The tweets were terse and, to the uninitiated, obscure. “Gowns” — “examination gloves” — “green aprons” — read the messages from the accounts of procurement leaders in the UK’s National Health Service. But to their colleagues in other hospitals, each represented a cry for help, signalling shortfalls of key items of personal protective equipment (PPE) needed to keep clinicians safe while they fought a once-in-a-century battle against coronavirus.
Behind the tweets — coded, because the managers feared bosses’ wrath for publicising the shortages — lies the story of a government slow to recognise the scale of PPE that would be needed during the pandemic, of shifting guidelines that left staff feeling confused and vulnerable, and of a belated operation to source the vast number of items needed that left the UK playing catch-up with other nations to secure its share of scarce supplies.
Health leaders had entered the crisis confidently. On March 17 top NHS officials told the Commons Health Select Committee there was “adequate supply” of PPE to “keep staff safe in the months ahead”. They acknowledged some “local distribution problems” but insisted two existing stockpiles — one for a pandemic, the other for a “no deal” Brexit — were sufficient.
Over the course of the next month those assurances would unravel acrimoniously, but the prospect of serious shortages seems to have been far from the government’s mind as the virus began to spread to the UK.
On February 11, with just eight confirmed cases in the country, Steve Oldfield, chief commercial officer at the Department of Health and Social Care, wrote a “dear colleague” letter reassuring staff that the “NHS and wider health system are extremely well prepared for these types of outbreaks”.
The soothing message was amplified in an NHS briefing for primary care workers on February 18, also obtained by the FT, which said that PPE “should not be needed” when dealing with Covid-19 patients, who would be isolated as part of a strategy to contain the spread of the disease. It added that there was a “large stock of face masks” and that “additional orders for PPE” had been placed with wholesalers.
The initial confidence seems to have overlooked the fact that the “bulk” of the existing pandemic stockpile — according to the NHS’s published Operating Framework — contained “surgical face masks, FFP3 respirators, gloves and aprons” needed to tackle an influenza outbreak but not enough of the fluid-repellent gowns and visors that would soon prove critical in the fight against a novel virus like Covid-19, which can survive for much longer periods outside the body.
Bill Morgan, an adviser to then-health secretary Andrew Lansley, who sat in on many pandemic planning discussions in the UK’s 2010-15 coalition government, said: “I can’t recall anyone raising the possibility of a non-flu pandemic, and we need to understand why that was because our future contingency plans need to cover everything with pandemic potential.”
As coronavirus took hold in early March, the initial reassurances rang increasingly hollow on the frontline, where medical staff were nervously preparing to face the kind of havoc seen in Italian hospitals.
Initially doctors and ambulance workers had swathed themselves in “Ebola-style” PPE to meet the first suspected cases, but by February 11 Public Health England (PHE), issued PPE guidance for doctors to wear a fluid-repellent gown, an FFP3 respirator mask and goggles or full-face visors.
On March 7 the guidance was revised, advising that workers on Covid wards needed only plastic aprons, surgical mask and eye protection based on a ‘risk assessment’ within 1 metre of a patient. Many doctors quickly saw the guidelines were less stringent than those of the WHO and EU Centre for Disease Control, deepening suspicions — strongly denied by the government — that the guidelines had been tailored to fit the stockpile. The change of the advice “came like a bombshell”, said one frontline doctor. “It felt like a dramatic downgrading.”
Ewan Macdonald, one of the UK’s leading occupational health specialists, wrote to Duncan Selbie, the chief executive of PHE, warning that the agency’s revised guidance was “flawed”. In a letter seen by the FT, Prof Macdonald said the level of protection would be “completely unacceptable in any other occupational setting”. He received neither reply nor acknowledgment.
“The whole thing was poor right at the beginning. It has gradually been improved, but it seems as if the government has been tailoring its advice to the availability of the PPE,” he said.
Some hospital trusts and infection control experts such as Pat Cattini, president of the Infection Prevention Society, backed PHE’s stance that gowns were not necessary in a general ward setting. Visors preventing the virus reaching the mucus membranes of mouth, nose and eyes were much more essential, she argued.
But as the government continued to fall short of its own pledges, and repeatedly changed its advice, many health workers simply no longer trusted that the guidance was scientifically motivated.
PHE said the UK guidance, written with NHS leaders and agreed by all four chief medical officers, in consultation with royal and medical colleges, “recommends the safest level of personal protective equipment”.
Behind the scenes, some hospital procurement chiefs moved unilaterally to protect their staff and began “parallel sourcing”, having lost confidence in the Health Department’s central procurement operation. The result has been confusion, according to one person with a ringside view of the process: “The NHS central team don’t know what the NHS hospitals are doing. The [Cabinet Office] team don’t know what the NHS are doing and the army — brought in to help with logistics — are pulling their hair out.”
According to one prominent procurement manager, a major stumbling block has been a lack of agility and expertise in NHS Supply Chain Co-ordination Ltd, a company owned by the Department of Health which manages the procurement of goods for the NHS. It had no experience of directly sourcing PPE overseas, and was accustomed to securing it through UK-based intermediaries, the manager said.
The person estimated that the UK had been “three to four weeks behind some of the biggest buyers in the world” in launching its overseas push for PPE “and that’s all that matters because that’s when all the deals were done”.
Part of the problem, said Peter Smith, a former Whitehall head of procurement who runs the consultancy Procurement Excellence, was that until the Covid-19 crisis PPE procurement was not a sensitive sector: “We didn’t need to do a lot of risk management or get risk alerts about what’s going on out in the country of manufacture — until three months ago, when the world totally changed.”
The health department said: “we are working around the clock to ensure [PPE] gets to the frontline as quickly as possible and have delivered more than 1bn items since this global outbreak began.” It added that it had set up “a dedicated unit to focus on securing supplies of PPE led by the government’s commercial function”. NHS Supply Chain’s PPE buying teams had been seconded to the unit “and work closely with their supplier base comprising multinational manufacturers and UK distributors with extensive global sourcing networks and the proven capability to supply product that meets the necessary safety standards”, it added.
But shortages of gowns needed to shield clinicians while they carry out aerosol generating procedures on Covid patients, have loomed ever-larger in recent weeks.
On March 30, the Health Care Supply Association, which represents health procurement professionals, tweeted: “We [are] grateful for the clarification that gowns were never part of PIPP [the pandemic stockpile].” According to insiders, this was the first time many health procurement leaders had learnt that the supplies of gowns they had assumed formed part of the stockpile did not exist.
About 10 days earlier, Simon Stevens, the head of England’s NHS, had suggested that domestic production of PPE needed to be “ramped up”. But insiders have painted a picture of confusion and delay as the government appointed Deloitte Consulting to run UK sourcing efforts, which were hampered both by the unavailability of suitable fluid-repellent fabric and a lack of domestic manufacturers able to make garments at scale.
Adam Mansell, the CEO of the UK Fashion and Textiles Association, which represents 2,500 companies and first engaged with the government on March 18, said the domestic procurement operation had been slow to grind into gear and failed to tap industry expertise.
“The overall response has been slow,” he said. “It took the government and the consultants time to understand supply chain issues. We should have been getting the sourcing directors for Primark and M&S, say, in a room and saying ‘here’s the problem, there’s a phone, go and sort it out’. But that hasn’t happened.”
There has been some progress, with Don & Low, the only British company that makes the specialist material for fluid-repellent gowns, going into full production this week with enough fabric to make 3.5m gowns over three months. Industry-led groups have also belatedly been set up to address production issues, a strategy Mr Mansell agreed was the “right one, though four weeks too late”.
But for many of the 8,000 British companies offering to help, the story has been one of frustration that their approaches have not been pursued.
On April 27, after a month of deepening shortages and broken promises over PPE, the heads of six Royal Colleges collectively warned that the government now had a “duty of candour” to its healthcare professionals, akin to a doctor’s duty to be honest with a patient when mistakes have been made.
The joint intervention can serve as a coda to a period that has tested NHS staff to the limit and exposed deficiencies — of planning, supply chain management and the UK’s manufacturing base — that might have remained permanently hidden had the pandemic not struck.