Advice on protective gear for NHS staff was rejected owing to cost

The Department of Health rejected high-level medical advice about providing NHS staff with certain protective equipment during an influenza pandemic because stockpiling it would be too expensive, the Guardian can reveal.

Evidence based decisions, economic assessment, reconsider, rewrite. It’s all in the words. Questions here for Jeremy Hunt to answer – Owl

Harry Davies  www.theguardian.com 

Documents show that officials working under former health secretary Jeremy Hunt told medical advisers three years ago to “reconsider” a formal recommendation that eye protection should be provided to all healthcare professionals who have close contact with pandemic influenza patients.

The expert advice was watered down after an “economic assessment” found a medical recommendation about providing visors or safety glasses to all hospital, ambulance and social care staff who have close contact with pandemic influenza patients would “substantially increase” the costs of stockpiling.

The documents may help explain a devastating shortage of protective gear in the NHS that is hampering efforts by medical staff to manage the Covid-19 virus pandemic.

Doctors are threatening to quit the profession unless they are properly equipped, and NHS trusts across England have been asking schools to donate science goggles due to the shortages, the Guardian revealed on Wednesday. The health secretary, Matt Hancock, has acknowledged “challenges” with the supply of protective material to NHS staff and has drafted in the army to get supplies to frontline workers.

In recent days, his department says, more than 15m face masks have been delivered to the frontline, including 24.6m gloves and 1.9m sets of eye protection delivered on Wednesday.

However documents seen by the Guardian suggest officials working under his predecessor resisted advice about stockpiling supplies of eye protection in case of a pandemic of this kind.

In 2015, what is now the Department of Health and Social Care tasked one of its independent advisory committees, the new and emerging respiratory virus threat advisory group (Nervtag), to review the UK’s approach to stockpiling personal protective equipment (PPE) for use in an influenza pandemic “to help inform future stockpile and purchasing decisions”.

Nervtag had been created the previous year to advise the government on pandemic influenza and new virus threats to the UK. The advisory group made a series of “formal recommendations” to the department in March 2016, which had been compiled by a subgroup of senior NHS clinicians and scientists, and agreed by the wider committee.

Asked what items of PPE would be required in a pandemic, the government’s advisers recommended “providing eye protection for all hospital, community, ambulance and social care staff who have close contact with pandemic influenza patients.”

They said the protection could be either visors or safety glasses, adding such equipment was necessary because there was some evidence of risk of infection via the eyes when in close contact with pandemic influenza patients.

However, according to minutes of a Nervtag meeting in June 2017, a health department official told the advisers to reconsider their advice as information had emerged about “the very large incremental cost of adding in eye protection.”

A minute from the meeting stated that “a subsequent internal DH health economic assessment has revealed that following these recommendations would substantially increase the cost of the PPE component of the pandemic stockpile four-to six-fold, with a very low likelihood of cost-benefit based on standard thresholds.”

The department asked Nervtag “to clarify the detail of their advice in light of the costings, and reconsider its recommendations against the strength of the scientific evidence of the ocular route as a source of infection, and the likely incremental cost-recommendations”.

The advisory committee then changed its official advice. The recommendation over protective eyewear was rewritten so that it instead told the department to buy enough eye protection for “exceptional usage” in higher-risk circumstances and when used with respirator masks during aerosol generating procedures.

According to a January 2018 minute, the update was made “in light of emerging evidence around cost-effectiveness, and the evidence around the incremental benefits of wearing eye protection.”

It is not clear at what level of seniority in the health department the Nervtag recommendations were considered back in 2016 and 2017. In a statement to the Guardian, DHSC said it would be incorrect to say ministers “intervened in this decision making”.

“As the public rightly expects, decisions of this nature are evidence-based and take into account a number of factors, including expert clinical guidance, cost effectiveness and practical consideration, such as shelf life and storage,” a DHSC spokesperson said.

“The government has prepared and stockpiled for an influenza pandemic. The documents clearly state that the scientific evidence did not support a vast increase in procurement expenditure on face masks with integrated eye protection for pandemic influenza.”

The DHSC is now scrambling to find ways to better supply hospital staff as it faces Covid-19, a highly infectious respiratory disease, with reports of doctors and nurses frantically trying to buy their own PPE and a particularly acute need for eye protection.

At prime minister’s questions on Wednesday, the Labour leader, Jeremy Corbyn, highlighted that the Healthcare Supplies Association had appealed to DIY shops to donate PPE. On Twitter, the association said it needed visors and protective glasses, tweeting: “Do we have to commandeer the stocks of DIY stores?????”

Hunt, who ran the department between 2012 and 2018 and now chairs the House of Commons health select committee, has in recent days led calls to better equip frontline staff battling the coronavirus. Last week, he told the BBC: “We must sort this out. We are asking people to put their own lives at risk on the NHS frontline…It is absolutely heartbreaking when NHS frontline professionals don’t have the equipment that they need.”

His spokeswoman told the Guardian: “Jeremy does not believe he was personally involved in decisions about PPE for NHS staff, but was acutely aware of the shortage of funds in the NHS budget which was why that year he fought for and secured an £8bn rise in the NHS annual budget followed by a £20bn rise two years later.”

However, the documents suggest the efforts by Hunt’s department to water down the advice on PPE impacted a round of procurement that was due to take place in 2017 to stockpile for a possible pandemic.

In addition to the discussions over eye protection, the documents also raise questions about the UK government’s policy regarding face masks for doctors, nurses and other health professionals dealing with Covid-19 patients.

In 2016, Nervtag advisers told the government that intensive care units (ICUs) should be designated “hot spots” carrying out aerosol generating procedures. Therefore, they said, a particular kind of mask known as an FFP3 respirator “should be recommended for all staff at all times in these areas when a patient with pandemic influenza is present”, except for some circumstances.

One intensive care nurse at a hospital in Yorkshire told the Guardian earlier this week she had had to spend £100 of her own money to buy a full FFP3 respirator mask online. In her unit on Monday, there were no masks or surgical gowns, another vital piece of PPE kit which has also been in short supply.

There have been other reports in recent days of NHS improvising in the face of insufficient PPE, with nurses in the Royal Free hospital in north London affixing clinical waste bags around their legs, while at North Middlesex hospital they have been tying plastic aprons around their heads.

Back in 2016, Nervtag advisers also recommended the government commission an update to its infection control guidance, which by then was seven years old. The guidance, they said, needed to recommend PPE usage “in line with the current evidence base and guidelines”.

In June that year, the department responded to Nervtag’s initial recommendations about pandemic stockpiling, saying work to reflect the advice was being prioritised and progressed. However, with regard to updating the control guidance to bring it in line with current evidence, officials replied: “This work is not considered a priority at this time and will be deferred for consideration at a future time.”

Frontline doctors and nurses have said recent changes to official advice in the UK have meant many NHS staff have been wearing less protective gear than the World Health Organization (WHO) recommends when caring for Covid-19 patients. The WHO’s advice recommends different standards of PPE to the UK advice in certain clinical situations.

 

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