Find the full version with references at Oxford have modifi ed a chimp [email protected] actual spike protein (“recombinant http://dx.doi.org/10.1136/bmj.m1790

262 23 May 2020 | the bmj EDITORIAL Health policy response to the pandemic Government prioritised the NHS but was slow to protect social care

he number of excess deaths in the UK during the pandemic has now reached 50 000.1 - 3 While T it is too early to assess how the government’s handling of the pandemic has shaped its impact, the policy response in England has been decidedly mixed so far. After a slow start, the scale and reach of policy change since March 2020 has been dizzying.4 Extraordinary measures—emergency laws, lockdown, the job retention scheme—have been accompanied by a heavy fl ow of policy No action secretary said the 100 000 tests a has long been inadequate, staff announcements, plans, and guidance plan could day target had been met, though this shortages are widespread, and care 16 documents. The result is a complex undo decades included tests that had been sent out providers are at risk of collapse. The combination of changes interacting of political but not necessarily completed. The failure of successive governments to with the health system and society. neglect target has been missed almost every reform social care is being laid bare. day since.10 And detail is lacking on Government must now give the same Widespread changes the government’s test, track, and trace priority to protecting the social care The NHS entered the outbreak with programme. Guidance on personal system as it has done to the NHS. fewer doctors, nurses, hospital beds, protective equipment has been Politicians have repeatedly claimed and equipment per capita than most revised several times, alongside major that they are “following the science.” comparable countries.5 The NHS was shortages reported for health and care But are they following or hiding? The promised “whatever it needs” to deal staff .11 science is neither singular nor simple. with covid-19,6 and it responded Policy decisions are choices with with widespread service changes. In Too lat e trade-off s—shaped by data, values, mid-March, NHS leaders introduced Government support for social care biases, and more. Greater clarity is measures to postpone all non-urgent came too late. A covid-19 “action plan” urgently needed on the values guiding elective operations, shift to remote for social care was published on 15 political decisions as social distancing general practice appointments, block April12 —nearly a month after country- measures are eased. buy independent sector capacity, wide social distancing measures had This must include a commitment to and more. Policy changes included been introduced. The plan promised health equity. Deaths from covid-19 in cancelling routine quality inspections, greater support for social care staff , the most deprived areas are more than suspending or replacing payment expanded testing, and a plan to double those in the least,18 and death systems such as the Quality and recruit 20 000 more workers. But rates are higher among black and other Outcomes Framework, and centralising implementing it across a fragmented ethnic minority groups than the white commissioning. These changes may system of around 18 500 organisations population.19 Social distancing policies have unintended consequences— will be a challenge. could also worsen health inequalities including showing barriers caused by Meanwhile, social care leaders in the short and long term. 20 “usual” NHS policy. report that staff and service users have Government has introduced Other aspects of the government’s not been adequately protected.13 By unprecedented measures to protect approach have been less clear or the time of writing, there had been people’s incomes during the crisis. consistent. Early talk of herd immunity 8312 deaths related to covid-19 in care But enhanced social protections Hugh Alderwick, quickly disappeared.7 And policies homes in England and Wales.14 Social and action to address structural assistant director on testing have been confusing and Hugh.Alderwick@ care staff —mostly women—have been inequalities must be part of the long constrained by lack of capacity. health.org.uk around twice as likely to die from covid- term strategy to protect population 15 The World Health Organization told Phoebe Dunn, 19 as other adults. health as the country moves out of 8 countries to “test, test, test.” The research fellow No action plan could undo decades lockdown and into the “new normal.” government stopped community Jennifer Dixon, chief of political neglect. The social care Cite this as: BMJ 2020;369:m1937 testing on 12 March.9 Testing has since system was in crisis before covid-19 executive , Health Find the full version with references at expanded and on 1 May, the health Foundation, London arrived. Government investment http://dx.doi.org/10.1136/bmj.m1937 the bmj | 23 May 2020 263 PUBLIC HEALTH REFORM How the erosion of our public health system hobbled England’s covid-19 response Tensions with central government, challenges in collaborating with the NHS, and the legacy of savage cuts have all hampered the reaction to the pandemic. Richard Vize reports

he covid-19 pandemic has laid bare Sources of data that While most of Lansley’s reforms were heavily the impact of years of spending cuts could have helped criticised, putting public health back into local and muddled structural reforms on save lives during the government is widely regarded as having been the eff ectiveness of England’s public covid-19 pandemic the right approach. Jeanelle de Gruchy, director of T health services. It has also shown that were scrapped population health at Tameside council and president their current position within local government is of the Association of Directors of Public Health, says, the best place for them but that they need clearer “Being in local government is crucially important in national leadership. terms of getting close to local communities. You’re working incredibly closely with social services, and at The 2012-13 reforms the same time we have strong links to the local NHS and the GPs, so you’ve got those links locally between Under the reforms implemented in 2013 by the then local government and the hospitals, and that’s health secretary, Andrew Lansley, in the Health certainly better than it was before.” and Social Care Act 2012, public health in England moved back into local government, where it had Communicable disease cut away been until 1974. Directors of public health became the strategic leaders tasked with a remit to tackle But the carving off of communicable disease local health inequalities, as well as commissioning control into Public Health England has been far services including sexual health, smoking cessation, less successful. Helen Walters, now public health drug and alcohol services, and early years support consultant adviser at the National Institute for Health for children, such as through school nursing and Research, was head of health at the Greater London health visitors. Authority while the Lansley reforms were being Public Health England was created to oversee implemented and was public health director for NHS emergency preparedness, health protection such as Westminster under the previous system. She believes communicable disease control, and public health that moving communicable disease control staff campaigns, as well as supporting local systems with away from public health directors has aff ected the data and evidence. It was an executive agency of the response to the covid-19 pandemic. Department of Health, not an independent body. Understanding the She says, “Under the old [pre-2013] system there However, the NHS retained some aspects of public local population was a closeness between the director of public health health—notably, vaccinations and immunisation— helps hugely if and the local communicable disease control people. and the chief medical offi cer remained the lead you’re organising Mine was on the same corridor. That was lost a bit advocate for public health throughout government contact tracing in the reforms because the communicable disease and leader of the public health profession. Helen Walters, NIHR people went to Public Health England.

264 23 May 2020 | the bmj “They [the local communicable disease control He compares it with the time before the 2013 people] did all the emergency planning: infl uenza, reorganisation, when the CMO was Liam Donaldson, pandemic planning, and outbreak control. If you were a former regional public health director. “He had a director of public health and a question on it came direct responsibility for the public health function along you would have an experienced consultant on across the country,” says Gill, “and that meant he your team. Now they’re not sitting in the team.” related to the regional directors of public health, She explains, “Public health directors understand and to the directors of public health at local level; the bigger system, but they don’t understand the and he was, for example in the H1N1 outbreak, infectious disease side so well, so [now] you’ve got unambiguously the professional lead.” to get that expertise from Public Health England. He adds that, now, Public Health England reports They become less local. Understanding the local They focused on to a director general in the Department of Health population helps hugely if you’re trying to organise the acute sector and Social Care, NHS England retains parts of public contact tracing or a large testing mechanism, so but neglected the health, and “the chief medical offi cer does not have that’s going to make it more diffi cult.” community sector any direct line relationship with the public health Allyson Pollock, function. Instead you have a plurality of leadership Pandemic planning Newcastle University fi gures, which is inevitably the cause of indecision without public health and muddle.” Gill believes that the government should Public health experts are concerned that the sector’s immediately give Whitty de facto control of Public voice has been lost in much of the government’s Health England. discussion about how to handle the pandemic, drowned out by epidemiologists and scientifi c Weaknesses and tensions advisers. Allyson Pollock, of public health The covid pandemic has exposed two key fault at Newcastle University says, “The people who lines of the public health system: weaknesses in should be in charge of the policy should be the local collaboration between the NHS and councils, communicable disease control experts and public and tensions between the local and national parts health. They have an overview of the system. It’s of the system. regrettable that the chief medical offi cers are no Data flows from When NHS England unveiled its long term plan longer from public health in England and Scotland, testing into the last year, with proposals for a bigger NHS role in because you need to understand the system at every local system need commissioning sexual health services, health single level. to be clear visitors, and school nurses, local public health “They’d have trained in most parts of the system, Jeanelle de Gruchy, directors bristled at what they saw as an attempted so they would have understood the importance of the ADPH land grab. local and the bottom-up—and how centralised, top- De Gruchy says that it was seen as the NHS down approaches don’t work.” (See timeline.) “wanting to do it all themselves, and so you have the Over the past month the national media have danger of trying to recreate public health within the gradually exposed the hitherto secret membership NHS, but not actually understanding or drawing on of the government’s emergency scientifi c advisory the expertise of public health.” group, Sage. Public Health England has three She traces the diffi culties in understanding local representatives among the 50 strong core of the implementation back to 2003, when the Health group, but the evidence it considers and the advice Protection Agency was established to take over work it gives remain hidden. Maggie Rae, president of the on infectious diseases from the health authorities. Faculty of Public Health, calls for more openness. “It Most of the agency was eventually absorbed into would be helpful if we had more transparency,” she Public Health England. “There is a story about the says. “If the evidence is published and people have There is no doubt disconnect between national and local,” she says. a chance to challenge that eff ectively, it is probably a that the austerity “You already start to see the local going up into a sort better strategy. Openness leads to trust, and trust is has hampered us of regional structure. It’s that local knowledge and what we want at the moment.” Jim McManus, expertise of communities and how [policy] is playing When took up the post of chief medical Hertfordshire out that is so crucial to ensuring that we have a good offi cer (CMO) for England in 2019 he retained his role health protection response locally.” as chief scientifi c adviser to the Department of Health and Social Care, with responsibilities including Test, track, and trace: health research and development and its life sciences national policy to local delivery strategy. His predecessor as CMO, , also held both roles for a while. For many public health teams the confusion, delays, Mike Gill, former regional director of public health and policy changes over the “test, track, and trace” for southeast England, believes that this expansion plans to control the spread of covid-19 exemplify of responsibilities has reduced the importance the lack of understanding at the national level about of public health at the centre of government. how to make policy work locally. the bmj | 23 May 2020 265 Government and Pollock refers to a widely quoted number of De Gruchy complains that, “despite leading so much contacts traced from 590 confi rmed cases. “Contact of this work, [public health directors are] left off time NHS responses tracing stopped on 12 March, and they’d only traced and time again from key communications or guidance In response to the 3500 contacts,” she says. “That’s pretty poor. They development by NHS England and some government comments presented said fi rst of all it was ineff ective, and secondly they departments. It’s not good enough, and it slows our in this article, Public didn’t have the resource. But one leads to the other. response at a time when we can least aff ord it. Health England said: “And yet they managed to throw hundreds of “It tells us how dominant the NHS is in terms of “Rest assured that public health advice millions of pounds at high tech solutions and [the politicians’ and the public’s understanding about what offered by Public Health Nightingale temporary] hospitals. They focused very health is, and how we get to have good health: health is England is at the heart much on the acute sector but neglected the community [seen to be] about the NHS. And the NHS struggles to of government, with a sector, which is where all the public health happens.” integrate within itself, never mind with other parts of range of public health De Gruchy says, “When it comes to testing and the public sector—it struggles to work in partnership. specialists advising contact tracing, policy has been set at national level, And, with public health having moved into local Sage [Scientific and then locally we are all having to implement it. government, that is an issue.” Advisory Group for You have Public Health England and NHS testing, The biggest test for sharing and using data will come Emergencies], CMO working through the Department of Health and with the expected second wave of covid-19. De Gruchy [chief medical officer] Social Care; then you have the Offi ce for Life Sciences says preparations for second and subsequent waves of and ministers from across all departments. working with Deloitte and others, which was totally the virus need to be “massive and long term.” The public health disconnected from the other testing. You are told the She says, “The data fl ows from testing into the local system is playing a vital night before that you’re going to have a testing site in system need to be clear. At the moment all the results role in what is rightly Manchester, and Deloitte is running it. are in diff erent systems. There is a lack of clarity on a truly national, multi- “So, you have two national initiatives that come who’s been tested and what the results are. To do agency response.” down and arrive, and you get told about the night contact tracing you need a slick testing programme.” The Department before. What do we do with the results? What’s the of Health and Social clinical governance? We didn’t have any input or Legacy of austerity Care said: “This is an say. So, what you get is the situation we have now unprecedented global in Greater Manchester, where we have fi ve diff erent But the biggest problem facing public health services pandemic and we testing sites that we have to try to marry up.” is not coordination with the NHS or working with have taken the right steps at the right time There is some evidence of government getting government, but money and staffi ng. A King’s Fund in order to protect the the message that it needs a better understanding of analysis reveals that like-for-like public health NHS and save lives. how national policy plays out locally. A letter from spending in cash terms was virtually the same in This government has Public Health England on 24 April explaining the 2019-20 as in 2013-14. The Health Foundation says been working with a developing policy on contact tracing emphasised the that this translates into a reduction of almost 25% in world renowned team of discussions with public health representatives and spending per person from 2014-15 to 2019-20. scientists, clinicians and local government. De Gruchy says, “At the same time as the transition public health experts. to local government you had these massive cuts, so “We have ramped Information sharing a lot of people retire and leave. And there are fewer up testing, overhauled people to deliver, so there is no surge capacity.” the way PPE is being and the second wave delivered to those who Cuts to other local government services, such as need it and helped the However, the fractures between national policy environmental health—which has an important role NHS cope with increased and local delivery, and between the NHS and local to play in contact tracing—and emergency planning, demand.” government, are evident in the repeated failures to have further undermined public health. De Gruchy NHS England share information during the pandemic. Jim McManus, concludes, “So, prevention and preparedness are two acknowledged receipt director of public health for Hertfordshire county areas that have been quite aff ected by the cuts, despite of an email presenting it council, says that one of the council’s biggest concerns the rhetoric around prevention.” with the comments but is “NHS England sharing of data. The partnership [with] McManus says, “There is no doubt local government did not respond. NHS England could and ought to have been better.” is the right place for us [directors of public health] to be 1974 1991 2003 2010 2012

Control of The purchaser- The Health The chief medical The Health and Social Care Act, SLOW public health provider split Protection Agency officer (CMO) for introduced by Andrew Lansley, DECLINE moves and creation is established to England, Liam defines the most extensive from local of the internal take over infectious Donaldson, a former reforms since the NHS’s inception Key moments authorities market. Health diseases from regional public to the new authorities health authorities health director, in England’s health lose power retires; Sally Davies, public health authorities to trusts a haematologist system without a background in public health, is appointed

266 23 May 2020 | the bmj in England. But there is also no doubt that the austerity “We’ve currently got this terrible debacle in the has hampered us. Had the cuts not happened, we pandemic with nursing homes and social care―we would have had more staff that we could have put in used to collect a lot more data from them, and that at a faster and harder pace. We would have had many was culled. That was partly because of so much more health visitors and school nurses.” privatisation [of care homes] that the government Around 170 clinicians from the services McManus couldn’t see any value in it. It doesn’t have data commissions have gone into the NHS response to covid- on staff or on the residents or their level of need.” 19, leaving around 200 to continue existing services Pollock believes that, had this information still been and be redeployed to other public health roles. Before collected, the danger facing care home residents 2013 there would have been around 400 left. Services could have been identifi ed sooner and NHS resources that have been hit include mental health services for If the evidence is and staff mobilised to support them. children and young people despite concerns that the published, people But, despite the tensions with government, the lockdown is undermining mental health. have a chance to challenges in collaborating with the NHS, and the Walters says, “I don’t think it’s been the challenge that savage cuts, there is little doubt among public health reorganisation per se—it’s been government austerity Maggie Rae, Faculty of directors that local government is the best place for that’s the problem. It’s the boots on the ground. Public Health their service. With suffi cient funding, the current structures Refl ecting on his experiences during the would work fi ne.” pandemic, McManus says, “I can see the collaboration between the local resilience forum and Long term covid-19 planning the Ministry of Housing, Communities and Local Government, the Ministry of Defence, police, local Walters believes that the lack of capacity in public media, and a whole range of agencies. It’s brilliant; health teams is undermining their ability to plan for it’s far better than it would have been in the NHS, coping with covid-19 in the long term. “The average because I am connected into a range of organisations public health team will be smaller,” she explains. and expertise with a diff erent perspective. “If you’re a director of public health and you have “As a director of public health I look right across fi ve public health consultants underneath you, the whole spectrum of issues in the community, you can say to one, ‘I don’t want you to think about from PPE and testing, running a hotline for schools, the acute phase, I want you to be thinking about running a whole load of work in care homes, recovery.’ If you’ve only got two consultants you There’s a plurality right through to advising on what the curve of the can’t aff ord to do that: you’re just dealing with what’s of leadership epidemic means for recovery. We’ve got stuck in far urgent. It’s about having that space in the system to figures, which more than we would have been in the NHS.” be thinking ahead.” is inevitably the Walters believes that the pandemic could prompt Cuts have also hit Public Health England and cause of indecision a reassessment of the role of public health in the NHS England, aff ecting services such as health and muddle nation’s life. She says, “It has given public health protection, screening, and immunisation. Public Mike Gill, former public a profi le which invites an examination by the Health England’s regional teams are thinly staff ed, so health regional director country on how much we value it, and how much they have been calling for council staff to help them money we’re spending on it. It’s been undervalued out. Pollock says, “You’ve got Public Health England compared with all the other medical specialties for a operating out of nine regional hubs servicing more long time. than 300 local authorities, and there is simply not “This has focused the eyes of the country on enough capacity.” something that was fairly invisible before. It gives us Inadequate staffi ng comes on the back of the an ideal opportunity to think about where we, as a longstanding erosion of data collection and analysis society, want to place public health.” since the creation of the internal market in 1991, Richard Vize , London says Pollock, which has impacted on England’s [email protected] ability to respond to covid-19. Cite this as: BMJ 2020;369:m1934 2013 2019 2019-20 2019-20 April brings into . . . however , a national NHS England unveils its Chris Whitty, an Public health force the main government agency, Public long term plan. Public epidemiologist, spending has changes of the Health England, is created to health directors sense becomes CMO, fallen in real 2012 act, among oversee elements including a power grab, with but he retains terms by 25% per them the move emergency preparedness proposals for a bigger NHS his role as person over the of public health and health protection. role in commissioning chief scientific past five years back to local The NHS retains some sexual health services, adviser to the government . . . aspects of public health, health visitors, and Department of Health and including vaccinations and school nurses Social Care immunisation

the bmj | 23 May 2020 267 Visual summary Covid-19 policy responses

Governments around the world scrambled to mitigate the health and economic impacts of covid-19, with a wide variation in choice and timing of Government actions National Regional measures. The corresponding outbreaks in affluent countries are orders of magnitude more or less severe. The timings below indicate that the UK was Schools required Internal movement slower to act than many countries, despite warnings from other regions and to close Closed or mostly prohibited the World Health Organization (WHO). Data from Blavatnik School of Government at Oxford University and WHO. Gatherings limited International arrivals quarantined ≤100 people from high risk regions

31 Dec 2019 30 Jan 2020 11 Mar Requirement to Testing of anyone showing stay at home Reports of pneumonia WHO declares "public WHO announces covid-19 symptoms with unknown cause health emergency of covid-19 as a Economic support Comprehensive contact in China sent to WHO international concern" pandemic >50% of lost salary tracing for all cases

JAN FEB MAR APR MAY Total covid-19 1.3 deaths reported per million population World 39.1 0 First reported case 0.2 China * 3.3

0 0.2 South Korea 5.0 0 16.1 Italy 519.2 0 Daily covid-19 deaths reported per million population 16.8 United States 251.4 0 3.8 † 94.4 0 18.2 Sweden 346.8 0 14.7 * † 505.8 0

24 Jan 10 Feb 3 Mar 19 Mar What next? UK scientific advisory SARS-CoV-2 UK government UK government downgrades This graphic shows reported groups choose not to declared a serious publishes its four covid-19, meaning that a deaths, as the best available assess lockdown and imminent threat phase coronavirus lower level of PPE is required metric at this time. When future measures to public health “action plan” to treat patients information on all cause mortality is available, it may Data sources 18 May 2020 give a clearer picture of the impacts of government policies https://covid19.who.int/ 25 Feb 12 Mar https://data.worldbank.org/ UK government tells people UK abandons contact tracing and https://www.bsg.ox.ac.uk/research/ returning from affected moves to delay phase of action plan research-projects/coronavirus- areas of Italy to self-isolate but rejects closing schools a day later Version .  May  government-response-tracker * China and the UK recalculated their deaths, reporting large numbers attributed † Both Germany and the UK introduced testing in January, but not of everyone to a single day. These values are off the scales of these graphs, which are showing covid-19 symptoms. By March, Germany was testing 600 people per intended to show the overall shape and timing of an outbreak. million population everyday,compared with only 100 per million in the UK.

268 23 May 2020 | the bmj EDITORIAL The UK’s public health response to covid-19 The government’s reaction to the pandemic has been too little, too late, too fl awed

he UK government and its advisers were confi dent that they were “well prepared” when covid-19 swept East Asia. The T four-pronged plan of 3 March to contain, delay, research, and mitigate was supported by all UK countries and backed, they claimed, by science.1 With more than 30 000 hospital and community deaths by 12 May, where did the plan go wrong?2 What was the role of public health in the biggest public health crisis since the Spanish fl u of 1918? And what now needs to be done? What is clear is that the UK’s response so far has neither been well prepared nor remotely adequate (see infographic). The weakness

of the preparations was exposed in 2016 by JENKINS/GETTYTOM IMAGES , a pandemic simulation, and Cheltenham Festival was allowed to go ahead in March just as Italy entered full lockdown the necessary remedial steps were not taken.3 On 30 January, the World Health Organization On 12 March the government Matters worsened when Vallance initially declared a public health emergency of inexplicably announced a move away rejected “eye catching measures” such as international concern and governments were from containment to the delay phase stopping mass gatherings or closing schools. urged to for global spread of covid- To widespread criticism, he fl oated an 19 from East Asia.4 Detailed case studies identify every new case and that all testing approach to “build up some degree of herd followed showing the need for high levels capacity across the UK, despite major regional immunity” founded on an erroneous view of and high death variation in cases, would be “pivoted” to that the vast majority of cases would be mild, rates.5 6 But the UK ignored these warnings. hospital patients. NHS 111 and Public Health like infl uenza. 13 When subsequent modelling England teams working on contact tracing estimated that 250 000 people might die in Delay and dilution were confused and overwhelmed. WHO’s this scenario, but that physical distancing By 11 March, Italy had taken fi rm public standard containment approach of fi nd, test, health action and was in full lockdown, treat, and isolate, which has worked well in followed closely by Spain and France. countries that have successfully suppressed The UK’s Scientifi c Advisory Group for viral spread, was abandoned; entry via ports Emergencies (SAGE) rejected lockdown, and airports remained unrestricted. 9 There believing that the population would was no future plan for community based not accept it. SAGE, chaired by Patrick case fi nding, testing, and contact tracing. Vallance, the government’s chief scientifi c Procurement and delivery of testing resources adviser, reports into the Civil Contingencies was ineff ective, despite a readymade viral test Committee (popularly known as Cobra), and off ers of help from university and private which coordinates the governmental response sector laboratories.10 to national or regional emergencies. 7 On 19 March, the status of covid-19 was One day later, the government inexplicably downgraded from level 4, the highest threat announced a move from the containment level, to level 3 by the four nations group phase in its strategy to the delay phase. 8 on high consequence infectious diseases Chris Whitty, England’s chief medical offi cer, and the Advisory Committee on Dangerous explained it was no longer necessary to Pathogens. 11 This enabled the standard of Gabriel Scally, visiting professor of public health, personal protective equipment to be lowered University of Bristol for staff in hospitals and to nurse patients in Bobbie Jacobson, senior associate, Bloomberg non-infectious disease settings. Meanwhile, School of Public Health, Johns Hopkins University, a reckless policy of discharging older patients

Baltimore, Maryland from hospitals to care homes without testing MARK THOMAS Kamran Abbasi, executive editor, The BMJ, allowed the virus to spread and kick start a In step? Matt Hancock (right), the health secretary, London [email protected] second epidemic of community infection.12 with Chris Whitty, England’s chief medical officer the bmj | 23 May 2020 269 measures could limit deaths to about 20 000, The most serious public health crisis of our times requires a strong 14 a sharp reversal of policy followed. and credible public health community at the heart of its response By the time the UK formally announced a lockdown with a huge package of on data science. 20 The involvement of two on case fi nding, testing, contact tracing, economic support measures, almost two infl uential political advisers makes a mockery and isolation is required for each of the months of potential preparation and of SAGE’s claim to provide independent four nations to inform and justify future prevention time had been squandered.15 scientifi c advice to the government. To decisions about how the lockdown can The delay in the face of emerging evidence date, we do not even know the details of be safely relaxed. The plans for case that the Italian lockdown reduced viral that advice. Such is the furore about SAGE’s fi nding, testing, and community contact transmission by about half16 looks likely to composition and operations, that David tracing must be adequately resourced, have cost many lives. King, the UK’s former chief scientifi c adviser, decentralised, and led by local public If the government failed in its duty to established an alternative “Independent health teams who know their communities protect the public, it also failed to protect staff SAGE” with a diverse membership including and the of the outbreaks in their in the NHS and social care by not delivering from public health,18 19 which advises localities. Public Health England and the suffi cient amounts of personal protective publicly on the UK’s response to covid-19.21 NHS must fully support these plans. And equipment (PPE) of the right specifi cation, Membership of SAGE and its national implementation of testing, data monitoring, again deviating from WHO advice.17 By late committees refl ects England’s marginalised and reporting must be optimised from all April, only 12% of hospital doctors felt fully public health infrastructure. Reorganisation sources: hospital, primary, and social care. protected from the virus at work, as staff of public health in England, largely resulting In time, fi ndings from the fi rst deaths in health and social care began to from the Health and Social Care Act 2012, population surveillance study will help rise. 18 The broken promises on testing were led to a critical loss of senior posts and staff . 22 eff ective targeting. 25 Meaningless political matched by those on PPE. The Health Protection Agency, regional soundbites promising to recruit 18 000 public health teams, and regional public contact tracers, test 200 000 people a day, Narrow scientific view health observatories were abolished, and or invest in unjustifi ed contact tracing How did a country with an international the remnants incorporated into a slimmed apps, divert focus and could lead to more reputation for public health get it so wrong? down Department of Health agency, Public deaths.26 These headline grabbing schemes The UK’s response to covid-19 is centrally Health England. This new agency lacks an should be replaced by locality led strategies coordinated through a series of scientifi c independent voice and clear public health rooted in communicable disease control. advisory groups led by Whitty and Vallance. leadership. England’s chief medical offi cer is An eff ective pandemic response requires Critical to this is the Scientifi c Pandemic no longer seen as the leader of public health. not only speed and clarity but also a Infl uenza Group on Modelling (SPI-M), which With these reforms, England’s new public willingness to accept mistakes and a models the future epidemic and feeds into health system was born critically fl awed. commitment to international cooperation. SAGE. SPI-M and SAGE are dominated by By the start of the coronavirus pandemic Sharing the science and the uncertainties modellers and epidemiologists. None of the only one of the UK’s four territories had a that inform political decisions will help members were experts in developing and trained public health physician as its chief rebuild lost public trust. Politicians and implementing a public health response, and medical offi cer. At a local level in England, their advisers cannot hide behind science other relevant groups such as communicable many public health responsibilities were to avoid responsibility for making diffi cult disease experts, women, and ethnic sensibly transferred back to local authorities decisions in a global crisis or merely repeat minorities are under-represented.19 with the 2012 act. But since then, close that they are following the science. The Guardian revealed that several SAGE to £1bn has been cut from public health Above all, the response to covid-19 is meetings had been attended by Dominic budgets and the position made worse by not about fl attening epidemic curves, Cummings, the prime minister’s chief cuts to other local authority services such as modelling, or . It is about political adviser, and Ben Warner, his adviser environmental health.23 24 protecting lives and communities most obviously at risk in our unequal society. Public health approach The most serious public health crisis of The UK government’s decimation of public our times requires a strong and credible health during years of austerity, and its public health community at the heart of impact on vulnerable groups, is for a public its response. inquiry to investigate, although any inquiry A UK government that prioritises report will be hollow without legislative the health and wellbeing of the public change. The system failings are being will see the importance of rebuilding exposed brutally by covid-19. For now, the the disempowered and fragmented focus must be on a strategy to minimise infrastructures of its public health system. harm from ill advised relaxation of physical Anything less is an insult to the tens of distancing in ways that will trigger further thousands of people who have lost their epidemic spikes with prospects of a vaccine lives in a pandemic for which the UK was or treatment still distant. forewarned but not forearmed.

MARK THOMAS First, SAGE must exclude political advisers Cite this as: BMJ 2020;369:m1932 SAGE, chaired by , England’s chief and recruit more public health experts. Find the full version with references at scientific officer, initially opposed lockdown Second, a clear population strategy based http://dx.doi.org/10.1136/bmj.m1932

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