Today I publish the third Report of the UK Covid-19 Inquiry.
This Report concerns the impact of the Covid-19 pandemic on the UK’s healthcare systems. I can summarise that impact as: we coped, but only just.
The healthcare systems came close to collapse. Healthcare workers carried the burden of caring for the sick and dying in unprecedented numbers. It came at a huge cost to them, to their families, to their patients and to the loved ones of patients. It also came at a huge cost to the non-Covid patients who were not seen and treated. Collapse was only narrowly avoided thanks to the extraordinary efforts of all those working in healthcare across the UK.
However, despite those efforts, some patients did not get the level of care they would usually receive. Some people were not admitted to hospital when they should have been. Those taken to hospital in an ambulance often waited hours to be admitted, putting them and the ambulance crews at risk. Healthcare staff had to be redeployed to the front line (leaving other aspects of care at risk), staff-to-patient ratios were diluted, the supply of medical equipment was a significant concern and some patients were not admitted to intensive care units despite their serious condition
The message to ‘Stay Home, Protect the NHS, Save Lives’ was designed, in part, to protect the UK’s healthcare systems from being overwhelmed. However, when the pandemic arrived, our healthcare systems were already overstretched and understaffed. This fragility had profound consequences when the numbers of people seeking treatment for Covid-19 started to increase dramatically.
In order to ‘protect’ the healthcare systems, extraordinary steps were taken to free up bed capacity and to ensure there were sufficient numbers of healthcare workers. They included:
Discharging patients, who were medically fit, from hospital more quickly. This is a matter to which I shall return in Module 6. Module 6 examines the impact of accelerated discharges on people living and working in the adult social care sector, especially those in care homes.
The suspension of ‘non-urgent’ elective care. Across the UK, millions of people had non-urgent operations cancelled. For many, it was devastating to learn that their long-awaited operation was going to be further delayed. To give one example: people waiting for hip replacements had to live in constant pain, with decreased mobility. For some, their condition deteriorated to such an extent that surgery was no longer an option.
In Scotland, Wales and Northern Ireland cancer screening programmes were paused. I recognise that this was not a decision taken lightly but again, it came at a high cost. The lack of screening for colorectal cancer, for example, led to missed and late diagnoses, longer waits for colorectal cancer treatment and ultimately loss of life .
The fact that the treatment of patients for life threatening and life changing conditions had to be postponed indicates the extreme pressure on the system. Desperate measures had to be taken to ensure people who needed treatment for Covid-19 could be cared for and that healthcare systems did not collapse entirely.
More people required ambulance services and this led to pressures on 999. Waiting times, even for the most urgent calls, grew, as did handover delays as ambulances queued outside hospitals. Ambulance crews could not discharge their patients, particularly in the winter of 2021, until there was a place available in emergency departments. The pressure inside hospitals was so great, this could take many hours – putting the crews and their patients at increased risk.
Once a patient was admitted, there was often a shortage of staff, in particular, highly skilled critical care staff to treat them. The understaffing in healthcare systems pre-pandemic, coupled with absences due to Covid-19 or the need to self isolate or shield, meant staff had to be redeployed from other areas of healthcare. This inevitably had a negative impact on those areas of care. Initiatives to recruit new healthcare workers were introduced and retired staff were encouraged to return to work where they were qualified and it was safe for them to do so.
However, this was not enough to bolster the numbers of critical care staff needed. At the end of March 2020 it was decided that staff to patient ratios in intensive care would have to be reduced . This meant that rather than a patient receiving 1:1 care, a single intensive care nurse could be responsible for up to 4 critically ill patients. As one intensive care nurse described:
“all you have time to do is to manage the alarms… The alarms are going off constantly — the syringe drivers, the ventilators, the beds, whatever you’ve got, the oxygen, and you’re putting out fires, rather than caring for the patient.”
Also, the necessary equipment was in short supply. At some hospitals in England demand for oxygen was so high that supplies of oxygen nearly ran out. This led to patients being diverted to other hospitals and oxygen supplies being rationed. In critical care there was a need for more ventilators and kidney dialysis machines. Clinicians were worried about the lack of guidance on rationing and how they would prioritise patients in the event that critical care resources were completely exhausted.
Although hospital staff worked long and stressful hours, many patients did not receive the quality of health care that they would have done in non pandemic times. Some people did not get taken to hospital and some were not admitted to intensive care, despite their poor condition. Today’s report lays bare the reasons for that and the devastating consequences this had.
For millions of people, Covid-19 caused only mild symptoms and they did not need admission to hospital but they still needed advice and information on how to treat Covid-19 and look after themselves and their loved ones. Where it was available, members of the public were urged to ring 111 in the first instance. This led to the inevitable increased pressure on 111 services. There were long delays in calls being answered such that many calls were abandoned.
More GP consultations were undertaken remotely. While this ensured that some primary care could be maintained, it was far from ideal and may have led to some conditions being missed. Also remote consultations are not appropriate for everyone, for example some disabled patients, patients for whom English was not their first language and for Deaf patients.
Preventing the virus spreading in healthcare settings was a major and controversial issue during the pandemic. Infection prevention and control (or IPC) measures are not new. Protecting patients and healthcare workers from becoming infected is of paramount importance. Three of my 10 recommendations are therefore focussed on IPC measures.
Fundamental flaws in the UK’s approach to IPC guidance (for example in relation to the use of Personal Protective Equipment (or PPE) put patients and healthcare workers at risk. Shortages of PPE, and poor quality PPE, caused immense anxiety amongst healthcare workers and jeopardised their own and their families’ health.
Tragically, there were many deaths of healthcare workers, in particular, those from ethnic minority backgrounds. In the Inquiry’s Module 1 and combined Module 2ABC reports I have already commented on the link between ethnicity and increased risk of mortality. This is a matter of particular concern given the diversity of the NHS workforce. .
It is unsurprising that healthcare professionals reported a decline in their mental health as a result of working in such a pressurised environment and for such sustained periods of time. Some healthcare workers were diagnosed with PTSD or decided that they no longer wished to remain in their role.
One of the strictest measures taken to prevent Covid-19 spreading was the introduction of visiting restrictions in healthcare settings. This meant that most patients were not accompanied to medical appointments, when admitted to hospital or after admission. This included pregnant women having to attend maternity appointments alone, even when they had to receive dreadful news about the loss of their baby or complications with the pregnancy.
Although there were some exceptions to the prohibition on hospital visitors, such as when a patient was at the end of life, visits were not always allowed. This led to some patients dying alone, without their loved ones being present. This was a horrific experience for family members. They cannot forget being excluded from the bedside of their loved one and/or having to say goodbye remotely. Healthcare workers also found this deeply upsetting.
The shielding programme was introduced in response to the need to identify individuals at high risk from Covid 19 and to try and protect the most clinically vulnerable people from becoming infected with the virus. Data systems differed across the UK and healthcare records were not always easily accessible or accurate. The quality, breadth and completeness of data available on clinical vulnerability initially impacted the accuracy of the shielding list. There need to be better data systems across the UK to ensure that people at the greatest risk of becoming unwell and dying are quickly identified and can be protected.
The shielding programme brought with it wide ranging consequences for the many millions of people who were advised to shield, disrupting their daily lives and affecting their access to healthcare. It inevitably resulted in many people who were shielding becoming lonely and socially isolated, and affected their mental health and wellbeing. Some have been unable to return to their pre-pandemic lives.
The harmful consequences of the introduction of visiting restrictions and the shielding programme illustrate the difficult balance to be struck when seeking to prevent infections spreading in healthcare settings and amongst clinically vulnerable members of society. This underlines the need for better pre-pandemic planning in order to mitigate, insofar as possible, the adverse effects of some of these decisions.
Another long term consequence of the pandemic was the emergence of Long Covid. While the symptoms vary, for some people Long Covid can be life-changing and enduring. I heard concerns about the length of time taken for people living with Long Covid to have their symptoms taken seriously and to be diagnosed. Access to healthcare for Long Covid has been and remains variable across the four nations. Each nation has adopted its own approach about how best to provide care and treatment. Although research into Long Covid continues, it has been significantly scaled back while the need to develop a greater understanding of Long Covid remains.
Finally, and it is a matter to which I shall return in the Module 6 care sector report, throughout the pandemic, there were reports of inappropriate and/or blanket Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) notices being imposed on groups of people, such as people with learning disabilities or older people. This should not have happened. These decisions were not as a result of any change in policy and were positively discouraged by the respective government health departments. The message does not seem to have got through to everyone.
Discussions about DNACPR notices and advance care planning more generally are necessarily sensitive and personal matters. They are best discussed before someone enters end-of-life care and before a pandemic strikes. Again we need better planning.
Module 3 was the first Module to publish a record of the Inquiry’s listening exercise, Every Story Matters, in which I heard from tens of thousands of members of the public – including thousands of healthcare professionals – from across the UK. The Healthcare Record sets out in stark and, at times, distressing terms, the very real personal impact that the pandemic had on:
- patients who were left traumatised by what they had experienced and witnessed;
- healthcare workers who described hospitals as a “war zone” and the impact this had on every aspect of their personal and professional lives and on their health and wellbeing;
- bereaved family members who were left feeling heartbroken, guilty and angry that they could not be with their dying loved ones.
The Record serves as an important reminder of why the Inquiry’s recommendations are so important.
Against this backdrop, I have made 10 recommendations that can be implemented now to improve the response of the healthcare systems to a future pandemic.
The recommendations I consider to be necessary to improve healthcare systems include the need to:
- increase 111, 999 and hospital surge capacity;
- enhance infection prevention and control decision making and guidance;
- improve data collection to identify people at highest risk of harm from infection and record deaths of healthcare workers more accurately; and
- increase support for healthcare workers.
We cannot know when, but there will be another pandemic. Whether it is another respiratory virus or ‘disease X’ – with different and as-yet unknown characteristics – healthcare will be at the centre of the response. My recommendations, taken as a whole, should mean that the UK is better prepared for that pandemic. In doing so, we shall avoid some of the terrible human cost of Covid-19. I urge the governments across the UK to work individually and collectively to implement these recommendations, in full and as swiftly as possible.