PPE does not stand for politics, philosophy and economics

The number of healthcare workers dying from COVID continues to climb. It is not unreasonable that every attempt should be made to protect people putting their lives on the line. The situation is not that dissimilar to the controversy surrounding the use the Snatch Land Rovers in Iraq - which was labelled the “Mobile Coffin” after servicemen died in the vehicle that provided insufficient armoured protection.

The Health Secretary has claimed ‘hand on heart at each stage I've done everything I possibly could’. How does the Government square this with Operation Cygnus, the three-day training exercise in 2016 that showed the NHS would be unable to cope with a severe flu outbreak? Or indeed from well publicised warnings from other sources that perhaps even an Oxford PPE grad could understand – from the now infamous Bill Gates TED talk to the 2011 movie Contagion. Indeed, the Singaporeans, Taiwanese, and South Koreans invested heavily in pandemic infrastructure that is now paying dividends, showing that a pandemic was reasonably foreseeable and more could be done.

On the ground, the personal protective equipment (PPE) debacle is high farce. The latest amusement was the extreme shortage of scrubs. This has necessitated drafting in old and surplus scrubs from a bewildering number of sources. We now have a choice of all the shades of blue, a fetching cyanide green along with some other truly lurid colours – although we are missing Guantanamo orange. Opinion is sharply divided as to whether one shade is maroon, Claret or Burgundy. None of the pockets seem to be intact.

We often run out of the most popular sizes – especially the small ones. Some of our nurses from the Philippines are literally falling out of their XXXL scrubs. Even our rugby players are showing quite extreme amounts of cleavage.

More seriously, there are attempts to prevent unnecessary use of the bio suits unless engaged in hazardous activities – such as being around patients receiving breathing support with CPAP which is notorious for creating a fine aerosol of COVID laden secretions. The job is akin to doing a dusty DIY job all day where at the end of the day you need to have no dust on yourself.

Unfortunately, patients coughing also create fine aerosols for which you get a surgical mask and a flimsy plastic apron. Some senior doctors with an eye on upward management seem deaf to the chorus of concern from their staff. Recently one of these good folks caught COVID – most likely as a result of the inadequate protection that they encouraged. Sometimes karma completes it’s circle faster than you might imagine.

So where does this leave us? Public Health England and the NHS bosses have been very quick to assert the types of PPE we require. The professions have been rightly sceptical. These recommendations seem to fit what is currently available rather than what is recommended by our colleagues overseas. It is clear from the number of healthcare workers both contracting the disease but also the number paying the ultimate price that the centralised recommendations have not been good enough. To put it another way, they are wrong and they were told so at the time. It is interesting that managers – from the Minister down – seem to pay lip service only to the very real concerns of the healthcare workers.

Frankly, this is what you get when you have a management class that is utterly non-clinical and simply does not face the consequences of their poor choices. Perhaps we need to go back to a more decentralised management model led by clinicians who have the power to stop unacceptable risk taking. Perhaps we need to think about the General Medical Council (GMC) or an equivalent body having the power to hear complaints and strike off healthcare managers thus preventing them ever working in healthcare again.

Is COVID driving next generation business model for public-private medical research?

One of the striking features of the current COVID crisis is the lack of disease specific treatments – ventilators support the function of the lungs but only the immune system of the body can actually clear the virus from the body.

Medics the world over have gone back to traditional methods to find potential medicines that could be used to improve the course of the disease and lessen its impact. In many cases, doctors work through complex pattern recognition that requires extremely subtle interactions with patients to elucidate the symptoms and physical signs of disease and weigh them appropriately against experience where no two patients are quite the same. This subtlety is why it takes so long for doctors to train and also is why non-clinically trained millennials in silicon roundabout pushing AI algorithms for healthcare might not be as successful as their investors might appreciate.

Typically doctors begin by noticing anecdotal associations that might be as simple as two or three patients doing better than expected and coincidentally receiving a particular drug. These observations are then broadened by discussions with colleagues and through the ‘invisible hand’ the myriad of associations are organically distilled down to identify hypotheses worthy of formal testing.

The recent announcement of a number of formal UK COVID trials - including the testing of malaria medicines in COVID – is notable because of the extremely rapid progression to significant enrolment after only a month. It is doubly exciting in the context of a post-Brexit Britain – the country has effectively demonstrated an extremely valuable capability for rapid recruitment of patients from a universal healthcare system that could be easily applied to other disease states.

The significance for industry is the uniformity of patient care diagnosed by world class physicians using modern diagnostics. Patient care is not affected by insurance status or wealth – which leads to varied and sub-optimal care that makes it harder to detect treatments that work. Patient data can also be accessed from all of the patients’ records – something which is difficult if not impossible in the likes of America, where patients often change health insurers as they change jobs, and where there is no obligation and often no ability for private insurers to share information. Britain already has the significant repositories of patient data along with the genetic and other data required.

Any new medicines regulator can further extend this advantage by enabling innovations such as ‘adaptive regulation’ which provides a framework for selected patients to be able to access experimental medicines that have shown good results, but where further clinical trials are required before the medicine can be used by less-specialist doctors for most general patients. This would provide support for patients – particularly those with rare and life threatening conditions – as well as important support for Britain’s biopharma industry. Could we see a world in which every patient care episode is generating data on real world effectiveness of medicines?

The next steps are exciting but will require Britain to develop it’s own approach to data usage – care must be taken not to simply sell the access to internet giants in Silicon Valley but instead to insist on measures that would develop the local industry. Robust safeguards are required for patient data with transparent understanding about data ownership. We should rethink publication to ensure the natural desire for academic publication does not lead to results being published in journals that cannot be accessed by the public, or which inadvertently give away intellectual property.

Updated (13/04/2020, 6.02pm): An earlier version of this post incorrectly listed the author. Dr Smith authored this article. See here for more information on this blog.

Will COVID force us to think about how quickly we need to see patients?

Just recalling the start of my A&E shift this morning – equivalent to a reef on which the tsunami of COVID is breaking. The volumes of patients are now tremendous. Unwell patients one after the other with little time for thought or reflection. Pulse rates over 120 per minute, and that’s just the doctors and nurses.

In awe of some of my colleagues – juggling multiple patients with gallows humour making a thankful return after years of sanitised political correctness. This is what we all trained to do. Usually patients have so little wrong with them that one of my colleagues describes going a whole day without seeing either an accident or an emergency. That's not the case now.

We are starting to see extraordinary positives coming to medicine as a result of this pandemic. Wars and plagues have been fertile grounds for the development of medicine and surgery since time immemorial. One specific area that is re-emerging is the art of triage – designed in the Napoleonic wars as a way of seeing patients in the order of medical necessity rather than as a simple bus queue or by ability to wait.

For many in A&E this is an odd feeling - so long have we imagined the death stares from the waiting room for seeing people ‘out of time order’ or in other words patients who have not queued as long and hence not ‘earned’ the right to be treated yet. No longer do I note the hushed grumbles as the waiting room speculates why an apparently fit and well person has been chosen to receive treatment first.

We had all been preparing for the end of the four hour A&E target being implemented but had no real idea of how this would play out in practice. We are no longer seeing hordes of patients coming to A&E to avoid the queue at the GPs. For once we are turning patients away because they were not appropriately showing up at A&E.

Many of us remember the A&E system in the UK before Tony Blair’s government introduced the four hour target – those who remember the difficulties in getting diagnostic imaging and lab tests will testify to the significant positive benefits of actually being able to access timely CT scans. However, the four hour target was always a blunt instrument, and accelerated the shift towards patients being consumers – as if complex medical interventions could be bought off the shelf with little or no knowledge.

Busy A&E departments mean that it is common for patients to be first seen by a doctor after nearly three hours. Due to the four hour target this leaves less than an hour for the doctor to see a completely unknown patient, organise tests and get results before the sisters and consultants are asking for an admission decision. Too often it is impossible to safely discharge patients with the inevitable result that patients are referred to medicine for admission hence worsening the shortage of available beds. In effect the bottleneck has been simply moved somewhere else in the system

Hence, the hope is that we can see a more finely grained triage system of which a range of targeted response times from immediate in the case of a person with life threatening injuries to the maximum two week wait for suspected new cancers through to longer targets for more elective procedures.

It remains to be seen just how long these changes last when COVID is gone. Hopefully the various powers from the Royal Colleges to the Government will start to see the potential benefits of a more transparent and ultimately most clinically relevant set of targets.

Photo: Flickr/Lydia

Wishing the Prime Minister a full and speedy recovery

It is difficult seeing the Prime Minister being hospitalised. For all the partisan politics in the NHS, most people I am talking too are shocked. Everyone respects the office, no matter their thoughts of the man. For the Government, it has now got intensely personal. I hope this does not distort decision making.

In hindsight, the officials could probably have handled the communications of this better. We were initially told he was being hospitalised only because of persistent symptoms and to do some tests. Most casualty departments will have seen similar patients – the disease certainly goes on longer than anyone would like. Persistent symptoms are not a reason for admission in and of themselves. Our priority is to identify those with any evidence of COVID pneumonia. These are the patients most at risk of requiring respiratory support.

Identifying patients at risk is a mix of clinical observation including respiratory rate and the saturation of oxygen in the blood along with imaging. Chest X-rays are the mainstay but they can miss the subtle disease. CT scans are the most sensitive but hard to obtain. Ultrasound in A&E is readily available and very sensitive.

We didn’t have have any inside information. But there was more than a bit of suspicion that the Prime Minister’s admission was not simply a precaution due to persistent symptoms. There wasn’t any surprise when the truth came out. It is still interesting watching the contortions of language as officials try to avoid telling plain truths. They want to avoid talking about potentially significant interventions like CPAP respiratory support – which seems to have the shortest odds in the workplace sweepstake.

To the credit of all involved, the Prime Minister is in the same healthcare facility as any other citizen and does not seem to be given any grossly different medical treatment – albeit we could speculate that there are some fairly advanced security procedures.

One thing that does make a few doctors chuckle is the idea he is being treated by the UK’s top respiratory doctor. Whilst I am sure this doctor is a fantastic physician, medicine is not like tennis - there are no world rankings. So quite how it was decided he was the top would be interesting.

Signing off for now and wishing the Prime Minister a full and speedy recovery.

A Ponzi scheme with a legal fig leaf

We continue to fight Coronavirus day-to-day at huge direct costs to the taxpayer for healthcare and business support schemes, and indirect cost to our economy. This will create many new liabilities, piling onto existing commitments.

For example, the size of the implied pension pot required to fund pensions is already gigantic. I say implied because we all know that for many of these pensions there is no pot of funds. Our pensions, funded through so-called ‘national insurance’, are a Ponzi scheme with a legal fig leaf. We ask everyone to commit funds today for the future. But we are not saving those funds, we are spending them right away. We will then ask future taxpayers to fund our pensions with new pounds. If you were to sell an insurance or investment product on the market with these features you would be put in jail. 

The liabilities are particularly bad in the public sector. A senior civil servant with 40 years service and a final salary of £150k looks forward to about two thirds of their final salary in a pension. Many of these legacy pensions also had the right to transfer the pension to their wives (or husbands). Crikey Moses – at today’s annuity rates such a pension would require a pot of about £2.6m. Accumulating this pot would require quite phenomenal contributions – using an online calculator this equates to saving £30k per year from the age of 20 even with a 5% return on investments. Put into perspective, this would be equivalent to a new starter receiving about 100% of their salary as a pension contribution. Not only is it unlikely that a young person could ever save this sum, but the life time tax allowance of only £1m means that much of the accumulation would be subject to taxation.

So perhaps it is not surprising that the Ponzi scheme has been shut for almost everybody. However, with about 4 million UK citizens over the age of 75 – even the death of some older people from COVID is unlikely to solve the inherited pensions problem.

The NHS: A nationalised industry in a free market economy

It is difficult to walk past any of the NHS staff rooms at the moment without having to navigate the huge piles of ‘free stuff’ that have been left by grateful patients and well wishers. For this doctor, it has included some of the best oranges and lemon drizzle cake I have ever tasted.

I would certainly say that my colleagues appreciate the gestures – although one wryly observed that he enjoyed getting the clap from his neighbours. However, behind this outpouring some healthcare staff are left feeling uncomfortable – if the public really valued NHS staff then why are they not prepared to help when there is no pandemic on? Where is the free stuff that really matters like housing or fuel?

The asymmetry can be expressed even more simply: why can’t I charge properly for my services? My services are in demand but enjoy no special deals or protection from non-nationalised professionals, who are always eager to charge the full whack. Name me the lawyer who only charges £50-100 per hour – which is the price of a locum middle grade or junior consultant doctor? Where I live, even a plumber charges you more.

So frankly, is it any surprise that the NHS is short of doctors when we pay them so little? I don’t think my fellow NHS workers bear the railwaymen a grudge but why would anyone train 6 years to start on a salary that Google tells me is half that of a tube driver. They also get a much more generous holiday allowance and don’t have to pay for their training. Even attempts to solve the issue with key worker housing are a joke – perhaps if NHS workers can’t afford to live in an area you just have to start paying them properly. 

It would seem that a national pay bargaining, and a highly politicised system, have left doctors and nurses begging for more money rather than being able to use the market system for pay that plumbers and lawyers and accountants take for granted every day. While they have multiple firms bidding up the value of their labour, the nationalised NHS acts with monosomy power, bidding down our wages. If the CMA were paying attention they would probably start an investigation.

Hopefully in the midst of perhaps the greatest post-war crisis we are beginning to realise that decisions taken over decades have left them in an uncomfortable position that cannot be rescued quickly – no matter what is promised in Hancock's half hour. Many in the NHS hope this will turn out to be more than virtue signalling.

A long shift

It has been the end of another long shift – filling of the hospital with elderly patients has led to some desperately sad scenes. Entire rooms of patients drenched in sweat, struggling to breathe, and entirely without visitors who remain banned except for perhaps those right at the end of their lives.

Colleagues have been incredibly brave making the hard decisions in advance to avoid futile resuscitation attempts. Through sheer chance I have found myself on a ward answering a cardiac arrest call with an nonagenarian – thankfully the DNAR [Do Not Attempt Resuscitation] order is in place and I am left with my own thoughts as I confirm life extinct – another real human at the heart of the grim daily statistic of numbers killed.

Are antibody tests and immunity certificates the path towards the exit?

Young patients I meet in A&E clearly want to know if they have the virus - Despite the lock down it is surprising how many young patients with classic coronavirus symptoms just want to drop by and ‘get checked up’ – by which there is a heavy hint that they also expect to get tested. It is already interesting to watch the doctors and nurses trying not to vocalise their thoughts – ‘just go home and stop adding to our workload’, ‘yes the virus makes you feel bloody awful but we don’t have any cure’.

The current recommendation here in this NHS hospital is not to swab patients who are well - so most of these patients will never know whether they had the virus or not. They cannot finish their isolation and go back to being productive members of society. Given the rush to establish a completely new diagnostic test – it is unclear whether the current tests are reliable for such critical decisions. It is hard not to feel sorry for the patients – they want to get back to work and to visit their elderly relatives.

Medical staff are clearly wondering what the exit strategy is - general opinion seems to rest on antibody tests holding the key. In short, these tests would identify whether a patient has ever been infected. Assuming you cannot be reinfected, then these tests would imply immunity that would protect them from infection and importantly not be the worst of all social evils, the super spreader.

The idea of a coronavirus immunity certificate is inescapably linked to the notion of enforced testing to claim benefits or the ‘right’ to return to work. But without a vaccine, is antibody testing the only realistic exit that governments have?

How should we decide who gets treatment?

The hospital is now almost full – the constant drip drip of Coronavirus patients hour-by-hour, shift-by-shift is taking its toll. After almost two weeks of eerie quiet, the last couple of days has seen a significant acceleration in the number of patients arriving.

Corridor conversations are abuzz with talk of how we will decide which patients to ventilate. Coronavirus can cause lungs to fill up with fluid that can take weeks to clear and give rise to secondary bacterial infections. Many of these patients also have multiple underlying medical problems which all adds up to the grim statistics we keep hearing of only 50% (an uncomfortably round number) of patients surviving to get off ventilators. These statistics make open heart surgery look like a Sunday picnic where a mortality of 10% would raise eyebrows and a referral to the GMC [General Medical Council].

So who should get intensive care treatments? The current conundrum is an extension of the rationing decisions that are taken every day. In ‘normal’ times no single approach to rationing dominates - talking this through with colleagues generates a moral equivalent of paper rock scissors.

Maximising the overall social benefit for the money we spend seems to be the starting point of the UK government. Unfortunately, it is not politically tenable to ask for the votes of a patient who has paid into the tax system all their life but is then denied care. It is no accident that NICE is kept at arm's length to government.

Equality of opportunity or ‘ending the postcode lottery’ might sound great as a political slogan. But in the midst of this outbreak this means denying curative heart treatments because a COVID patient should have an equal right to the ventilator, even though they are not likely to survive. Do doctors really weigh the life of a drug addict equally against a war hero?

Equality of outcome – ‘levels the playing field’ by prioritising treatment for the worst off in society and completely ignores potential for clinical benefit. Using this approach we could see ventilators apportioned based on people with the worst health or even based on a complex and ultimately arbitrary web of identity politics.

But these times are not normal – clinical decisions are often made very rapidly in the middle of the night with imperfect information. For instance, should we intubate a patient? Should we commence CPR? Decisions must be made within seconds or minutes. As case numbers rise they'll be made by people with less and less experience of normal intensive care treatments. 

As we end our break, my fellow doctors seem unable to answer how we will decide who will get ventilator treatment when faced with multiple patients with little to choose between them.

In truth, I sense we will continue to fudge the rationing system and get to an answer that has at least a veneer of a considered ethical approach. Discussions such as this one help doctors caucus their colleagues' opinions and smooth out the greatest sources of disagreement. Thankfully we are partly satisfied in the knowledge that our decisions cannot be undone and each patient is sufficiently distinct that we can offer reasons to (retrospectively) rationalise our actions.

Welcome to Despatches

Despatches is a new blog from the Adam Smith Institute featuring insights from a senior NHS doctor who has returned to a hospital, just outside of London, to support the fight against COVID19.

We believe in these difficult times it is important to provide a platform for a wide array of perspectives: to show diversity of thought, opinion, and experience.

Friedrich A. Hayek explains, in The Use of Knowledge in Society, that useful knowledge “never exists in concentrated or integrated form but solely as the dispersed bits of incomplete and frequently contradictory knowledge which all the separate individuals possess”. 

In that spirit, we believe this blog will offer an important perspective on what is happening within the UK’s National Health Service. This ‘bottom up’ view will naturally be different from those we normally hear from — those at the top of the system. We to expand understanding of what is happening on the ground. This is one real personal perspective at one particular hospital. The views are those of this doctor, and may not reflect those of the ASI’s staff, fellows or directors.

This doctor is writing under the condition of anonymity. We shall call him Dr Smith.

Matthew Lesh is the Head of Research at the Adam Smith Institute