this week MARCUS RASHFORD page 339 • UK DEATH RATES page 340 • COVID VACCINES page 342 DAN KITWOOD/GETTYDAN English tiers return with rapid tests surge

England will move to a revised system contact with someone with covid. Instead, Areas deemed to be on high of regional, tiered restrictions when the they will be off ered regular tests and will alert will be placed in a revised national lockdown ends on 2 December, the have to self-isolate only if they test positive. tier 2 after national lockdown prime minister has announced. Liverpool will trial the approach, followed by is lifted In a statement to the House of Commons care homes, health settings, universities, and on 23 November set out workplaces before the end of the year, with a a covid-19 winter plan, confi rming that nationwide roll-out in January. current national restrictions would revert to Johnson said rapid lateral fl ow tests had a modifi ed version of the three tier system. contributed to a “very substantial fall in Johnson said each tier will have t ougher infections” in Liverpool and that all tier 3 restrictions than before, including, in tier 1, authorities would be able to take part in a six working from home where possible; in tier week testing surge. “If it works, we should 2, alcohol in hospitality settings only with be able to off er those who test negative the a meal; and, in tier 3, closure of indoor prospect of fewer restrictions,” he said. entertainment and all hospitality settings Chaand Nagpaul, BMA council chair, LATEST ONLINE except for delivery and takeaways. warned the plan was “full of risks.” He Use UK aid to The plan sets out indicators to determine added, “The prime minister says the new train doctors each area’s tier—due to be announced on measures are tougher than October when in developing 26 November—including latest data on case in reality many are far more relaxed, at a countries, says MP detection rates, the rate at which cases are time when infection rates and covid related Trainees call for rising or falling, the positivity rate in the hospitalisations and deaths remain high.” transparency after local population, and current and projected Sheila Bird, formerly of the Medical Royal College of pressures on the NHS. Research Council’s Biostatistics Surgeons raises bar Johnson also pledged an extra £7bn Unit, questioned Johnson’s testing claims. for passing exam to “expand testing and improve contact “I hope the prime minister will publish the President Trump tracing,” bringing the total expenditure on in-context evidence on which he relies when issues orders test and trace to £22bn this fi nancial year. claiming the use of lateral fl ow testing to aimed at lowering The plan outlines the use of frequent, identify asymptomatic cases,” she said. prescription drug rapid testing as an alternative to self- Shaun Griffin, London prices in US isolation for people who have had close Cite this as: BMJ 2020;371:m4577 the bmj | 28 November 2020 337 SEVEN DAYS IN Millions will face surgery delays unless anaesthetist numbers grow, college warns The Royal College of Anaesthetists has urged the government to invest in increasing the number of anaesthetic trainees, aft er a census found vacancies in most hospitals. The college gathered data from 145 NHS trusts in England, fi ve in Northern Ireland, 15 health boards in Scotland, and six in Wales, with an overall response rate of 97%. The census found that 90% of anaesthesia departments have at least one unfi lled consultant, specialty and associate specialist doctor, or post. This equated to 680 vacant consultant posts and 243 vacant SAS doctor posts, it said. The workforce gap was unsurprising, the census report said, given the fall in newly qualifi ed anaesthesia specialists, from 569 in 2013 to 373 in 2019, a 34% reduction. “Alongside that reduction in supply, demand for senior anaesthetists has increased as the elderly sick population grows, new complex surgical procedures require more experienced senior anaesthetists, anaesthetists in training work more restricted hours, and the amount of weekend and evening work has increased,” it said. The college warned that more than a million procedures would need to be delayed every year unless the anaesthetic workforce were increased. “The consequences of continuing to underinvest in NHS staff will leave anaesthetists—who care for more than two thirds of all NHS hospital patients and who have had a central role on the frontline during covid-19—continuing to struggle to provide full surgical services,” it said.

DOUG MARTIN / SPL DOUG MARTIN / Abi Rimmer , The BMJ Cite this as: BMJ 2020;371:m4579

Covid-19 followed by a full dose, interim “Questions remain” over check-ups, the researchers Arthritis drug tocilizumab phase III trial results showed. The UK’s preparedness report reported in BMJ Open . may help severe illness analysis included 131 covid-19 Moosa Qureshi, an NHS doctor Healthcare practices need to Critically ill patients with covid- cases and showed the vaccine who launched a legal action implement systems for follow-up 19 who received the rheumatoid to be 62% effective when given in the High Court to force the of women who have declined arthritis drug tocilizumab as two standard doses (8895 Department of Health and Social or missed a postnatal check, were more likely to improve participants) one month apart, Care to publish a 2016 simulation they wrote, and the benefits of than patients who received no but this rose to 90% when a half report on the UK’s pandemic attending these appointments immune modulator (odds ratio dose was followed by a standard preparedness, dropped his should be better promoted. 1.87), showed the early results dose regimen (2741). No case after the report was finally of the Remap-Cap international admissions or severe cases were published by the government. But Essex trust is warned platform trial. Anthony Gordon, found in anyone who received the Qureshi, who filed an application over service failings UK lead for the trial, said that vaccine. The findings have not yet in April for a judicial review of the this was a larger odds ratio than been peer reviewed or published. government’s refusal to publish the 1.43 seen with the steroid the report, said dexamethasone in the trial. Sweden restricts that questions remained over However, the results were based gatherings to eight people how its recommendations were Sweden’s 10 million people implemented, and he believed have been subject to tougher that more data existed on the restrictions since 24 November, UK’s pandemic preparedness. after the prime minister Basildon University Hospital announced that gatherings would Obstetrics had conditions placed on its be limited to eight people for Women miss out on registration after the Care Quality four weeks—down from events key postnatal check-ups Commission found that maternity on a combined outcome measure involving as many as 300 people, More than 350 000 women in services remained “inadequate of survival and the length of which had been permitted until the UK may be missing out on for being safe, effective and well time patients needed on organ now under the country’s highly key postnatal check-ups every led” despite a previous formal support, and the results have not debated “soft” approach to year, researchers estimated warning to improve. Separately, yet been peer reviewed. controlling the pandemic. after examining the records of a coroner blamed Mid and On 13 November latest 241 662 women and finding South Essex NHS Foundation “Oxford vaccine is up to data showed a daily that just over half (56%) had Trust, which runs the hospital, 90% effective” record of 5990 cases had a structured postnatal for the stillbirth of Frederick The covid-19 vaccine candidate in Sweden, bringing check-up. Teen mothers Terry in a botched attempt at developed by Oxford University its overall total to and those in the most forceps delivery at another of its and AstraZeneca is 90% effective 177 355 cases and deprived areas were the hospitals, Broomfield Hospital, in when initially given as a half dose 6164 deaths. least likely to get these November 2019.

338 28 November 2020 | the bmj SIXTY SECONDS ON . . . MARCUS Drug resistance RASHFORD World health leaders unite to protect medicine YOU DON’T USUALLY COVER FOOTBALL The heads of the World Health True, but the Manchester United and England Organization, the UN Food star has recently been making as many and Agriculture Organization, headlines for his positive contributions off the pitch as on it. and the World Organisation for Animal Health launched the One A ONE MAN TEAM V MINISTERS? Health Global Leaders Group Pretty much, yes. Not content with forcing on Antimicrobial Resistance Ghebreyesus leads a the government into two U turns over free global group to tackle to work towards protecting school meals for children from low income antibiotic resistance antimicrobial . WHO’s families outside term time, the striker’s latest director general, Tedros Adhanom goal is to improve child literacy by setting up Ghebreyesus, said the rapid rise Management Centre and the a book club. And if that wasn’t enough, he’s of antimicrobial resistance was research institute RAND Europe, FUNDING also teamed up with the fashion company Burberry to fund youth centres. one of the world’s most urgent some GPs in rural areas said that This year and threats to human, animal, plant, the policy was too often designed next, covid-19 RASHFORD FOR PM! and environmental health— for urban areas and was difficult His determination, work ethic, and moral endangering food security, to implement in rural settings. alone is likely to compass may count against him. But he’s international trade, and economic generate extra arguably doing more than ministers to meet development, as well as leading Inequalities health service the Marmot review’s recommendations for to increased healthcare costs, US doctors vow to tackle costs of around improving health equity. hospital admissions, treatment racism in healthcare WINNING FANS, EVEN IN L IVERPOOL failure, severe illness, and death. The American Medical £40bn Being in favour of feeding children and Association has acknowledged a year, including helping them read seems easier than scoring Flu vaccination that racism and unconscious an open goal. But, while Rashford has had Free flu vaccine for bias within medical research £27bn widespread support, that hasn’t stopped 50-64 year olds and healthcare delivery have some from trying to show him a red card. People aged 50-64 in England caused harm to marginalised for PPE and test will be eligible for a free flu communities and society as a and trace FOR MAKING JOHNSON LOOK BAD? vaccination from 1 December as whole, and it vowed to support [Health Some commentators (and the odd Tory MP) part of the expanded programme. policies that combat racism. It Foundation] say that Rashford’s campaigning is politically Provisional data from Public will also encourage government driven and amounts to “virtue signalling”—a Health England issued on agencies and non-governmental curious phrase to imply that conveying 20 November suggest that 73% organisations to increase funding support for a moral cause is a negative thing. of over 65s, 45% of 2 year olds, for research into the risks and WHAT DOES RASHFORD SAY? and 47% of 3 year olds have been damages related to racism and That he’s not party political and just wants vaccinated. When a covid vaccine how to prevent or resolve them. to help disadvantaged children. In a moving becomes available people will letter to his 10 year old self he writes about be able to receive flu and covid- Overseas staff the importance of family and community: 19 vaccines in parallel, said the Visa extensions “Whenever you feel like you have very little, Department of Health. will be renewed free know that there are always people Healthcare workers whose visa willing to give.” Primary care networks extensions expire before the BUT CAN A LONE STRIKER “More effort is needed” end of March 2021 will be able TACKLE HEALTH INEQUALITIES? to engage with GPs to renew them for 12 months The BMJ asked Michael Marmot. He The networks set up to improve free of charge, after campaigns said he was “delighted with what primary care in England have by the BMA and other unions. Marcus Rashford is doing” and said good potential but have been Chaand Nagpaul, BMA council it showed that “civil society” can held back in their first year by chair, welcomed the removal of influence government. He added, a lack of engagement from GP “this unnecessary, bureaucratic, “With free school meals he shamed surgeries and deficiency in and costly barrier to international the government into action. That it took a management capacity, a report healthcare staff continuing to young footballer to do it is as remarkable as it found. In an evaluation study of offer their services and expertise is impressive.” primary care networks, carried here in the months ahead.” out by a team from the University Gareth Iacobucci, The BMJ of Birmingham’s Health Services Cite this as: BMJ 2020;371:m4562 Cite this as: BMJ 2020;371:m4512

the bmj | 28 November 2020 339

Covid-19: Excess deaths vary widely across England and Wales, data show

xcess deaths in England total of 1937 deaths involving covid- adding, “These fi gures most likely and Wales remain above 19 were registered in England and refl ect people who contracted the We will need to the fi ve year average, Wales in the week ending 6 November, virus in October. So, given we are yet brace ourselves while deaths from covid- an increase of 558 (40%) from 1379 to see a fall in the number of cases, we for further E 19 rose 40% in the week the previous week. will need to brace ourselves for further increases over to 6 November, the latest data show. Deaths involving covid-19 increased increases over the weeks ahead.” the weeks Offi ce for National Statistics in all English regions and Wales in The latest data show that the ahead fi gures show that, in the week ending the week ending 6 November, with number of deaths in hospitals was Sarah Scobie 6 November, deaths registered for any the north west of England having the above the fi ve year average for the reason were 14% (by 1481) above largest number (568 deaths) and the third consecutive week (520 more the fi ve year average for England highest proportion of deaths involving deaths). The numbers of deaths in and Wales. But within this was wide covid-19 (30%). In Wales, 166 deaths private homes and care homes were regional variation, with sharp rises in (20% of all deaths) involved covid-19. also above the fi ve year average (997 the north of England and Wales but no In the same week, all English and 38 more deaths, respectively). But excess deaths in London. regions and Wales had the same deaths in other locations were below The number of deaths involving overall deaths as the fi ve year average the fi ve year average (76 fewer deaths). covid-19 increased for the ninth or higher. London saw no excess Kevin McConway, emeritus consecutive week, the data show. A deaths, and the south east had only professor of applied statistics at 16 deaths (1%) more than the fi ve the Open University, said he was London saw no excess deaths in the week to 6 November, year average. The north west saw 496 concerned about the number of deaths and southeast England had only 16 deaths (1%) (35%) more deaths than would be at home, which amounted to 140 expected, and Wales had 207, 33% excess deaths a day. more than the five year average, the north west saw 496 higher than the fi ve year average. “Deaths at home have been at that (35%) more deaths than would be expected, and Sarah Scobie, deputy director of kind of level, over 100 above average Wales had 207, 33% higher than the five year average research at the Nuffi eld Trust, noted each day, since mid-May, just after the “stark” regional diff erences, the fi rst peak of the pandemic. I still

Legal action over j eweller’s in consumption over the past five years has, £250m PPE contracts however, been seen in other community The government is facing another legal challenge for settings (28.7%) and in awarding £250m worth of personal protective equipment secondary care (8.8%, contracts to a Florida jewellery company. accounting for 21% of The not-for-profi t organisation the Good Law Project and total consumption). EveryDoctor, a doctor led campaign group, claimed that Antimicrobial resistant Antimicrobial one of the contracts was awarded to the jewellery company infections still rising resistant bloodstream without any advertisement or competitive tender process. infections have risen by The case is one of several lawsuits launched against the Antimicrobial resistant Antimicrobial Utilisation a third (32%) since 2015 government by the legal campaigning group over contracts infections in England and Resistance. from 13 671 to over and positions awarded during the pandemic. rose from 61 946 in This decrease was 18 000. Escherichia coli The latest charge says Saiger had no experience of 2018 to 65 162 in 2019, mainly because of a has remained the most supplying PPE and had not previously been awarded a despite antibiotic use sustained reduction common bloodstream public contract by any central government department. The continuing to fall. ( of 12.2% between infection, rising 14% challenge relates to a contract entered into on 4 June for The quantity of 2015 and 2019) in the from 68.3 cases per £70.5m to supply 10.2 million gowns. T he lawsuit claims antibiotics consumed quantity of antibiotics 100 000 population in the Department for Health had overpaid, paying £7.05 a last year was 17.9 prescribed by general 2015 to 77.5 in 2019. gown despite the weighted average price of £4.60. defined daily doses practice (which The report found Saiger’s owner has also fi led a lawsuit against a per 1000 people per accounts for 71.4% of that in 2019-20 half of consultant who they paid $50m to act as a middleman. It day, down from 19.4 in total consumption). A clinical commissioning alleged that the middleman stopped supplying the PPE and 2015, according to the reduction of 19.5% has groups met or exceeded that there were delays in delivering equipment to the NHS. English Surveillance also been seen in NHS the national target to Elisabeth Mahase , The BMJ Cite this as: BMJ 2020;371:m4489 Programme for dental practices. A rise reduce antibacterial

340 28 November 2020 | the bmj In England the north west had the largest number and the highest proportion of deaths involving covid-19 US lags behind other rich nations in maternal healthcare

More women die from complications INTERNATIONAL FIGURES of pregnancy and childbirth • The US had 17.4 maternal in the US than in 10 other rich deaths per 100 000 live births, countries, concludes a study by the whereas the number was Commonwealth Fund. • 1.7 in New Zealand and Laurie Zephyrin, assistant • 6.5 in the UK. professor of obstetrics and Rates in the other countries were gynaecology at New York University • 1.8 in Norway Langone Health, vice president • 3 in the Netherlands MARTIN RICKETT/PA of the Commonwealth Fund, • 3.2 in Germany haven’t seen any clear explanation of and a coauthor of the report, • 4.3 in Sweden why this might be happening, and that blamed systemic racism that has • 4.6 in Switzerland worries me,” he said. a deleterious eff ect on all facets of • 4.8 in Australia David Spiegelhalter, chair of the life for black people in the US. “It’s • 8.6 in Canada, and Winton Centre for Risk and Evidence where you live, where you work, • 8.7 in France Communication at the University of where you play, your healthcare, The rate among black non-Hispanic Cambridge, said, “These extra home your food, your jobs, your insurance US women was 37.1, more deaths, very few of which are from benefi ts,” she told The BMJ . than double the rate among white It would be covid-19, have continued since March. Factors contributing to the high women (14.7). The UK has an even It would be good to know the quality good to know mortality rate were lack of universal worse difference by ethnic group: of end-of-life care being received and the quality of healthcare, a shortage of providers maternal deaths were five times as high among black women as how many of these deaths might have end-of-life care of maternity care, a reliance on among white women and twice as been delayed through, for example, being received obstetrician-gynaecologists as high among Asian women. more rapid treatment of heart attacks David opposed to midwives, inadequate and strokes.” Spiegelhalter postpartum care, and a lack of paid Aff ordable Care Act the supply of Gareth Iacobucci , The BMJ parental leave. midwives is so low many women Cite this as: BMJ 2020;371:m4500 “Universal, comprehensive cannot fi nd one. Midwives are also maternity coverage, along with limited by state laws calling for exemptions from cost sharing, are supervision and limiting Antibiotic consumption last Infection Service the norm in other high income their practice. year fell to 17.9 defined director, said, “We want countries,” the report says. In the More than half of pregnancy daily doses per 1000 people the public to join us in US coverage often depends on the related deaths in the US occur tackling antimicrobial woman’s type of insurance and the after delivery—but it is alone in not a day, from in 2015, 19.4 resistance—listen to your state where she lives. Out-of-pocket guaranteeing at least one visit by a according to the English Surveillance Programme for GP, pharmacist, or nurse’s costs may vary hugely. nurse or midwife within a week of Antimicrobial Utilisation and advice and only take In many countries midwives birth. WHO recommends at least Resistance antibiotics when necessary. provide care in normal pregnancies four health contacts during the fi rst “It’s worrying that more and during the postpartum period six weeks, but US women typically items to 0.965 or below. infections are becoming and also help with the social and have one visit to their doctor. Meanwhile, 90% of resistant to these life saving personal needs of the mother, baby, The US is also the only high CCGs met or exceeded medicines.” and family. In the US obstetrician- income country not to guarantee the targets to reduce the Last year WHO urged gynaecologists provide hospital paid maternity leave, although some proportion of co-amoxiclav, governments to implement based care and are trained to identify states have some form of paid leave. cephalosporins, and the AWaRe tool, which and treat abnormal conditions. Janice Hopkins Tanne , New York quinolones to ≤10%. classifies antibiotics into The World Health Organization Cite this as: BMJ 2020;371:m4546 However, only 43 (30%) three groups—access, recommends midwives as an acute NHS trusts met or watch, and reserve—to evidence based approach to exceeded the NHS standard enable clinicians to know reducing maternal mortality, the contract requirement to which to use for common or report says. The US and Canada have deliver a 1% or greater cut serious infections, which the lowest numbers of midwives and in antibiotic consumption should be used sparingly, obstetrician-gynaecologists: 12 and from their 2018 calendar and which should be used 15 per 1000 live births, respectively. year baseline value. only as a last resort. In the US midwife care is not always Isabel Oliver, Public Elisabeth Mahase, The BMJ covered by private health insurance, Health England National Cite this as: BMJ 2020;371:m4502 and although it is covered by the the bmj | 28 November 2020 341 COVID-19

What do we know about the late stage vaccine candidates?

As some phase III trials report early and, as yet, unpublished results, Elisabeth Mahase summarises the evidence so far on the frontrunners

10 severe covid-19 cases in the trial LARGE SCALE were in the placebo group. manufacturing of the Pfi zer said the vaccine could be Oxford/AstraZeneca available to high risk populations in vaccine has been set up in the US by the end of December. The UK government has agreed more than 10 countries a deal for 40 million doses (enough for 20 million people) and expects for 100 million doses of the vaccine, to have 10 million doses by the end once it has been approved by the of the year. Meanwhile, the EU has Medicines and Healthcare Products secured a deal for 200 million doses, Regulatory Agency (MHRA). That with an optional 100 million extra number of doses could vaccinate doses. Globally, 50 million doses University of Oxford and AstraZeneca 66 million people if the half dose plus are expected in 2020 and up to The ChAdOx1 nCoV-19 has been full dose regimen is followed. 1.3 billion doses by the end of 2021. tested across the world, with trials The Oxford team has emphasised Submission processes have begun starting in the UK and branching that it wants its vaccine to be in Australia, Canada, the EU, and out to Brazil, South Africa, and the accessible around the world and not Japan. The vaccine is estimated to US. Phase II results, published in just in high income countries. As such, cost around £15 a dose—much higher the Lancet, found that the vaccine large scale manufacturing has been than the Oxford-AstraZeneca vaccine. produced a similar immune response set up in more than 10 countries, and Concerns have also been raised over in old and young participants. the team expects the vaccine to be logistics, as the vaccine must be Phase III interim results, based available at a low price—around £3 stored at −70°C. on 131 cases, have been made a dose. The vaccine can be stored at available through a press release fridge temperature (2-8°C). (dated 23 November), and these THE UK has agreed suggest that the vaccine could be up Pfizer and BioNTech a deal to buy enough of to 90% eff ective when a half dose Pfi zer and BioNTech’s BNT162b2 the Pfizer/BioNTech is given, followed by a full dose one is the fi rst vaccine candidate to be vaccine to vaccinate

A half dose month later. When two full doses are submitted to the US Food and Drug regimen given one month apart, however, the Administration for emergency use 20 million may be more eff ectiveness drops to 62%. authorisation. The submission people , who is leading the was fi led on 20 November, after effective as it vaccine team at Oxford University, the conclusion of a phase III trial. Moderna and National mimics a real said the half dose regimen may be The results, announced by press Institutes of Health infection more eff ective because it “better release, evaluated 170 confi rmed The mRNA-1273 vaccine, developed Sarah Gilbert, mimics” a real infection. They are cases of covid-19 and reported that by the US biotech company Moderna Oxford team still, however, investigating the eff ect. the vaccine was 95% eff ective 28 in partnership with the US National leader The government has agreed a deal days after the fi rst dose. Nine out of Institutes of Health, is 94.5%

The seven vaccine developers the UK government has agreed deals with Name Phase Agreements Efficacy Oxford-AstraZeneca Phase III 100 million doses Up to 90% efficacy (preliminary data) Pfizer-BioNTech Phase III 40 million doses 95% efficacy (preliminary data) Moderna Phase III 5 million doses 95% efficacy (preliminary data) Novavax Phase III 60 million doses No phase III data Janssen Phase III 30 million doses No phase III data GSK-Sanofi Phase II-III 60 million doses No phase III data Valneva Preclinical 60 million doses No phase III data Source: UK government (information up to date as of 23 November)

342 28 November 2020 | the bmj GPs need more clarity on vaccine logistics and planning, say primary care leaders

GPs in England must not be sidelined in the everyone is clear what role they are playing,” planning and logistics of how to deliver covid- Rankine said. She added that GPs were 19 vaccination around the country, primary “definitely concerned that too much is being care leaders have urged. asked of them,” particularly with the sudden Earlier this month the NHS published a announcement on 20 November that people draft agreement to enable general practices over 50 in England should ask their GP for a flu eff ective, according to the interim to start delivering a covid-19 vaccine from vaccination. “People are already saying that fi ndings of US based phase III trial as early as December through local primary the phones are ringing off the hook,” she said. results. The analysis was based on care networks (PCNs). Designated sites will 95 covid-19 cases, of which 90 (11 be expected to deliver vaccines seven days a “Staff need a little bit of warning” severe) were observed in the placebo week from 8 am to 8 pm if supply allows, and Joe McManners, a GP in Oxford and clinical group and fi ve were reported in the practices will be paid £12.58 a dose. director of a PCN, said, “The major issue is vaccine group. But the final agreement is yet to be that there’s so much uncertainty and so much The trial enrolled more than 30 000 published, and uncertainty persists over we don’t know. We could definitely administer US participants, including 7000 aged which vaccines GPs will administer, what 50 vaccines in a practice in a week. But we over 65 and 5000 under 65 with high volume of patients they will be expected to probably couldn’t do thousands. We don’t risk chronic diseases. More than one vaccinate, and how their sites will link up with really know what the ask is, so it is quite third (37%, 11 000) of the participants the mass vaccination centres the government difficult to try to recruit people or get people to were from “communities of colour.” Of is setting up around England. do extra time. You need to give them a little bit the 95 cases, 15 were adults over 65, These centres, likely to be run by a local of warning. and 20 were identifi ed as being from organisation such as an acute and community diverse communities (12 Hispanic, health trust, are unlikely to be operational four black, three Asian American, and straight away. But England’s health secretary, one multiracial). , told BBC’s Today programme Moderna intends to submit the on 20 November that training “is under way” interim safety and effi cacy data to the to recruit thousands of staff to “one of the FDA for emergency use authorisation biggest civilian projects in history.” soon, following a fi nal analysis of 151 cases and a median follow-up of Clarity and coordination more than two months. Primary care leaders told The BMJ that GPs The US government has agreed were keen to play their part in the national a deal for 100 million doses, while effort, but they highlighted a lack of clarity and the UK government has secured fi ve coordination over key elements. MANUEL DORATI/NURPHOTO/PA million doses. If approved by the Ruth Rankine, director of the NHS Desmon, an Italian company, will be the transport and refrigeration hub for the Pfizer vaccine MHRA, the vaccine could be delivered Confederation’s PCN Network, told The BMJ, to the UK in spring 2021. “There is real frustration among our members “There is definitely a massive good will out Moderna’s vaccine can be stored at that they’re planning their PCN programme there in general practice to make it work. We room temperature for up to 12 hours, but with no line of sight of what’s happening just need the back-up and support to make in a household fridge for 30 days, in the wider system. From our perspective it sure that the planning and the notice periods and at −20°C for up to six months. appears that there is no coordination.” are good.” However, at around £25 a dose, it is Rankine said that PCNs were not clear about Tracey Vell, chief executive of Manchester far more expensive than the Oxford- how their local sites would coordinate with Local Medical Committees, said the message AstraZeneca and Pfi zer vaccines. mass sites. She asked, “Obviously there are from a meeting with local PCN leaders was Elisabeth Mahase, The BMJ interdependencies between the two, because that “we really want to do this.” Cite this as: BMJ 2020;371:m4576 if a patient is vaccinated at a mass vaccination But she noted anxiety over some issues, site, how does their practice know? In terms of including staffing levels and how prescriptive the sharing of records, and the call and recall the enhanced service would be on things such MODERNA’S system, how do you know?” as the number of vaccination sites allowed in PCNs also want more clarity over whether each local area. VACCINE can be they would be vaccinating people in care She added, “I think we’re prepared, but stored at room temperature homes or whether residents would be seen sometimes NHS England is known to throw a for up to 12 hours, in a by mobile teams, which the government has curve ball. I’m hoping that the reason they are household fridge for 30 days, promised to roll out, she added. taking their time [to publish more information] “It’s really difficult to understand the is because they’re listening first.” and at −20°C for up to logistics of it all and how it all ties together Gareth Iacobucci , The BMJ six months into a comprehensive programme where Cite this as: BMJ 2020;371:m4555 the bmj | 28 November 2020 343 THE BIG PICTURE Shining a light on wellbeing

As fears grow for the mental health of people forced to endure winter in lockdown, self-isolation, or quarantine, Phil Benton, a self- taught photographer, has found a way to ease his own depression. Benton, who fi rst turned to the camera after an ME diagnosis at 19 triggered his depression, is sharing his pictures of northeast England inscribed with inspirational quotes on social media. He has been overwhelmed by the response, particularly from people coping with symptoms of . “ME is also called chronic fatigue syndrome and causes extreme tiredness. It sounds a lot like the symptoms they have described for long covid,” he says. “The lockdown would have fl oored the old me, but I thought, no, I’m not letting it. My work is my therapy. The fact it also brings a lot of other people joy is the icing on the cake.” Benton is pictured near his home holding his image of South Shields lighthouse, The Lights (also below), which was highly commended in the National Landscape Photographer of the Year competition. See www.philbentonphotography.com Alison Shepherd, The BMJ Cite this as: BMJ 2020;371:4565

344 28 November 2020 | the bmj the bmj

| 28 November 2020 345

HIGHLIGHTS PUBLIC RELATIONS EDITORIAL Trends in suicide durin g the covid-19 pandemic Prevention must be prioritised while we wait for a clearer picture

s many countries face We must remain alert to emerging new stay-at-home risk factors for suicide but also restrictions to curb the recognise how known risk factors may spread of covid-19, be exacerbated—and existing trends A there are concerns that and inequalities entrenched—by the rates of suicide may increase—or have pandemic. In 2019, suicide rates already increased.1 2 Several factors among men in England and Wales underpin these concerns, including were the highest since 2000, and a deterioration in population mental although suicide in young people is health,3 a higher prevalence of relatively rare, rates have been rising reported thoughts and behaviours in 10-24 year olds since 2010. 17 of self-harm among people with covid-19,4 problems accessing mental Known risks health services, 4 and evidence Tackling known risk factors that suggesting that previous epidemics are likely to be exacerbated by the such as SARS (2003) were associated pandemic is crucial. These include with a rise in deaths by suicide.5 depression, post-traumatic stress Widely reported studies modelling disorder, hopelessness, feelings of the eff ect of the covid-19 pandemic entrapment and burdensomeness, on suicide rates predicted increases substance misuse, loneliness, ranging from 1% to 145%,6 largely domestic violence, child neglect or refl ecting variation in underlying Any change are preprints, letters (neither is peer abuse, unemployment, and other assumptions. Particular emphasis in the risk reviewed),9 10 11 or commentaries fi nancial insecurity.1 5 has been given to the eff ect of the of suicide using news reports of deaths by Services must be made available for pandemic on children and young suicide as the data source.12 people in crisis and those with new associated 14 people. Numerous surveys have with covid-19 Nevertheless, a reasonably or existing mental health problems. highlighted that their mental health consistent picture is beginning to Of greatest concern, is the eff ect of has been disproportionately aff ected, is likely to emerge from high income countries. economic damage from the pandemic. relative to older adults,3 7 and some be dynamic Reports suggest no rise in suicide Appropriate safety nets must be put suggest an increase in suicidal rates in the early months of the in place or strengthened for people thoughts and self-harm.8 pandemic. The picture is much less facing fi nancial hardship, along with Supposition, however, is no clear in low income countries, where active labour market policies to help replacement for evidence. Timely data the safety nets available in better people who are unemployed obtain on rates of suicide are vital, and for resourced settings may be lacking. work. Responsible media reporting also some months we have been tracking News reports of police data from has a role: promoting the importance and reviewing relevant studies for Nepal suggest a rise in suicides,12 of mental health support, signposting a living systematic review. 6 The fi rst whereas an analysis of data from sources of help, reporting stories version in June found no robust Peru suggests the opposite.10 of hope and recovery, and avoiding epidemiological studies with suicide Any change in the risk of suicide alarmist and speculative headlines as an outcome, but several studies associated with covid-19 is likely that may heighten risk of suicide.19 20 reporting suicide trends have emerged to be dynamic. Evidence from One guiding principle, however, more recently. Overall, the literature previous epidemics suggests a is that suicide is preventable, and on the eff ect of covid-19 on suicide short term decrease in suicide can action should be taken now to should be interpreted with caution. occur initially—possibly linked to protect people’s mental health. Most of the available publications a “honeymoon period” or “pulling We must remain vigilant and 5 Ann John, professor of public health and psychiatry, Swansea together” phenomenon. Trends in responsive, sharing evidence early University Medical School, Swansea, UK [email protected] certain groups may be hidden when and internationally (such as in the Jane Pirkis, director, Centre for Mental Health, University of Melbourne looking at overall rates, and the International Covid-19 Suicide 21 David Gunnell, professor of epidemiology, University Hospitals Bristol National Child Mortality Database Prevention Research Collaboration ) and Weston NHS Foundation Trust, University of Bristol has identifi ed a concerning signal in these evolving uncertain times. Louis Appleby, director, National Confidential Inquiry into Suicide and that deaths by suicide among under Cite this as: BMJ 2020;371:m4352 Safety in Mental Health, University of Manchester 18s may have increased during the 16 Find the full version with references at Jacqui Morrissey, assistant director, Samaritans, UK fi rst phase of lockdown in the UK. http://dx.doi.org/10.1136/bmj.m4352

346 28 November 2020 | the bmj EDITORIAL The language of ethnicity Collective terms BAME and BME should be abandoned

he disproportionate impact of covid-19 on ethnic minority groups1 2 has attracted global T attention, causing journalists, broadcasters, politicians, the public, and academics to grapple with the most appropriate way to describe people of minority ethnic backgrounds.3 4 Various collective terms have been used to describe ethnic minority groups, including BAME (black, Asian, and minority ethnic), BME (black and Researchers The ONS groupings have also been terminology such as race that wrongly minority ethnic), ethnic minority, should avoid criticised,12 but BAME and BME are implies inherent biological diff erences non-white, and people of colour. reinforcing particularly problematic because they between ethnic groups. Disaggregating BAME and BME, both commonly used are often used to label people who minority populations allows studies 5 perceptions of 3 in the UK, are problematic as they homogeneity do not identify as such. The term to acknowledge diff erent histories indiscriminately combine people from BAME also identifi es black and Asian and social and economic experiences diff erent geographical, behavioural, where none communities as inherently diff erent in comparisons of outcomes. social, and cultural backgrounds. They exists from other ethnic minorities and The 18 ONS categories are a also focus on skin colour. Few minority may sustain anti-black or anti-Asian good start despite limitations such people identify with these acronyms,3 sentiments.13 Although it is unclear as combining all black African and in one poll only 13% of who “minority ethnic” includes, nationalities and ethnic groups. 7775 respondents, selected BAME or it is widely understood to exclude But even with greater granularity, BME as an appropriate term.6 So what disadvantaged minorities typically analysing minority populations terms should we use? coded as white, such as Gypsy, separately could still result in Some historical context may Roma, and Travellers, who despite inappropriate conclusions through be helpful. Before the American disproportionately poor health 14 are erroneous assumptions of common civil rights movement of the mid- not recognised as an ethnic group in shared experience. 20th century, the term black was the NHS data dictionary.15 Where granularity is not possible Kamlesh Khunti, derogatory.7 Although activists (in studies with small sample professor of primary and academics subsequently used More nuance sizes for example) we suggest that care diabetes and black politically as a collective vascular medicine Defi ning individuals as non-white “ethnic minority groups” is a more term covering all “non-white” kk22@ does not adequately describe the appropriate collective term than 8 populations —a use maintained, for leicester.ac.uk cultural, social, and religious nuances BAME or BME, placing the focus on 16 example, by the domestic violence Ash Routen, research that defi ne ethnicity. South Asian all minority groups regardless of organisation Southall Black Sisters— associate and black people are no more skin colour. others associated it with people of Manish Pareek, homogeneous than white people There will never be a perfect term solely African heritage. associate clinical in their health status, service use, to encompass ethnic diversity, but As a result, it was argued that the professor in socioeconomic position, 17 or social researchers should avoid reinforcing use of black did not recognise the infectious diseases, and cultural experiences.16 - 19 For perceptions of homogeneity where experience of South Asians in the UK. 9 University of Leicester example, Black Caribbean people have none exists, or excluding groups that References to black populations were Shaun Treweek, a higher mortality risk from covid-19 do not fi t within BAME terminology. then reframed as black and Asian, professor of health infection than Black African people— Even ethnic minority groups is and later black, Asian, and minority services research, inviting us to look beyond ethnicity for an imperfect collective term, and University of ethnic (BAME). Though widely used, the source of such inequalities.20 researchers should be prepared to Aberdeen this term has no direct counterpart However problematic ethnic break it down further to ensure that Lucinda Platt, in routine data collection, which categories are, scientists need them their fi ndings benefi t those who need professor of social relies on disaggregated categories policy and sociology, to enable systematic and comparable them most. Language does matter. of ethnic identity developed and London School of scientifi c study to examine and Cite this as: BMJ 2020;371:m4493 regularly reviewed by the UK Offi ce Economics and address social inequalities and 10 11 Find the full version with references at for National Statistics (ONS). Political Science injustice. Researchers must also avoid http://dx.doi.org/10.1136/bmj.m4493 the bmj | 28 November 2020 347 DATA BRIEFING Will covid-19 vaccines be cost effective— and does it matter? The costs of other pandemic measures mean vaccines will probably turn out to be a good buy, says John Appleby, and the full calculations will raise questions about NICE methods

The UK fi zer and BioNTech, the NHS reprioritised its work, to people’s the uncertainties of their clinical government University of Oxford health. A rolling series of lockdowns eff ectiveness, let alone their cost has amassed and AstraZeneca, and and targeted isolation have been eff ectiveness.The UK government a stockpile Moderna and US National the only interventions available for has amassed a stockpile of around of around P Institutes of Health, restricting coronavirus transmission, 340 million vaccine doses (fi g 3). have all announced the early results but they are not the ultimate answer On the other hand, the 340 million of their covid-19 vaccine trials, to tackling covid-19. It seems chancellor’s words cannot be taken vaccine doses and immunisation for the novel inconceivable that governments literally; clearly there must be a coronavirus could be available in would dither over the value for money limit to what the government, any months. Of course hurdles remain, and of an eff ective covid-19 vaccine. government, would—or could—fund. more data need to be gathered about The chancellor, Rishi Sunak, has Whether the fi rst covid-19 vaccines the effi cacy and safety of the vaccines said that the government will “do are cost eff ective remains to be being trialled. One hurdle that new whatever it takes” to fi nancially seen—there are too many unknowns health technologies usually have to support businesses and people to make a sensible, even rough, jump is cost eff ectiveness: is the value in lockdown and that “whatever calculation at the moment. of the benefi ts worth the costs? resources the NHS needs to deal Although they have saved lives, the with coronavirus it will get.” Many Savings against existing pandemic tactics used so far to try to get on top governments have already signed measures of the pandemic have had huge costs deals for covid-19 candidate Given the deals done by to people’s livelihoods and, as the vaccines in development even with governments, however, a covid-19

348 28 November 2020 | the bmj Covid Covid 56 057 680

2704 388 610 average total total deaths daily patients

Non-covid Non-covid 332 553 2024

Fig 1 | Cumulative registrations of deaths (covid-19 and non-covid-19) in England Fig 2 | Average number of patients with and without covid-19 per day on and Wales, March to October 2020 from 2 April to 5 November 2020 (NHS England)

Whole inactivated Other tax measures £2bn 60 million doses Cultural recovery fund £1bn Welfare spending £9bn Employment Oxford Adenovirus Other public support University 130 million doses services £16bn £62bn Valneva AstraZeneca Plan for Jobs £20bn 340 million GSK total doses £193bn Sanofi total Pateur Business support: Janssen loans and guarantees £20bn Novavax BioNTech Pfizer Protein adjuvant mRNA 120 million doses 30 million doses Business support: Health services tax and spending £30bn £32bn

Fig 3 | Covid-19 vaccine deals by the UK government Fig 4 | Cost of UK government coronavirus policies up to 20 July 2020 vaccine will probably be deemed Budget Responsibility’s Fiscal If NICE were the fact that healthcare technologies a good buy—not least because of Sustainability Report in July, “the assessing a might have wider benefi ts or costs the savings in costs associated with UK is on track to record the largest vaccine’s cost and that these can be reported current pandemic measures. decline in annual [gross domestic effectiveness, separately with prior agreement of The Offi ce for Budget Responsibility, product] for 300 years, with output the wider the Department of Health and Social a public fi nance watchdog, estimates falling by more than 10% in 2020.” Care. economic that the current measures to support If NICE were given the task of Covid-19 may be unusual (to say individuals and the economy, as well assessing a covid-19 vaccine’s cost losses and the least) but it draws attention to as extra spending on the NHS and eff ectiveness, these wider economic effects would a debate for NICE (and its ongoing other public services,7 add around losses and eff ects of spending not directly review of its assessment methods ) £193bn to this year’s defi cit (fi g 4). would not directly feature in its feature in its about the extent to which we want Public sector net borrowing could calculations. This is because its calculations it to broaden its perspective. As total around £322bn (up from £57bn perspective on costs and benefi ts the world has painfully learnt, in 2019-20), net debt could be 104% is drawn fairly tightly around health (and care) and our economic of the UK’s gross domestic product, those falling on or accruing to the lives are (and always have been) and tax receipts could be down by health and care services and the inseparable. almost as much as is spent on the health benefi ts to patients and John Appleby, director of research and chief NHS in England. others (fi gs 1 and 2). Nevertheless, economist, Nuffield Trust, London Add to these fi gures the probability NICE guidance on the approach to [email protected] that, in the words of the Offi ce for economic evaluation does recognise Cite this as: BMJ 2020;371:m4491 the bmj | 28 November 2020 349 BREXIT How leaving the EU will affect patient care and medical research As we near the end of the Brexit transition period, Layla McCay assesses the potential impact on access to care and research

How will patients’ ability to access care in UK citizens What is happening with the European other countries be affected? legally Health Insurance Card arrangements? resident in an Currently, by prior arrangement, UK patients can travel EU country, Both parties in the negotiations have said they want to an EU country, and vice versa, to receive specialist care or vice versa, to continue something like the EHIC, as the scheme is or to have regular sessions of treatment such as dialysis mutually benefi cial and works well. If, however, there is or chemotherapy while abroad. These arrangements will can continue no deal then arrangements will depend on the UK having not apply after 31 December, and it’s not yet clear whether to get negotiated a bilateral reciprocal agreement with each a replacement scheme will be put in place and, if it is, to healthcare in member state. This is likely to be possible with some, whom it will apply. their country but not necessarily all, EU countries. Where no such If a replacement is not agreed during the current of residence agreement exists, people travelling in either direction will negotiations, existing agreements between healthcare need to take out comprehensive healthcare insurance, as commissioners and providers are likely to continue, albeit they do now if travelling to a country outside the EU. on a diff erent contractual basis. Unless mitigation is put in It’s worth emphasising that travellers have always been place domestically by the relevant governments, however, strongly advised to take out healthcare insurance and people with pre-existing conditions who want to travel on not to rely solely on their EHIC, as this only entitles them either side of the EU-UK border and to arrange specialist to medically necessary treatment on the same basis as care while abroad could fi nd themselves “uninsurable.” local citizens and they may still face considerable bills. UK citizens who are already legally resident in an EU Also, UK citizens who are already legally resident in an country, or vice versa, before the end of 2020 are covered EU country (or vice versa) before the end of this year have by the Brexit Withdrawal Agreement and can continue to a pre-existing entitlement under the Brexit Withdrawal get healthcare in their country of residence as they do now, Agreement and can continue to use their EHIC when for the rest of their lives. Arrangements for the provision of travelling. specifi c cross border healthcare services between Northern Ireland and the Republic of Ireland are not based on EU How would a no deal Brexit affect UK legislation and so should not be aff ected by Brexit. medical research, and what might a good negotiated outcome look like?

Without an agreed future relationship agreement, it could become more diffi cult to conduct EU-UK clinical trials, to share data, and for researchers to travel. Despite both sides concurring on the benefi ts of collaboration and UK participation in EU framework programmes such as Horizon Europe, the detail and extent of participation are yet to be agreed. Without association with Horizon Europe, joint research projects would become more diffi cult to progress as funding and long established collaborative networks that facilitate cooperation would be lost.

350 28 November 2020 | the bmj JOHN MACDOUGALL/AFP /GETTY IMAGES JOHN MACDOUGALL/AFP

The UK will also lose access to EU clinical trials The UK Projects Agency to be established with an investment infrastructure, which risks disrupting UK participation government’s of around £800m, aiming to support the “high risk, in cross border clinical research. EU-UK clinical trials research and high reward science” that might not be funded outside benefi t patients across Europe, particularly in rare development EU programmes. Additional funding streams have also disease areas where there are often few participants in roadmap been suggested, such as Cancer Research UK’s recently any one country, making international collaboration proposes announced major global funding partnership, to leverage vital. and award large grants to multinational teams. increased To continue work in pan-EU clinical trials, the UK’s future regime should be as compatible as possible with investment How many researchers might leave the UK EU regulation to avoid extra quality and safety checks to £22bn per and will they be replaced? that could delay trial drugs entering the EU from the year by 2025 UK. Further, although the UK doesn’t currently have any A survey conducted last year found that two thirds of covid-19 focused research projects directly funded by European engineers and scientists working in the UK the EU, the pandemic has highlighted the imperative for have considered leaving because of Brexit. Worries about international collaboration and pooling of expertise to job security and losing EU funding were cited as the main fi nd a vaccine or treatments as early as possible. reasons, as well as feeling less welcome in the UK. More recently, a 2020 survey by the Association of How will the UK make up for shortfalls in Medical Research Charities (AMRC) found that concerns research funding or projects? persist and that almost a fi fth of researchers asked had considered an exit from research because of Brexit. If the UK’s association with future EU Framework The sector warns that this will only be exacerbated by Programmes is not possible, a funded alternative would the eff ects of the pandemic. Medical research charities be needed to minimise disruption. fund the salaries of around 17 000 UK scientists, but the In a 2017 survey, 84% of 135 UK research facilities impact of the pandemic is already aff ecting these funding reported receiving funding from EU sources, so many streams. could be left short if the fl ow were to stop. While the UK Funding uncertainty could particularly impact junior could continue to participate in some parts of Horizon researchers’ likelihood of remaining in the UK. For Europe, UK researchers would be locked out of some instance, half of the respondents to the AMRC survey of the programme, including the European Research reported that their funding will dry up by the end of next Council (ERC) and Marie Skłodowska-Curie Actions. year, while 82% said that they feel less secure in their There is some commitment to make up shortfalls. career than they did last year. For example, the UK government announced plans to In terms of “replacing” researchers who leave the UK, launch discovery funding to replace prestigious EU the new UK Global Talent visa presents an opportunity. science funding streams, like the ERC. The government’s It off ers an accelerated path to permanent settlement, research and development roadmap proposes increased putting applications from EU citizens on the same footing investment to £22bn per year by 2024-25 and full as people in the rest of the world. association with Horizon Europe. Layla McCay, director of international relations, NHS Confederation Further, there are discussions on a new UK research [email protected] agency modelled on the US’s Advanced Research Cite this as: BMJ 2020;371:m4380 the bmj | 28 November 2020 351 PUBLIC HEALTH Farewell to PHE: controversial from creation to abolition , the (fi rst) fall guy for the nation’s covid response, was hamstrung by its lack of independence from government. Richard Vize charts its highs, lows, and ultimate downfall

orn from one of the most controversial reforms in NHS history, Public Health England has been killed off just seven years later, the fi rst casualty of a blame game for tens of thousands of deaths from covid-19. B Under the Health and Social Care Act 2012 as championed by the then health secretary Andrew Lansley, PHE was established as an executive agency of the Department of Health, meaning that it had operational independence but took instructions from ministers. In contrast, the Health Protection Agency, which PHE replaced, had had independence as a non- departmental public agency. This lack of autonomy would undermine PHE’s relations with parliament, would stoke criticism from public health specialists, and would eventually prevent it from defending its reputation when the covid pandemic took hold.

DUAL ROLE TOP MAN

As well as taking over the Health Protection Agency’s PHE’s creation brought together civil servants, academics, role of protecting the public from infectious diseases scientists, medics, and local government offi cers. Its fi rst and environmental hazards, PHE absorbed many other and only chief executive was Duncan Selbie, a career organisations including the National Treatment Agency public servant who grew to prominence in the New for Substance Misuse, the public health observatories, Labour years as the director general for programmes cancer registries, and national screening programmes. and performance in the Department of Health, playing The Rare and Imported Pathogens Laboratory, at the a leading role in the drive to improve quality and government science facility in Porton Down, also came productivity in the NHS. with the Health Protection Agency. He had an unusual but appealing style, with a lugubrious Launched in April 2013, PHE was responsible charm and a soft Scottish accent that could leave you You got health for managing infectious diseases and tackling the craning to hear. While many speakers try to fi nish on a protection social determinants of ill health, such as obesity and crescendo, Selbie’s passionate talks on the root causes of ill and health alcohol abuse. It promised to “protect and improve health and inequalities often tailed away to silence, leaving improvement the nation’s health and wellbeing, and reduce health his words hanging—and his audience refl ecting. joined up inequalities,” using “world-leading science, knowledge He could be demanding, but his natural empathy won Jim McManus and intelligence.” Meanwhile, public health directors— him support and even aff ection among staff . Despite his already joint appointments between primary care trusts civil service and NHS roots he championed the move of and local authorities—moved to local government when local public health services to councils, and he spent a lot of primary care trusts were abolished. time in the fi eld. Hertfordshire County Council’s public health director, Jim McManus, saw several strengths in the INDEPENDENCE QUESTIONED new structure. “You got health protection and health improvement joined up, and you gained a national As PHE was now reporting to a director general at the champion for ideas such as using behavioural science Department of Health, observers were looking for signs in public health,” he says. “On work such as obesity and of whether and how it would exert independence. In HIV, they brought stakeholders together in a way that what was seen as a bizarre decision, its fi rst big report six hadn’t been done for a while.” months later was a review of the public health risks from

352 28 November 2020 | the bmj A CRAVEN RESPONSE TO CUTS

Funding and staffi ng have been broadly stable over PHE’s lifetime, with a net expenditure of £4bn in 2018- 19 and around 5000 staff . Since the transfer of public health from the NHS to local government, however, funding for local services has been cut savagely. The core public health grant of £2.4bn for 2020-21 is 19% below 2015-16, and the Health Foundation estimates that around £1bn more would be needed to resolve the service cuts. But PHE’s response to the prospect of the sustained and severe reductions announced in the 2015 spending review—four months after an in-year cut to It alienated local public health spending of £200m—was criticised a great for being craven. It told the health select committee deal of the that the planned cash cuts “are manageable. Local public health authorities have a demonstrable record of getting community more for less and PHE will support local authorities in Gabriel Scally this task using our intelligence and expertise.” KEY CONTROVERSIES

PHE’s biggest scientifi c dispute came when it concluded, in 2015, that e-cigarettes were 95% less harmful than tobacco. An analysis in The BMJ accused PHE of using weak and uncertain evidence, while some local public health directors worried that e-cigarettes would re-normalise smoking and could provide a new route for young people to become nicotine addicts. Cancer Research UK and the British Lung Foundation fracking—then being championed by the government but defended PHE. hardly a priority for a new public health agency. It was Scally says, “They alienated a great deal of the public attacked for writing the report and concluding that the health community. As everyone knows, a substantial Duncan Selbie risks were low. proportion of the vaping industry has been taken over (above) tried Gabriel Scally, a former regional public health by big tobacco companies, and that alone should give to bring in director, says the report “showed an abandonment of people pause for concern.” a culture the public health precautionary principle. It’s not good The row highlighted Selbie’s approach of working of getting enough simply to say, ‘There is no evidence this will be with human behaviour to reduce harm rather than harmful.’ You have to say, ‘What are the possibilities of waiting for conclusive proof that e-cigarettes were safe. things done being harmful? Where are the gaps in evidence?’ and McManus says, “He tried to bring in a culture of getting so on. It didn’t do that, so that was a signal [of a lack of stuff done and taking more risks. The e-cigarettes work independence].” would just not have happened in other organisations.” Selbie was given a rough ride at a health select With tobacco companies as signifi cant players in the committee hearing in November 2013. Minutes after e-cigarette market, the dispute also exposed the issue assuring MPs that he had “unfettered freedom to speak,” of PHE’s relations with the manufacturers of harmful he said that it would be too controversial for him to products. This was blown open in 2018 when PHE identify government policies that were widening health decided to launch a health promotion partnership with inequalities. The select committee’s review of PHE the Drinkaware, an organisation funded by the alcohol following year accused it of failing to provide a “fearless industry. Ian Gilmore, hepatology professor and an and independent” voice. expert on alcohol harm, quit as a PHE adviser in The committee questioned PHE’s independence again protest, arguing that the campaign’s focus on personal in 2015 when Selbie acceded to pressure from the then responsibility was intended to divert attention from health secretary, Jeremy Hunt, not to publish a review more eff ective policies such as minimum unit pricing. There was a of the scientifi c evidence around a sugar tax policy, Martin McKee of the London School of Hygiene and sense that it which ministers opposed. He was hauled before the Tropical Medicine agrees, seeing PHE’s approach to was too close committee and subjected to interrogation by its chair, alcohol and tobacco as “all about individual level to industry the Conservative MP Sarah Wollaston, who accused interventions, not tackling the upstream determinants” him of undermining public debate around tackling of poor health. “There was a sense that they were too groups Martin McKee childhood obesity. close to industry groups,” he says. the bmj | 28 November 2020 353 Refl ecting on the Drinkaware controversy, Sian Griffi ths, While ultimate responsibility for pandemic preparation emeritus professor at the Chinese University of Hong Kong rests with the Cabinet Offi ce, PHE was blamed for failures and associate non-executive member of the PHE advisory outside its remit or control, such as organising mass board, says, “Lessons were learned from that. You really testing, supplying personal protective equipment, and have to have a clear ethical framework you’re working [to] even ensuring that the NHS had enough ventilators. . . . How do we maximise the health improvement message The former Conservative leader Iain Duncan Smith within the safe confi nes of making sure it’s evidence claimed that PHE was guilty of “arrogance laced with based and not infl uenced by the industry?” incompetence,” and Boris Johnson pointedly said that “some parts of government” had responded to the SIGNIFICANT SUCCESSES pandemic “sluggishly.” But there was no escaping blame for a spreadsheet error One of PHE’s most admired successes was its role in that came to light this October, in which PHE failed to suppressing the Ebola outbreaks in 2014-16, with more transfer 16 000 covid-19 cases to the test and trace system. than 150 staff deployed in Sierra Leone, Guinea, and Ian Gilmore The agency undermined its case by handling crucial Liberia. It trained new public health scientists to manage (above) quit select committee appearances badly. On 25 March Sharon future outbreaks and helped to build laboratories and as an adviser Peacock, director of the national infection service, had other health infrastructure. It also screened more than over PHE’s failed to give convincing answers on why the UK was not 14 000 passengers arriving into the UK from west Africa. Drinkaware pursuing the mass testing strategy adopted by South Back in England, the agency drove a 44% reduction in Korea. The committee chair and Tory MP, Greg Clark, told collaboration tuberculosis from 2011 to 2018 as part of its elimination the Financial Times that the hearing “shook confi dence” strategy. National surveillance was stepped up, genome and was “certainly material in raising questions about the sequencing was used to determine susceptibility to kind of dependable role of PHE in all this.” antibiotics, and there was greater focus on helping people Two months later John Newton, PHE’s director of health at high risk, such as those who were homeless. improvement, and its medical director, Yvonne Doyle, UK smoking rates have fallen to their lowest on record endured bad tempered exchanges at the same committee and were the second lowest in Europe in 2017, although on the same question. cuts to public health budgets have compromised progress. In 2015 PHE established the world’s fi rst infant FINAL DAYS meningitis B vaccination programme. By the third year, cases of the disease among eligible children had fallen PHE had the opportunity to make a powerful intervention by 62%. in the management of the pandemic crisis with its review In September 2019 its review into addictive of the disproportionate impact on people from ethnic prescription medicines revealed the vast scale of minorities. But its report, published in June, caused anger consumption, as 11 million adults—a quarter of the adult and frustration by failing to lay bare the reasons why population in England—were taking medicines such as PHE is guilty death rates were so diff erent or to make robust policy opioid painkillers and antidepressants, with high rates of arrogance recommendations. among women and in deprived areas. It pushed the NHS laced with Appropriately, after all of the briefi ng against it in the to provide better information and support for patients. incompetence media, PHE’s staff discovered that the agency was being An assessment of PHE’s performance by the Iain Duncan disbanded when the government leaked the decision International Association of National Public Health Smith to the Telegraph in mid-August. Selbie was forced out. A Institutes said that its experience in change management government source told the newspaper that PHE should and managing essential public health functions should be have been on alert for pandemics instead of trying to used as best practice by other countries. prevent ill health. In a parting shot, Selbie pointed out that it was always the Department of Health and Social Care’s PANDEMIC PREPARATION responsibility to deliver a national testing strategy. PHE’s pandemic response work is being merged with Each spring, a ministerial letter to Selbie set PHE’s goals for NHS Test and Trace and the Joint Biosecurity Centre— the coming year. The letter in March 2019 from Steve Brine, which existed for only around 100 days—to form the public health minister, identifi ed 14 priorities. Pandemic National Institute for Health Protection. This will formally preparation was not among them. Brexit was top. take over in April 2021. A year later, as community transmission of the In 2003 Griffi ths chaired the Hong Kong government’s SARS-CoV-2 virus took hold in the UK and modelling inquiry into the SARS outbreak. She recalls, “We said, ‘We predicted that cases could quickly reach one million, the are not looking to apportion blame, we are looking at . . . government decided to abandon its limited eff orts at mass what could be done better and diff erently in future.’ You do an testing and , and a week later the country In the vilifi cation of PHE, that has not been done. You do went into lockdown. As the scale of the UK’s failure to inquiry on the an inquiry on the basis of fact, not partial fact.” manage the covid-19 outbreak became clear, with one of basis of fact, As one PHE insider puts it: “Bring on the public inquiry.” the highest mortality rates in the world, the government not partial Richard Vize, journalist , London and parts of the press increasingly directed the blame fact [email protected] towards PHE. Sian Griffiths Cite this as: BMJ 2020;371:m4476

354 28 November 2020 | the bmj