17.Government had a Pandemic Influenza Preparedness Programme and a stockpile of PPE for managing an influenza pandemic, but not a coronavirus pandemic (such as COVID-19). Public Health England told us this was because the national risk register identified an influenza pandemic as the number one risk. Public Health England owned and managed the PPE stockpile for an influenza pandemic on behalf of the Department, and the Department also had a smaller stockpile of PPE to manage a ‘no deal’ exit from the European Union.
18.In March 2020, officials from NHS England & NHS Improvement publicly assured the Health and Social Care Select Committee that these stockpiles meant the country was well placed to manage the COVID19 pandemic. However, the NAO report found that the stockpiles provided no more than two-weeks’ worth of most types of PPE needed by the NHS and social care during the pandemic and did not hold all the PPE they had been expected to hold (such as visors and gowns). Some of the stockpiled PPE had also passed its expiry date or did not meet current safety standards. Furthermore, government (and its contractors) struggled to distribute the stockpiled PPE as quickly as the situation required.
19.The Department told us that it had not been complacent over the stockpiles, but that COVID-19 was a novel virus and it learned more about it over time. Unlike influenza, COVID-19 can be passed on by people who are not showing symptoms of the illness. The Department explained that this meant government needed to provide PPE to a much larger group of people to stop the spread of the virus. It also said that while there were vaccines and antiviral medication available for managing influenza, this was not the case with COVID19, and that government did not have the gowns needed for managing COVID-19 because its infection control policy had been to use aprons rather than gowns.
20.Almost all the PPE was manufactured abroad and had to be shipped, flown or put on a train to the UK. This meant it took a long time to be delivered. Therefore, despite the creation of the parallel supply chain, the time lag between ordering PPE and it being available, the Department could barely satisfy local organisations’ requirements. Representatives of the frontline of health and social care sector told us they experienced various problems accessing the PPE they needed, and in some cases could not access it at all. The British Medical Association and the Royal College of Nursing told us that, in March and April, the PPE they ordered by providers through the NHS Supply Chain was not provided and when government did eventually provide PPE it provided only tiny amounts. Care England explained that providers had to buy their own PPE at hugely inflated costs, buying from suppliers they were unfamiliar with and running the risk of being sold substandard PPE. The British Medical Association provided one example of paying £150 for five respirator masks which, as shown in the NAO report, would have cost around £1 each in 2019. Care England told us that the situation within the social care sector was even worse than the NHS, with established supply chains being disrupted and reports of PPE being redirected from social providers to the NHS. The Department assured us it did not did not make any ‘contractual engagements’ to divert PPE from social care to the NHS. The British Medical Association and the Royal College of Nursing told us that a helpline created to provide PPE to local organisations was sometimes unable to provide PPE and referred them to PPE suppliers that were also unable to provide PPE. They also told us that NHS organisations came very close to (sometimes within hours of) running out of PPE and Care England told us that some social care providers actually did run out of PPE and staff did not have the PPE that they needed.
21.The Department explained that its formal reporting arrangements did not identify any provider organisation, in health or social care, as having run out of PPE completely. It monitored the risk that social care could run out within 48 hours. It told us the national supply disruption emergency helpline, which was available from mid-March, would supply immediately to any organisation which would run out within 24 hours. The Department told us it had put in place a process to understand the PPE available to local organisations. This included daily calls with NHS regional officers (who in turn were liaising with individual trusts), with local resilience forums and with government’s emergency helpline. We asked whether the Department triangulated this with information from the trade unions whose members may have reported a very different story about shortages. The Department noted it did have conversations with the Royal College of Nursing and the British Medical Association “at times”, but its main source of information on access to PPE was the process of daily calls. It acknowledged that its reporting mechanism for understanding how much PPE social care providers held was not all that it would have liked at the start of the pandemic but told us its data improved from around May.
22.We have previously noted that the COVID-19 pandemic has shown the tragic impact of delaying much needed social care reform and integration with health, and instead treating the sector as the NHS’s poor relation. Between March 2020 and July 2020, the Department provided NHS trusts with 1.9 billion items of PPE, equivalent to 80% of their estimated need. Over the same period, it provided 331 million items to the adult social care sector, equivalent to 10% of its estimated need. Of the total PPE distributed between March and July, trusts received 81% and adult social care 14%. The Department told us that this imbalance was a consequence of the arrangements for supplying PPE before the pandemic. Prior to the pandemic, social care providers tended to buy their PPE directly from wholesalers, while trusts tended to buy from the NHS Supply Chain. The Department told us its intention therefore was to provide PPE to social care providers as an “emergency top-up” when their usual suppliers could not provide it, rather than the Department becoming their main supplier. But social care representatives told us that providers were unable to get PPE from their usual suppliers or from the Department, and consequently providers reported shortages.
23.Care England and the British Medical Association told us that the contingency planning process for a pandemic appeared to focus on the NHS at the expense of the social care sector despite some of the most vulnerable people being in social care. Care England told us this lack of planning included discharging 25,000 patients from hospitals into care homes, some without first testing them for COVID-19, even after it became clear that people could transmit the virus without ever having symptoms. In our report Readying the NHS and social care for the COVID-19 peak we previously highlighted that for around one month NHS trusts had been told to discharge medically-fit hospital patients before there was a policy to test patients for COVID-19 before discharging them to care homes. It considered this had contributed to the 20,000 deaths of people in care homes during the first wave of the pandemic. Care England told us that it was only after the high number of deaths became clear, that there was recognition that people in care homes were at the frontline of the pandemic. Care England also highlighted the high mortality rates among people with learning disabilities and told us domiciliary care and learning disabilities services appeared to be of a lower priority than other types of care when PPE was being distributed. The Department told us that it had now set up an e-portal, and that over 80% of eligible social care providers, including care homes and domiciliary care agency, and primary care providers had registered to use it to obtain free PPE.
24.Witnesses from organisations representing staff working in health and social care told us that providers received unusable PPE from central government. The Royal College of Nursing told us of instances where it had received masks on which the elastic was rotten, goggles which took significant amounts of time to assemble and were later recalled for being unsafe, and of opening a box of gowns to find insects inside. It also told us that it had received stock with stickers with dates showing the products had passed their expiry dates, and new stickers replacing these, with no explanation of any process to assure that the equipment was still safe. It noted that frontline staff were faced with unfamiliar-looking PPE and lacked confidence whether it was safe, and they were sometimes very frightened as a result. UNISON agreed that similar experiences were causing distress and anxiety to frontline workers. In its letter to us after our evidence session, the Department stated that it had recalled and quarantined 40 million items of faulty PPE.
25.Staff representative organisations ran surveys in which frontline staff reported not having the PPE they needed. The British Medical Association, the Royal College of Nursing, the Royal College of Physicians and Unison ran surveys that showed at least 30% of participating doctors, nurses and care workers reported having insufficient PPE, even in high-risk settings. Among the survey findings was that 51% of nurses reported being asked to reuse single-use items of PPE in a high-risk setting; 33% of Black, Asian or other minority ethnic (BAME) doctors felt they did not have the PPE they needed, compared with 14% of white doctors; and 49% of BAME nurses reported being fit tested for a respirator mask compared with 74% of white nurses.
26.We asked about the experience of BAME staff and whether this had been different to that of their white colleagues. The British Medical Association told us that its surveys showed between two and three times as many BAME doctors as white doctors felt pressured to work without adequate protection. It also told us that it called for BAME staff to be given risk assessments in early April, when it became clear that COVID-19 was having a disproportionately high impact on staff from BAME backgrounds. But information from its members suggested that risk assessments were not being carried out until the end of May. The Department said that, since the initial PPE shortages, it had worked hard to listen to the concerns of BAME colleagues and ensure that all staff have a risk assessment. It also explained that it had a respirator mask fit-testing project and worked hard to ensure it could provide PPE in a range of sizes, so that everybody could get the PPE they needed.
27.By October 2020, employers had reported 8,152 diagnosed cases of COVID-19 and 126 deaths as being linked to occupational exposure among health and care workers. The British Medical Association and Unison asserted that the Department should investigate whether PPE shortages contributed to staff infections and deaths from COVID19. The Department told us that there was currently no evidence to show that shortages of PPE had contributed to staff deaths, but that that investigations were ongoing. It told us that all deaths in trusts are investigated by medical examiners, who refer to the Health & Safety Executive any cases where there is a chance that work-related exposure led to the death. The Health & Safety Executive will examine these cases, and the Department told us it awaited the outcome of this investigation and would act on its findings.
28.Witnesses representing the health and social care sectors raised a number of concerns about the PPE guidance issued by government. The Department told us that it held conversations with the Royal Colleges (and with the NHS and public health services of the UK nations) about the PPE guidance issued. The British Medical Association told us that, in March, the government guidance differed from the guidance of the World Health Organization: in particular government guidance did not recommend the use of eye protection in GP practices. Government did revise its guidance to recommend eye protection in early April. The NAO report stated that PPE guidance had been updated 30 times by 31 July, and the Royal College of Nursing highlighted that the frequency of changes was difficult for a provider organisation to manage and that the changes were often issued late on a Friday with providers required to implement them from Monday. Care England and UNISON were concerned that the language of the guidance was not relevant for social care, and UNISON told us that government guidance permitting the re-use of masks led to many social care workers being required to wear the same mask for an entire 12-hour shift, which they felt was unsafe. The British Medical Association said it had concerns around the guidance for PPE use during aerosol-generating procedures because it did spread far enough in protecting all circumstances of aerosol generation.
29.By the end of June, 44 Transport for London workers had lost their lives to COVID19. We asked representatives of health and social care staff organisations about the provision of PPE to non-healthcare key workers, such as taxi drivers, cleaners, transport, supermarket and security workers. The British Medical Association considered that these workers deserved to be protected and noted that failing to protect them led to more hospitalisations and increased the pressure on the NHS. The Department told us it would consider providing PPE to a wider group of people, such as key workers, as part of its pandemic planning if the evidence suggested that this would be effective. It also noted it had provided PPE guidance for some groups of workers, such as police and prison officers, during the first wave of the pandemic, and provided PPE to the Home Office and the Ministry of Justice.
27 Qq 109–110, 116–118, 120, 146; C&AG’s Report The supply of personal protective equipment (PPE) during the COVID-19 pandemic, Figure 3
28 Qq 13, 120, 145–146; C&AG’s Report The supply of personal protective equipment (PPE) during the COVID-19 pandemic, paras 8, 1.8–1.9, 1.14, 1.16, Figure 4; House of Commons Health and Social Care Committee, Oral evidence: Coronavirus – NHS Preparedness, Session 2019–2021, HC 36, 17 March 2020, Qq 129–132
29 Qq 144–147
30 C&AG’s Report The supply of personal protective equipment (PPE) during the COVID-19 pandemic, paras 13 and 2.22, Figure 9
31 Qq 8–10, 13–14, 17–18, 22, 29, 34, 37, 38, 40, 46, 66–67, 122
32 Qq 125–128
33 Qq 140–143, 156; C&AG’s Report The supply of personal protective equipment (PPE) during the COVID-19 pandemic, paras 2.5–2.6
34 Qq 131, 142–143, 156; C&AG’s Report The supply of personal protective equipment (PPE) during the COVID-19 pandemic, paras 2.5–2.6
35 House of Commons Public Accounts Committee, Readying the NHS and social care for the COVID-19 peak, Session 2019–2021, HC 405, 29 July 2020, para 3
36 C&AG’s Report The supply of personal protective equipment (PPE) during the COVID-19 pandemic, para 19
37 Qq 11, 17, 37–38, 66–67, 121, 123
38 Qq 11–12, 17, 23–24, 37, 66, 123; House of Commons Public Accounts Committee, Readying the NHS and social care for the COVID-19 peak, Session 2019–2021, HC 405, 29 July 2020, para 9
39 Qq 71–72 131, 194
40 Qq 14–16, 29–33, 39
41 Letter from Department of Health & Social Care, 15 January 2021
42 Qq 7–8, 11, 17, 49, 62, 142–143; C&AG’s Report The supply of personal protective equipment (PPE) during the COVID-19 pandemic, paras 18, 3.19–3.21, Figure 16
43 Q 49; Royal College of Nursing, (national survey results), 18 April 2020; C&AG’s Report The supply of personal protective equipment (PPE) during the COVID-19 pandemic, para 3.26
44 Qq 53–57, 260–261
45 C&AG’s Report The supply of personal protective equipment (PPE) during the COVID-19 pandemic, paras 3.22–3.23, Figure 17
46 Qq 53, 276
47 Q 142
48 Qq 20–21, 26, 69, 73–75, 82; C&AG’s Report The supply of personal protective equipment (PPE) during the COVID-19 pandemic, paras 17, 3.3–3.7, Figure 14
49 Qq 24, 79–80, 277–278