Covid-19: Invitation for written evidence

Thank you for the opportunity to respond to the Health Social Care and Sport Committees’ invitation for written evidence on Covid-19. The Royal College of Physicians (RCP) Cymru Wales used the results of our two surveys looking into the availability of Personal Protective Equipment (PPE) and testing accessibility for our members and fellows to form our evidence base to this inquiry. We have also worked with consultant physicians, trainee and specialty doctors, and members of our patient carer network in Wales to produce this response.

We would be happy to organise further written or oral evidence if that would be helpful.

Name of organisation: Royal College of Physicians (RCP) Cymru Wales

Lead contact: Senior Policy and Campaigns Advisor (Wales)

Our response

Introduction

We welcome the Health Social Care and Sport Committee’s inquiry into COVID-19.

As a leading health organisation with an aim of being person centred and clinically let, our members are committed to supporting the global response to COVID-19 and are at the centre of the NHS response in Wales.

The RCP has been tracking the impact of COVID-19 on frontline clinicians during the pandemic through membership surveys. The first of which took place on the 1-2 April [1], followed by a second on the 22-23 April.[2] We had 120 responses to both surveys.

We will conduct a third survey between the 13-14 May with a focus on the restart of non-COVID-19 services. These surveys alongside continued engagement with our members have informed the evidence in this submission.

Summary

· There have been improvements in the management of coronavirus in the last month, with a reduction in staff absence and increased access to tests for NHS frontline workers. Yet respondents to our surveys continue to highlight the clear problems that remain with access to Personal Protective Equipment (PPE) and access to tests for NHS workers’ households.

· RCP Cymru Wales is concerned that access to PPE appears to have worsened despite an increased public focus on the issue. Access to PPE declined over April, with over a quarter (27%) of members saying they couldn’t access the necessary PPE to manage coronavirus patients at the end of the month, compared to 22% at the start. These figures raise concerns about the level of protection provided to staff.

· The supply of PPE must be increased and stabilised so all healthcare workers can access the protective equipment they need when they need it. Welsh Government should be open and transparent with NHS workers about the challenges faced in sourcing PPE – while doing everything it can to direct supplies to where they are needed.

Recommendations:

· The Welsh Government must do everything it can to procure PPE and stabilise logistics to ensure that no NHS and social care staff go without appropriate levels of PPE when they need it.

· The Welsh Government must continue to develop access to testing ensuring that household members of NHS staff are able to access testing. There must also be a focus on improving turnaround times for results.

· The Welsh Government should seek to continue to build trust with the professions by being open and transparent about ongoing challenges.

· The Welsh Government should seek to learn the lessons of the last few months and work with the professions to ensure that this learning is actioned going forward.

How well is Wales dealing with the outbreak

Testing and the workforce

· Access to testing has improved since our first survey with 93% of our members with symptoms saying that they were able to access tests for their patients and 91% for themselves (up from 26%). We found that where tests are available, the turnaround for results varied from 24 hours to a week for members. Therefore, it is crucial that we continue to work towards routine testing with timely results for all our NHS workers in Wales.

· Our surveys show that more needs to be done to increase the availability of tests for people who live with frontline NHS workers. 31% said they were still unable to access testing for a symptomatic member of their household. Knowing whether household members have coronavirus could be the difference between an NHS frontline worker returning to work or potentially self-isolating for 14 days without confirmation of diagnosis. Those with symptoms or live with a symptomatic household member need to know as soon as possible whether they should rest or return to work.

· Increased testing may have reduced the number of people off sick due to suspected COVID-19 over April. Many members said that the potential negative effects of staff absence in their teams had been mitigated by re-deploying staff. Over a quarter (29%) of clinicians told us that they were working in an area of medicine that is different to their usual specialty.

· Annual leave has been cancelled or postponed in some Health Boards. These short-term fixes are not sustainable as the NHS begins to re-open and encourage the public to come forward for treatment for cancer, heart attacks, strokes or mental health conditions. Although every area prepared for a COVID-19 surge, the virus has affected different parts of Wales more than others. That means in some areas, where core services are reduced but the number COVID-19 patients has been relatively low, staff resource is stronger than usual.

· As we begin to restart and reset non-COVID-19 services, we must not only build in the time and space for staff to recuperate, restore and reflect, but also plan for how staffing levels will be affected by a surge in non-COVID-19 patients while the need to treat the virus continues.

· Although staffing levels have been a problem in areas of increased prevalence, one of the other big impacts of staff absence has been on team morale, as frontline NHS workers worry about whether their friends and colleagues who are off work unwell, with confirmed or suspected coronavirus, will recover. Many respondents said that the absence of staff members threw into sharp relief the importance of consistent access to PPE as the best protection against contracting the virus in the first place.

Personal Protective Equipment

· It is concerning that access to PPE appears to have gotten worse over April, with over a quarter (27%) of RCP members saying they couldn’t access the PPE they needed to manage coronavirus patients at the end of April, compared to 22% at the start of the month. Only half of doctors surveyed had consistent access to protective goggles. 49% said they could not always access a full-face visor and 30% could not always access a long-sleeved gown if working in high risk aerosol generating procedure (AGP) areas.

· Some members have begun sourcing their own items of PPE such as masks or scrubs because of their concerns that official stocks will run out, with 17% reusing PPE because of shortages. This follows with findings from the British Medical Association (BMA) that just over a third of hospital doctors reported sourcing their own PPE for personal or departmental use or had relied upon donations[3]. Doctors must be able to focus on treating patients with COVID-19 safe in the knowledge that the PPE they need will be there when they need it.

· PPE is only effective when it is properly fitted, so it is concerning to see that 21% either had not been fit tested or were unable to access fit testing for their PPE. Clinicians should not have to choose between protecting their own health or that of their patients. Fit testing and fit checking must take place to properly protect staff.

· If masks are being reused it becomes even more important that fit checking takes place to protect staff. The RCP has been encouraging our members to have a PPE partner when donning and doffing PPE to ensure that this is done correctly to minimise risk. The BMA has raised concerns about the additional problems faced by women trying to get a secure fit for their PPE masks.[4]

· Despite the high proportion of female clinicians working in the NHS,[5] PPE masks are largely designed for male frames.[6][7] One RCP member told us that they only passed fit testing when the mask was tied very tightly – something that they worried might not be replicable in an emergency situation.

· Opaque PPE masks also present problems for healthcare workers, patients and carers who are deaf or suffer from hearing loss, whereas hoods with respirators which are transparent have been used with positive feedback from both wearers and patients in some hospitals. The RCP would encourage Government procurement teams to seek to expand the selection of PPE equipment that they are purchasing with the aim of ensuring that all members of the NHS workforce have the PPE that they need[8].

· Members have suggested that good communications around PPE availability is key. Welsh Government needs to ‘work with the sector’ on messaging to ensure confidence.

Medicines and consumable shortages

· We also asked our fellows and members to tell us about access to medicines, oxygen and consumables. We asked them whether these shortages were new (since COVID-19) or pre-existing.

· 23% reported shortages in consumables since COVID-19, compared to 3% before its onset. New shortages in medicines were also reported in both inpatients (17% compared to 9%) and outpatients (12% compared to 11.5%).

· It is crucial that the flow of medicines and consumables is available to NHS staff and patients when it is needed.

Response of health boards

· The innovation seen during this period should be evaluated as plans to return to a ‘business as usual’ NHS Wales are developed. Health Education and Improvement Wales (HEIW) will need to consider trainee doctors who were redeployed from their usual specialty training and will need to return to it.

· While some things - like redeployment of staff - are not sustainable in the long term, other solutions for managing the outbreak of COVID-19 like virtual appointments and digital consultations could have equal benefit as we move forward.

· In December 2019 a survey of RCP members found that fewer than 10% of respondents had conducted more than 4% of their outpatient consultations by video in the last week[9]. Yet social distancing has forced more clinicians to rapidly incorporate digital communication into their practice – with largely positive response from staff. New ways of working could be a positive to take from the pandemic.

Rehabilitation

· In some of the more serious cases of COVID-19 recovery will mean the need for rehab services. Rehabilitation must be recognised as an unmissable part of COVID-19 recovery, and leaders and policymakers need to be taking urgent action to ensure that this is delivered.

· A comprehensive strategic approach to meeting rehabilitation needs is required as we work to help the recovery efforts from the pandemic.

Patient and staff safety

COVID-19 on BAME communities

· Data has shown us that 94% of the doctors who have died from COVID-19 are from black and minority ethnic (BAME) backgrounds. The RCP has recently called for an individual risk assessment for healthcare workersin such areas in light of this alarming problem.[10]

· The RCP therefore welcomes the announcement that the Welsh Government will work with Public Health Wales to investigate why such a high number of people from BAME backgrounds are dying from the virus. The sooner we have more detail on the inquiry and when it will launch, the better.

Training, Education and research

· During the pandemic many trainees have been working in emergency rotas. Shifting trainees into ‘normal’ rostering needs to happen as soon as possible. We also need to make sure that people get adequate time to rest and recuperate from the past two months.

· We need to get our clinical academic trainees back into research and look for ways to extend their time in research to ensure they do not lose out. Improved patient care is most likely to be achieved in units where clinicians are participating in research. The time for which needs to be protected and there needs to be a commitment to invest in increasing medical student numbers in Wales.

· It is important to expand training opportunities for doctors and allowing for flexible career development, all with the aim of expanding and creating the modern workforce that will deliver uniformly high-quality care across Wales.

Health and wellbeing of staff

· The mobilisation of different parts of the workforce has been one of the successes of the response to the pandemic. This expanded workforce needs to be redistributed for the next phase and this gives rise to a few issues.

· Our survey showed that around a third (29%) of physicians are currently not working in their usual clinical areas. Reallocation of staff will need thought and care. We must be conscious that healthcare workers will need some time to recover and we need to be sure that the demands of the first wave have reduced enough to ensure appropriate capacity across specialties.

· Staff being redeployed to acute medicine and other areas, 41% of those working outside their specialty felt they were not getting enough support psychologically and emotionally. It is key that the impact of COVID-19 and working in new areas is not underestimated and staff wellbeing is cared for. We must also take care of forward planning to ensure staff can get time off and recuperate during future periods of activity.

· We welcome the steps taken so far to support the mental health and wellbeing of frontline health workers. It is important not to underestimate the toll of COVID-19 on doctors’ mental health and wellbeing and the subsequent impact on the NHS’ ability to deal with the outbreak.

· Although staff may not yet be absent from work as a result, many will be experiencing understandable mental health difficulties. 41% of those working in a different clinical area to normal felt they had not been given enough psychological or emotional support. Other polling for IPPR revealed 50% of healthcare workers surveyed said their mental health had deteriorated since the virus began[11]. Time off for NHS and social care staff to rest and recuperate must be part of any Government plan to ‘restart’ core NHS services in Wales.

· Whilst measures put in place regarding wellbeing across all health boards for the acute phase have been welcome. Evidence shows that doctors can be in their posts between three and five years which can sometimes lead to a strain on their health and wellbeing. Longer term investment is needed in this area and the RCP is producing a Wellbeing roadmap.

International workforce

· The RCP recently commissioned YouGov to undertake polling. The results showed clear public support for acknowledging the contributions of NHS and social care staff who have worked during the coronavirus pandemic.

· Sixty-seven per cent of respondents thought it was unlikely that the NHS would have been able to tackle coronavirus without international staff, while 59% thought international staff who have worked in the NHS during the coronavirus pandemic should have the right to permanently stay in the UK.

· Currently, many people coming to work in the UK must pay an upfront annual fee (the NHS Health Surcharge) in order to be eligible to use the NHS as well as paying their visa fees. Today’s polling showed that 59% of the public think international NHS and social care staff should not have to pay an annual charge to use the NHS.

· The polling also revealed immense public appreciation for the international NHS and social care staff who have worked throughout the COVID-19 pandemic, with 69% of them calling for the government to publicly acknowledge their invaluable contributions.

· The RCP has called on the government to create a new deal for international NHS and social care staff that recognises their vital role in the frontline response to COVID-19 and the important part they will continue to play in the future.

· The proposed new deal includes three asks:

o All NHS and social care staff, and their spouses and dependants, should be exempt from the International Health Surcharge.

o All NHS and social care staff who have worked during the pandemic, and their spouses and dependants should be given indefinite leave to remain.

o The proposed NHS Visa should be extended to social care staff.

What we are doing

· The RCP continues to raise the issues that are important to our members such as the supply of PPE and access to testing at every opportunity. The RCP Vice President for Wales Dr Olwen Williams continue to work closely with national NHS Wales leaders across the UK including the Chief Medical Officers and national medical directors.

· We will continue to support our members with access to development materials, wellbeing resources and guidance.

Further evidence

As part of our evidence, we are also submitting the following RCP Cymru Wales reports and recommendations for consideration. All of them can be accessed below or on our website.

· Survey of fellows and members about the impact of COVID-19 (2020)

· Time for research: Delivering innovative patient care in Wales (2019)

· Doing things differently: Supporting junior doctors in Wales(2019)

· Feeling the pressure: Patient care in an overstretched NHS in Wales(2017)

· Physicians on the front line: The medical workforce in Wales in 2016(2016)

[1] RCP (2020) first survey of membersabout impact of Coronavirus

[2] RCP (2020) second survey of membersabout impact of Coronavirus

[9] RCP (2019) https://www.rcplondon.ac.uk/news/survey-reveals-barriers-providing-good-care-and-confidence-new-solutions