The UK's public health response to covid-19

Too little, too late, too flawed

Health is complex, the solutions are long term

The debate on folic acid fortification of food to prevent neural tube defects in babies, for example, hasn't progressed in more than two decades (doi:10.1136/bmj.p1158).8 The worrying rise in perinatal suicides requires better funded services and support for women and young families to prevent deaths (doi:10.1136/bmj-2023-075414).9 And are the mandatory school inspections that harm the mental health of teaching staff even necessary (doi:10.1136/bmj.p1147)?10 The same applies to overzealous and discriminatory processes implemented by medical regulatory bodies such as the General Medical Council, despite claims of improvement by its chief executive (doi:10.1136/bmj.p1295 doi:10.1136/bmj.p1252).1112 The prevention principle would urge us to support a ban on vaping (doi:10.1136/bmj.p1266) and consider new options for reducing the number of days people experience migraines (doi:10.1136/bmj.p1249).1314 It would also induce bewilderment at the decision to wind down the UK's world leading covid surveillance network when covid-19 is still with us and future pandemics are inevitable (doi:10.1136/bmj.p1157).15 It would not, however, lend support to a non-evidence based screening programme for haemochromatosis (doi:10.1136/bmj.p1264).16 The first steps of an "avoid, reduce, reuse, recycle, research, rethink” framework (doi:10.1136/bmj-2021-069044) focus on better clinical practice that avoids low value care and inappropriate admissions and minimises blood tests and other interventions.17 This latest article in our series on achieving net zero and environmental sustainability in clinical practice examines critical care. The challenge isn't entirely a clinical one, because achieving net zero will depend on commitment across healthcare professions, engineering, waste management, hospital leadership, and beyond. A research paper assessing the value of routine monitoring of people being treated with methotrexate finds that frequency of monitoring should be adjusted according to risk, reducing the burden of work on clinical staff and making life more manageable for patients (doi:10.1136/bmj-2022-074678 doi:10.1136/bmj.p1120).1819 The difficulty here is one of getting research into practice, a timescale of 17 years by some estimates.

The scandals of covid-19

Where clinicians once believed "there is no harm trying,” they realise that CPR offers little benefit to patients but brings significant risk to staff as they wait for the protective equipment that was promised in the UK and globally (doi:10.1136/bmj.m1423;doi:10.1136/bmj.m1367). Adding to the scandals of unpreparedness and lack of personal protective equipment is the scandal of testing. Germany's relatively low case fatality rate is helped by an "early and high level of testing” (doi:10.1136/bmj.m1395).

Rashford, racism, and bankrupt excuses

Ian Sinha and colleagues include the rising tide of food insecurity in their list of ways in which children's health and wellbeing are being sidelined by covid-19.1 The long term harm of poor health in childhood is well established, and a policy focus is urgently needed, they say. Children don't choose the poverty they are born into and live with, or the parental circumstances that lead to them being unvaccinated, unfed, or brought up on junk food.23 The incidence of covid-19 is low in children, but evidence grows of a rare, multisystem inflammatory syndrome related to Kawasaki disease.4 The illness is severe and disproportionately affects black children, although outcomes are favourable with intensive hospital care. The ISARIC study of 20 000 hospital inpatients clarifies the comorbidities that lead to hospital admission.7 But our ability to understand the high impact of covid-19 on ethnic minority patients and staff continues to be hampered by absent, limited, and poor quality data.

Covid-19: Questions of conscience and duty for scientific advisers

England is abandoning lockdown and possibly hope of containing a second wave of covid-19. From 1 June schools will open to children other than those of key workers. Outdoor markets and car showrooms will reopen. In two weeks, it will be the turn of all non-essential retailers. This is meant to be a moment of optimism, a green recovery, centred on the health of people and the planet (doi:10.1136/bmj.m2077, doi:10.1136/bmj.m2076), backed by an effective system of testing and contact tracing and possibly informed by a public inquiry (doi:10.1136/bmj.m2052).Instead, England arrives here in a state of utter confusion (doi:10.1136/bmj.m1785). The public's confidence in the official lockdown advice is shaken. The covid-19 response is short on testing, uncertain on contact tracing, and reliant on unreliable apps (doi:10.1136/bmj.m2085). Scotland, Wales, and Northern Ireland are not following England's lead. The UK has the second highest number of covid-19 deaths of any nation and, by some calculations, the most deaths per capita.

Behavioural fatigue: a flawed idea central to a flawed pandemic response

With new research casting doubt on the reliability of serology tests for covid-19 at the point of care, the fundamental pillars of a pandemic response—namely, test, trace, and isolate—are wobbly at best.13 None of this provides any confidence in the government's proposed "radical shake up” of the NHS.14 Nor does divergence in national strategies rebuild public trust that was destroyed not by behavioural fatigue but by Dominic Cummings, England's most senior government adviser.15 Scotland wants all four UK nations to follow an elimination strategy, aiming for "zero covid.” Northern Ireland has already committed, but England, persistent in its flawed response, is content for the virus to hover around, to hope it doesn't overwhelm health services, and to play "whack-a-mole” with local outbreaks. 1 Islam N Sharp SJ Chowell G. Physical distancing interventions and incidence of coronavirus disease 2019: natural experiment in 149 countries. Diagnostic accuracy of serological tests for covid-19: systematic review and meta-analysis.

How the private sector benefitted from a £2bn NHS covid contract

[...]who will staff those extra beds and ambulances? The data for this investigation have been obtained through a long and exhaustive process, involving freedom of information requests and persistence, to break through a governmental wall of secrecy around levels of activity in private hospitals during the pandemic. King's Fund. 5 May 2021. https://www.kingsfund.org.uk/blog/2021/04/nhs-nightingale-hospitals-worth-money 6 Oxford E. The NHS paid private hospitals £2bn in the pandemic: did taxpayers get value for money? BMJ 2023;380: p329. 10.1136/bmj.p329 36792133 7 Ryan S. "A gift to the sector”: why did the NHS's contract with independent hospitals allow private patients to be treated when the NHS was overwhelmed? BMJ 2023;380: p348. 10.1136/bmj.p348 36792134

A peer says the government is "in deep shit,” and it couldn't be more real

Study after study in The BMJ and other major journals has indicated the effectiveness of this vaccine technology (doi:10.1136/bmj.o2865 doi:10.1136/bmj-2022-073070 doi:10.1136/bmj-2022-072065).567 Now, a new study in The BMJ shows that maternal mRNA covid-19 vaccination during pregnancy protects infants against SARS-CoV-2 infection and hospital admission (doi:10.1136/bmj-2022-074035).8 It is perfectly reasonable to hold an evidence informed view that mRNA vaccines are effective against SARS-CoV-2 and should be widely administered while demanding full disclosure of the safety data (doi:10.1136/bmj.o102).9 As this study of vaccination in pregnancy highlights, there are also other nuances that must be considered before research evidence becomes policy, such as timing of treatment (doi:10.1136/bmj.p241).10 Vaccine manufacturers' next goal is to develop mRNA vaccines to prevent cancer, one of the original ambitions for this breakthrough science (doi:10.1136/bmj.o3041).1 Research is already advanced, although a reasoned debate on the wider application of mRNA vaccines seems unlikely. The political or commercial control of public interest data is an undesirable endpoint worthy of Warneresque levels of plain speaking condemnation. 1 Baraniuk C. When will the world get cancer vaccines? BMJ 2023;380: o3041. 10.1136/bmj.o3041 36609365 2 McEvoy J. Microchips, magnets and shedding: here are 5 (debunked) covid vaccine conspiracy theories spreading online. Vaccine effectiveness of primary series and booster doses against covid-19 associated hospital admissions in the United States: living test negative design study.

By failing older people we perpetuate the health service crisis

[...]there can be improvements in clinical practice and processes, but the clear sense from voices at the front line of the health service is of a systemwide collapse. Resolving the NHS crisis, therefore, requires a sharp focus on care for older people (doi:10.1136/bmj.p97).14 And that focus involves a greater deal of complexity than simply providing an exit route from hospital care (doi:10.1136/bmj.p83).15 The numbers here do speak for themselves. BMJ 2023;380: p97. 10.1136/bmj.p97 36639153 15 Oliver D. David Oliver: Will block purchasing care home beds solve the urgent care crisis? BMJ 2023;380: p83. 10.1136/bmj.p83 36634959 16 Launer J. John Launer: All's well that ends well? BMJ 2023;380: p104. 10.1136/bmj.p104 36649963

Sunak fiddles while the NHS burns

The collapse is undeniable—except that is if you are Prime Minister Rishi Sunak, one of his ministers, or someone senior in the health service whose denial of the collapse is an unedifying daily ritual.4 If your genuine concern is the health and wellbeing of the population, then you don't waste time contesting plausible data on excess deaths or refusing to hold meaningful talks with unhappy staff.56 The assumption here is that the people in charge do support the principles of universal health coverage funded by taxation. The problem is an unwillingness to tackle glaring failings.11 It doesn't take much common sense or empathy to understand that pensions and pay for junior doctors are driving the retention crisis.12 When people, even health professionals, aren't being heard, can't provide the level of service they believe they should be delivering, and can barely make ends meet, it is understandable that they see no option but to strike.1314 It's clear that unless you deliver and then implement your long promised plans for social care you won't fix the "flow” problems in acute care. Or that, without prioritising primary care, public health, the wider determinants of health, and ending austerity, you won't ease the pressure on hospital services or improve baseline population health and narrow inequalities. None of this is new or revelatory, yet none seems a priority for today's politicians.15 Other solutions are available.16 To begin with, investing in the workforce and a workable plan, as was the case with the waiting list initiatives of the first decade of this century, can seed optimism, catalyse change, and improve outcomes.17 Investing in early child health delivers longer term health and economic benefits;instead the health of children is worsening, and more and more families rely on food banks as the cost of living crisis deepens.1819 Innovations such as moving patients to "care hotels” while they await social care may improve access to acute hospital services.20 Any solution, however, must not be underfunded and ill thought out "political symbolism.”

Our vulnerable world of vanishing safety nets

Perhaps the most tragic statistic is that 10.5 million of the world's children are now orphaned by covid-19 (doi:10.1136/bmj.o2838).1 The impact is greatest, as ever, in the poorest countries and among the most disadvantaged populations. [...]far, solutions are few and specific initiatives rare, even in rich countries. Helen Salisbury argues that safety netting—"come back if she doesn't get better”—works only if patients and carers have easy access to primary care doctors (doi:10.1136/bmj.o2936).3 When workforce shortages make out-of-hours appointments, and home and return visits, harder, what sense is there in the media vilifying doctors for providing virtual consultations and a virtual safety net (doi:10.1136/bmj.o2934)?4 Innovation, a popular solution to health service crises, isn't so welcome when it can be used as an excuse to advance an agenda against health professionals. Management strategies have been established (doi:10.1136/bmj-2022-070750), although endometriosis is easily missed (doi:10.1136/bmj-2021-068950) and remains a complex and disabling illness whose symptoms are hard to relieve.910 Investing in women was a reason for Sri Lanka's favourable health outcomes and prosperity relative to other south Asian countries, but an economic collapse has triggered a health crisis and reminds us of the importance of strengthening health systems and access to essential drugs (doi:10.1136/bmj-2022-073475).11 Those were two of the factors that Adrian Hill and Sarah Gilbert sought to overcome with their approach to the manufacture and distribution of a covid vaccine (doi:10.1136/bmj.o2592).12 Their institution's partnership with AstraZeneca and vaccine breakthrough ended up being a first mover disadvantage, despite its aspirations for global equity.

Poor housing and dark satanic mills

Articles in The BMJ this week featuring mills and housing may seem like a throwback, but the problems they raise, from science to social welfare, are very contemporary. The impact of the cost of living crisis is clear for health professionals to see, and, where once poor laws offered relief to people who were disadvantaged, recent law making and spending plans will not do enough for people feeling the “consequences of creaking public services in a nation getting poorer” (doi:10.1136/bmj.o2837).1

How Big Oil is manipulating climate science

The UK has a new king (doi:10.1136/bmj.o2196),1 one who believes that modern medicine must combine the “best of new technology and current knowledge with ancient wisdom” (doi:10.1258/jrsm.2012.12k095),2 and a new prime minister, Liz Truss, who promises to deliver, deliver, and deliver (doi:10.1136/bmj.o2147).3 England has a new health secretary, with a worrying track record on health (doi:10.1136/bmj.o2193).4 The US has introduced a law that limits the profiteering of drug companies(doi:10.1136/bmj.o2163).5 Scotland is considering legalising assisted dying (doi:10.1136/bmj.o2205).6 And The BMJ has appointed three new columnists (doi:10.1136/bmj.o2201, doi:10.1136/bmj.o2195, doi:10.1136/bmj.o2206).789 And yet, covid persists in posing questions that are difficult to answer (doi:10.1136/bmj.o2183),10 including the merits and role of testing (doi:10.1136/bmj-2022-071215, doi:10.1136/bmj.o2055).1112 A plan to solve the workforce crisis has many obvious factors to consider yet remains elusive (doi:10.1136/bmj-2022-072977)13;new evidence underscores the worrying link between doctors’ burnout and deterioration in patient care (doi:10.1136/bmj-2022-070442, doi:10.1136/bmj.o2157)1415;health service whistleblowers still receive shoddy treatment (doi:10.1136/bmj.o2187)16;and people at the end of life continue to struggle to benefit from palliative care (doi:10.1136/bmj.o2202).17 Another constant in our ever changing world is industry’s attempts to manipulate science, behaviour that we would now describe as disinformation. Two particular areas of focus are the push for fracking, something of which Liz Truss has spoken favourably—despite evidence pointing to climate harm from methane leaks (doi:10.1136/bmj.k2397)19—and for developing carbon capture technology, a response to carbon emissions that has seen universities receive huge donations even though industry’s internal documents accept that carbon capture doesn’t make economic or environmental sense. Evidence of attempts to manipulate science were persuasive in our decision to stop publishing research funded by the tobacco industry (doi:10.1136/bmj.f5193).20 We already support divestment from fossil fuels, and this new investigation is another spur for medical and healthcare organisations to join us (doi:10.1136/bmj.m167).21 Our policy is also to decline all research funded by companies that produce fossil fuels, although their involvement in research into alternative green energy solutions makes this calculus more complex.

After covid, politicians are failing us again over the energy crisis

kabbasi@bmj.com 
Follow Kamran on Twitter @KamranAbbasi With “biblical” floods affecting tens of millions of people in Pakistan, and a cost of energy crisis that threatens the health and wellbeing of millions of children and elderly people in the UK alone (doi:10.1136/bmj.o2113),1 there are only four certainties: death, taxes, a worsening climate emergency, and the relentless growth in energy companies’ profits. A new investigation by The BMJ finds that hospitals in the UK are predicting that they will be forced to cut patients’ services to pay their “eye watering” energy bills this winter (doi:10.1136/bmj.o2088).2 Inevitably, the commitment of staff will be relied on to keep the health service going, but how much is left in the well of goodwill? Besides workload pressures, NHS consultants remain aggrieved over pay and pensions (doi:10.1136/bmj.o2073),3 while GPs are losing the sense of “specialness” that attracted them to primary care (doi:10.1136/bmj.o2002).4 It may be worth remembering how August 2022 feels, because a politician or a commentator may tell you in a year or two that the NHS and energy crises were figments of our imaginations, that the public or experts panicked and foisted disastrous policies on politicians. [...]with the prospect of a catastrophic winter ahead, amid dire warnings of a humanitarian crisis from the NHS Confederation and Michael Marmot, to name but two (doi:10.1136/bmj.o2113, doi:10.1136/bmj.o2088, doi:10.1136/bmj.o2129),1213 the sense that the politicians of the day and their supporters haven’t grasped the depth of crisis we are facing—or that if they do grasp it they have chosen not to help the people most in need—means that the public and health workers must be ready to be failed again. 1 Mahase E. Doctors warn of “significant humanitarian crisis” as half of UK households face fuel poverty.