Evidence shows that those of BAME origin are amongst those at highest risk of infection and death from COVID 19. People of BAME origin often work in low paid employment in jobs where it is not possible to work at home such as cleaners, carers and bus drivers. These are also jobs which put workers in close, protracted contact with the public. Doctors in Unite believe that when a safe vaccine against COVID 19 becomes available that those in such high risk roles should be prioritised to receive it and they should be recognised as front-line staff.
In the NHS, it is usual for low paid jobs to be contracted out to private corporations and these outsourced workers, for example in NHS domestic services and portering, do not get treated on a par with directly employed staff. While it has been shown that clinical staff in intensive care units have been well protected against Covid 19 with high quality risk assessment, PPE, air purification and more, other front line clinical workers, especially outsourced BAME workers, have had high mortality.
In addition, public facing workers of BAME origin often live in overcrowded, multi-generational households. Potential exposure to COVID 19 at work not only puts them at risk, but their extended families.
Doctors in Unite believes that these high risk, front-line workers should be among those at the front of the queue to receive a safe COVID 19 vaccine, and applauds the International Workers of Great Britain for their groundbreaking court victory over health-and-safety protection for workers in the gig economy.
The media recently highlighted the fact that NHS England has announced:
“The NHS is set to radically overhaul the way MRI, CT and other diagnostic services are delivered for patients . . . . Community diagnostic hubs or ‘one stop shops’ should be created across the country, away from hospitals, so that patients can receive life-saving checks close to their homes. The centres could be set up in free space on the high street or retail parks.”
“The need for reform of NHS diagnostics was recognised in the Long Term Plan” – so begins the recent report by Professor Sir Mike Richards, ‘Diagnostics. Recovery and Renewal’.
The key recommendations are:
Acute and elective diagnostics should be separated wherever possible to increase efficiency.
Acute diagnostic services (for A&E and inpatient care) should be improved so that patients who require CT scanning or ultrasound from A&E can be imaged without delay. Inpatients needing CT or MRI should be able to be scanned on the day of request.
Community diagnostic hubs should be established away from acute hospital sites and kept as clear of Covid-19 as possible.
Diagnostic services should be organised so that as far as possible patients only have to attend once and, where appropriate, they should be tested for Covid-19 before diagnostic tests are undertaken.
Community phlebotomy services should be improved, so that all patients can have blood samples taken close to their homes, at least six days a week, without needing to come to acute hospitals.
Motherhood and apple pie
On the surface of it, these are laudable aims that have been welcomed by hospital bosses. The COVID-19 pandemic has had a devastating effect on management of non-covid conditions with, for example, a 75% reduction in cancer referrals and a reduction in 210,000 imaging procedures each week. Before the pandemic there were 30,000 patients who had waited longer than 6 weeks for a diagnostic test, a figure that has now increased to 580,000. Urgent consideration must be given both to how the NHS is put back on its feet and how it addresses the huge backlog of problems as well as the ongoing pandemic. There is logic in separating acute and non-acute service provision into covid and covid free areas, and who could object to patients having convenient and rapid access to the best available technology? This does of course depend on many factors, not least having an efficient coronavirus testing system at some point in the future, but raises other crucial issues.
Where will the staff be found?
The plan as set out requires the recruitment of around 11,000 staff including 2000 radiologists, 500 Advanced Practitioner radiographers, 3,500 radiographers, 2,500 assistant practitioners, 2,670 administrative staff and 220 physicists. Bear in mind the current staffing crisis on the NHS, with around 140,000 vacancies across the board exacerbated by low pay and workplace stress. Cancer Research estimated that staff would need to double by 2027 to meet demand, with one in ten posts in diagnostics unfilled at the start of the pandemic. Furthermore, massive investment in equipment will be needed. The report points out that in relation to the 20 other countries making up the Organisation for Economic Cooperation and Development, the UK ranks bottom for CT and 3rd from last for MRI scanners. The Clinical Imaging Board claims that nearly 30 per cent of the UK’s MRI stock is at least ten years old, with no replacement plans for almost 40 per cent of systems more than seven years old.
All that’s left to find – money and staff
The last settlement for the NHS was £20.5 bn, which over a five year period amounted to an annual increase in budget of 3.4%. This did not include funding for training and employing the staff of the future. Most commentators thought a minimum 4% increase in funding was needed, and the Office for Budget Responsibility put the figure at 4.3% in order to meet increasing demand. COVID-19 has now blown all these estimates out of the water with the additional costs of restarting and sustaining the service, dealing with COVID-19 long term and developing and implementing a workforce transformation.
Private sector – the spectre lurking in the wings
In Simon Stevens’s letter to health care providers in July this year, he mandated:
“Ensuring that sufficient diagnostic capacity is in place in Covid19-secure environments, including through the use of independent sector facilities, and the development of Community Diagnostic Hubs and Rapid Diagnostic Centres”.
As pointed out in The Lowdown in a comment on diagnostic hubs:
“References . . . to high street and retail park sites are possibly of no real concern – perhaps they’re more about exploiting cheap-to-rent locations during the pandemic-driven economic recession than a push to link-up with high-profile brand sponsors – but the well-established presence of private sector interests operating in the diagnostic and pathology arena suggests there may be rich pickings on offer somewhere in the hub programme, if only until the backlog is cleared”.
In fact the privatisation of diagnostic and laboratory facilities is already well underway. There is no comfort here in Professor Richard’s report which even cites as a case study:
“The East Midlands Radiology Consortium (EMRAD) was launched in 2013 to create a common digital radiology system. Pioneering work led to the development of a Cloud-based image-sharing system through which the seven NHS trusts involved in the partnership could share diagnostic images, such as X-rays and scans. In 2018, EMRAD formed a partnership with two UK-based AI companies, Faculty and Kheiron Medical, to help develop and test AI tools in the breast cancer screening programme in the East Midlands.”
There is no mention of the fact that EMRAD paid £30m for the picture archiving and communication system from GE Healthcare but refused to pay full service costs until GE sorted out chronic problems causing a dangerous backlog of CT and MRI images.
Like many of the aspirational service developments contained within the Long Term Plan, ‘one stop shops’ could offer real value to patients. As the report by Professor Richards recognises:
“These new services will require major investment in facilities, equipment and workforce, alongside replacement of obsolete equipment. Training of additional highly skilled staff will take time but should start as soon as possible. International recruitment should be prioritized.”
This is no small ask and needs to be part of a generous new funding settlement for the NHS by government. This should be an investment in the NHS as a public service rather than a source of rich pickings for private companies.
This article was written by John Puntis for Keep Our NHS Public
Experience from other countries such as Germany, South Korea and Japan has shown that if the correct measures are adopted the case rate of COVID 19 can be substantially reduced and unnecessary deaths prevented. Equally these proposals are not alien to the United Kingdom as virtually all of the recommendations are already policy in our devolved administrations.
However, despite governing one of the richest countries in the world, Boris Johnson and the Tory Party callously ignore what can be done and what needs to be done and instead throw billions of pounds at private sector providers such as Serco, Sitel and Deloitte whose national “test, trace, isolate and support” programme is demonstrably unfit for purpose, and is contributing to the current alarming rise in Covid-19 infection.
Doctors in Unite call on the Tory Government to take off their ideological blinkers and to listen to the experts and people on the front line, to give the NHS and Public Health the tools they need to crush the virus and to immediately adopt i-SAGE’s emergency ten point plan”
We did suggest an amendment to point 2 of the plan which says there should be “no return to workplaces until they are certified Covid-safe”. It is very difficult to make any indoor space completely Covid-safe and the Health and Safety Executive (HSE) has suffered swingeing cuts over the last decade to the point where it is unable to fulfil its statutory duties in the workplace. We suggest therefore that there should be no return to the workplace “until it has been fully risk-assessed”, which will allow for trade union and worker involvement in ensuring that workplaces are as safe a possible.
Dr Applebee proposed the motion by TOWER HAMLETS DIVISION of the BMA: That this meeting, in response to COVID 19, demands that government:
i) ensure that workers are not under pressure to attend work either for financial or workforce reasons while they are unwell or self-isolating and at risk of inadvertently passing on the disease;
ii) provide the equivalent of day-one statutory sick pay to those on zero hours contracts;
iii) allow the NHS to requisition private health care facilities to accommodate effective COVID-19 treatment and quarantine provision if needed;
iv) ensure workers are paid in full while they are unwell or self-isolating.
With respect to point iii)
The COVID 19 pandemic has surely blown the myth that private is good and public is bad.
We have heard repeatedly today how the NHS has stepped up to the plate to deal with the crisis, though years of an unprecedented funding squeeze has led to the collateral damage that Chaand (Dr Chaand Nagpaul, Chair of the Council of BMA) referred to earlier of those whose other health needs could not be met due to the lack of slack in the system.
On the other hand outsourcing to the likes of Deloitte and Serco has led not to the world beating test trace isolate and support system trumpeted by Boris Johnson, but a wholesale fiasco where people are having to drive miles to get a COVID test and where, despite the billions spent, the global multinationals cannot do as well with contact tracing as the very poor relation that are local public health departments.
Private hospitals were handed hundreds of millions back in March to increase capacity to deal with COVID 19 but they were largely unused, gifting a nice windfall to their shareholders at a time when their usual work had all but dried up.
Now they are likely to commissioned to help with the backlog of NHS care. Don’t get me wrong the backlog needs to be cleared, patients need their treatment, but the private sector should not be able to profit from this. They should be brought into the NHS family and their activity now should be offset against the money they were given in March. There must be value for public money spent.
The fact that the NHS had to shut down everything except dealing with COVID in March is a stark illustration of the chronic underfunding and that there has to be spare capacity inbuilt into the system to deal with crises. The extra money thrown at the system should have been thrown at the NHS not the private sector.
With respect to points i), ii) and iv):
If we are going to crush COVID, really get on top of it, we need people to be able to afford to stay at home and isolate if they are in contact with an index case. If there is enough money in the economy to subsidise eating out there is surely enough to guarantee that if someone is in quarantine that they are paid in full.
Many of the lowest paid, for example cleaners, refuse collectors and care workers, many of whom have looked after patients with COVID, often of precarious zero hours contracts, cannot work from home, and to make ends meet many of them have two jobs. They need to be reassured that they wont’ lose out financially if they stay off work otherwise they will have no choice but to go in and the virus will continue to spread.
Covid is with us but Government could do so much more to minimise it’s devastating impact.
The pandemic has surely underlined the huge value of publicly funded, publicly provided health service which is free at the point of delivery and the demonstrated the dedication of the staff who work within the NHS and Social Care.
As has been said today already, we have an opportunity to reshape the future, it’s up to us whether we grasp the nettle.
Please support this motion in all it’s parts.
The Motion was passed with overwhelming support from delegates
Workers and local communities are not to blame; responsibility lies with employers, regulatory agencies and government
It seems nearly every day there is another outbreak of Covid-19 in Britain’s factories, in the food processing industry, in the garment industry and elsewhere. It is increasingly clear that working conditions in the factories are largely responsible for the outbreaks, in particular by means of airborne spread of Covid-19. In contrast spread between workers outside the factory and in local communities plays only a small part. The timing, circumstances and pattern of the outbreaks, points to them being typical “super-spreader events”, caused by airborne spread of the virus within the same enclosed indoor space of the factory, from one or two infected individuals to large numbers of other workers. The actions of workers themselves play only a minor role in these outbreaks; the task before us is to urgently take measures to address the airborne route of spread, not only in factories but in all workplaces and schools, if we are to reduce outbreaks.
The spread of Covid-19 in indoor spaces is extremely difficult to prevent entirely. There is in reality no such thing as a “Covid-safe” workplace or school, unless transmission in the community is eliminated. The rate of community transmission will determine what happens in our workplaces and schools and a national “Zero Covid” strategy is therefore essential. We can make indoor spaces safer by hygiene measures, distancing, wearing masks and proper ventilation. We should be spending as much time talking about ventilation as we do the other measures. The Health and Safety Executive, the Food Standards Authority and other regulatory authorities have a crucial role in ensuring this is done properly; so far we have heard very little from them during the whole of the Covid-19 pandemic.
This briefing discusses airborne spread and the lessons we need to learn from super-spreading events which have occurred here and in other countries. This is all the more urgent as we head into autumn and winter when we all move indoors to a much greater extent.
The British Medical Journal published a leading article on 22 August on airborne spread of Covid-19 , which summarises what is now very convincing evidence for aerosol transmission through the air. The article says that current official guidance, which says transmission occurs only through contact and droplet spread and that aerosols are produced only during so called “aerosol generating procedures” in hospitals, does not withstand scrutiny, and gets in the way of much needed measures to combat the virus. The authors state, “Heavy breathing, coughing, talking, and singing all generate aerosols……This has important practical implications for infection control, the prevention of outbreaks and superspreading events, and for the new social behaviours that are being implemented in an effort to control the pandemic.”
The article states that airborne spread is now the plausible cause of super-spreader events, and it seems very likely that several outbreaks here in the UK, for example Greencore in Northampton, the garment factories in Leicester, meat and poultry packing plants in Wales and West Yorkshire and Coupar Angus in Scotland have been just such events. It is striking that according to press reports, in some of the outbreaks employers insist they have been fully implementing all recommended workplace safety measures. Greencore is a case in point: the company stated, “All of Greencore’s sites have wide-ranging social-distancing measures, stringent hygiene procedures and regular temperature checking in place”. Yet nearly 300 people working there were still infected.
2. Greencore outbreak
It is instructive to look at the Greencore outbreak in some detail, to ascertain how the virus spread. It is unlikely that a large number workers breached handwashing and distancing measures at the factory all within a few days, especially as management says they are so careful. It is also implausable that community transmission carried infection into the factory to such a large extent. This would mean a large number of discrete, small outbreaks in the community all at the same time, and very many more cases in the community outside the factory, which does not appear to have happened. In fact, the BBC reports  that “Testing data and analysis from the Joint Biosecurity Centre shows the spike is “almost solely down” to the outbreak at Moulton Park-based Greencore, which employs 2,100 people”. The timing of the outbreak indicates instead a typical super-spreader event. The graphs below demonstrate this clearly; one is of the Greencore outbreak: there was a low and steady number of cases in the Northampton area until mid-August when there was an abrupt jump in cases – over 200 within 3 days; a typical super-spreader pattern. The second graph is of the super-spreading event in a call centre in Seoul in March 2020, and shows a similar pattern: 94 out of 216 employees working in an open plan office on the same floor became infected over a few days in this outbreak.
We have appended below a press photograph of the Greencore factory floor: assuming this accurately portrays current working conditions, there are lots of people sharing the same, indoor space for many hours at a time each day. We have no information about the ventilation in the factory, but food processing plants are usually kept cool for hygiene reasons, and colder temperatures favour the survival of the SARS-CoV-2 virus. The ventilation often also involves recirculation of colder air in such plants, at least in part, rather than complete air changes with fresh outside air. Even with several air changes per hour it seems that some live virus can still be present in the air indoors (see below). And the direction of ventilation and air flow within the space is also important; it may carry the virus from an infected worker towards others. This is thought to have happened in the well documented restaurant outbreak in Guangzhou. 
We do not know if the photograph reflects recent practise, but if so, the lack of mask wearing is striking. Greencore workers told the local press they were “terrified” of being required to work while they awaited test results for Covid-19, and were told it was up to them if they wanted to wear a face mask or not. 
3. Tönnies meat packing plant studyIt is helpful to look at a detailed study of a similar super-spreading event also in the food processing industry – at the Tönnies meat packing plant in Germany in June. [3 – not peer reviewed as yet]. The study analysed a range of possible factors involved in the outbreak, including the timing of infection events, spatial relationship between workers in the meat processing plant, climate and ventilation conditions, sharing of living quarters and transport, and performed full viral genome sequences (i.e. genetic fingerprinting) from virus recovered from PCR-confirmed SARS-CoV-2 cases. The viral sequencing established that spread was from a single index case within the factory to other workers, and not from multiple entry points by different workers bringing infection into the plant. It also established that shared accommodation and transport did not play a material role in the outbreak. Over a 3 day period, 29 workers out of 147 who worked the same shift as the index case became infected before the index case was quarantined. 60% of workers within an 8m radius of the index case became infected. In addition, before the workers caught in the first outbreak were quarantined, they had had contact with others elsewhere in the factory, which led to a secondary outbreak leading to over 1500 workers becoming infected in the Tönnies factory overall. This led to a lockdown of a large area in the North Rhine-Westphalia region in western Germany.
3. Tönnies meat packing plant study
It is helpful to look at a detailed study of a similar super-spreading event also in the food processing industry – at the Tönnies meat packing plant in Germany in June. [3 – not peer reviewed as yet]. The study analysed a range of possible factors involved in the outbreak, including the timing of infection events, spatial relationship between workers in the meat processing plant, climate and ventilation conditions, sharing of living quarters and transport, and performed full viral genome sequences (i.e. genetic fingerprinting) from virus recovered from PCR-confirmed SARS-CoV-2 cases. The viral sequencing established that spread was from a single index case within the factory to other workers, and not from multiple entry points by different workers bringing infection into the plant. It also established that shared accommodation and transport did not play a material role in the outbreak. Over a 3 day period, 29 workers out of 147 who worked the same shift as the index case became infected before the index case was quarantined. 60% of workers within an 8m radius of the index case became infected. In addition, before the workers caught in the first outbreak were quarantined, they had had contact with others elsewhere in the factory, which led to a secondary outbreak leading to over 1500 workers becoming infected in the Tönnies factory overall. This led to a lockdown of a large area in the North Rhine-Westphalia region in western Germany.
The diagrams below are reproduced from the study and show: A: the distance between the index case (B1) and spread to other workers; diagram B shows the relationship of distance to infection risk and diagram C shows that spread within the factory was the cause of the outbreak and not shared accommodation or car pools. A full description of these findings is in the paper at reference .
It is worth quoting from this study at length:
“Aerosols are believed to be particularly important in cases where a single source transmits the virus toa large number of individuals, so-called super spreading events. Whereas droplets typically travel no farther than 2 m, aerosols can stay in the air for prolonged periods of time and may deliver infectious viral particles substantially beyond 2m distances, especially in indoor settings with low fresh air exchange rates. Factors such as temperature, humidity and air circulation are thought to significantly influence stability and transport of droplets and aerosols and consequently transmission efficiency.
Meat processing plants have recently emerged as hotspots of SARS-CoV-2 around the world. This is thought to result not only from operational practices (e.g. close proximity of workers in the production line combined with physically demanding work that promotes heavy breathing), but also from sharing of housing and transportation that may facilitate viral transmission. The requirement to operate at low temperature in an environment with low air exchange rates is another factor that may promote spread of the virus among workers.
Transmission occurred in a confined area of (the) meat processing plant in which air is constantly recirculated and cooled to 10°C. ……. Analyzing housing and commuting parameters, along with spatial and climate conditions in the work area, this study provides evidence that transmission occurred over a radius of at least 8 meters around the index case…… Physical work and relatively low fresh air exchange rates together with continuous re-circulation of cooled air may have favoured the transmission of SARS-CoV-2…
The universal point of potential contact among all cases was work in the early shift of the beef processing plant. The shift comprises 147 individuals, most of whom work at fixed positions in a conveyor-belt processing line……
….. while some secondary infections may have occurred within apartments, bedrooms or carpools, our collective data strongly suggest that the majority of transmissions occurred within the beef processing facility, with (index) case B1 being at the root of the cluster.
Our findings indicate that a physical distance of 2 meters does not suffice to prevent transmission in environmental conditions such as those studied here; additional measures such as improved ventilation and airflow, installation of filtering devices or use of high-quality face masks are required to reduce the infection risk in these environments.
Our findings suggest that the facilities’ environmental conditions, including low temperature, low air exchange rates, and constant air re-circularization, together with relatively close distance between workers and demanding physical work, created an unfavourable mix of factors promoting efficient aerosol transmission of SARS-CoV-2 particles.
It is very likely that these or similar factors are also responsible for current worldwide ongoing outbreaks in other meat or fish processing facilities. The recurrent emergence of such outbreaks suggests that employees in meat or fish processing facilities need to be frequently and systematically screened to prevent future SARSCoV-2 outbreaks. Furthermore, immediate action needs to be taken to quarantine all workers in a radius around an infected individual that may significantly extend beyond 2m.
In contrast to work-related exposure, shared apartments, bedrooms, or carpools appear not to have played a major role in the initial outbreak described in this study. Nevertheless, later viral transmission within shared living quarters or work rides very well may have been a confounding factor in context of the second, larger outbreak occurring one month after the first outbreak. Our genotyping results are fully compatible with the hypothesis that this second outbreak was seeded by cases related to the initial cluster.
The significance of this study is imminent for the meat and fish processing industry but might well reach beyond these industries, and points to the importance of air quality/flow in confined spaces to prevent future superspreading events
Common operational conditions in industrial meat processing plants promote the risk of SARS-CoV-2 superspreading events. Additional measures such as improved ventilation, optimized airflow management, installation of filtering or ultraviolet light devices or the use of high-quality face masks are required to reduce the infection risk in these environments.”
Community spread and spread among workers outside the factory have been pointed to as the cause of the Greencore outbreak. This seems to be mere supposition rather than any evidence-based assessment for such spread. The Tönnies study involved a similar group of workers, i.e. workers sharing accommodation and transport, and specifically looked at these issues and disproved them as the reason for the outbreak. There is a lack of awareness and therefore no consideration of the role of indoor aerosol spread driving factory outbreaks, which perhaps explains why the press, public and even health experts look for possible explanations outside the factory gates.
4. Preventive measures taken by Tönnies and lessons learned
The study reports that the company took the following measures after the outbreak:
Hygiene regulations and one-way traffic in hallways were reinforced.
An internal multi-lingual information campaign was started to raise awareness for all staff of prevention and self-detection of early COVID-19 symptoms.
Temperature checks were set up to check all employees entering the building.
Workers were made aware of the availability of testing and were motivated to report any events where they see themselves being at risk. Staff were tested based on self-reported symptoms, possible contacts to other infected persons, returning to work after more than 96 hours absence from work, or possible work place contact with infected colleagues.
Work place assessments were performed to see if it was possible to extend distances between workers.
Simple one-layer face masks were made compulsory.
Regulations to prohibit rotation between working places were imposed. (Shift workers were employed by an outsourcing company who had changed their workplaces according to demand by the employer.)
Measures in the canteen were imposed to reduce physical contact and to ensure that workers would spend their break times exclusively with workers from their own shift.
Implementation of the measures was audited within a month by unannounced inspections of the Occupational Health and Safety Experts of the competent authority.
There are a number of important lessons from this study:
Airborne spread is particularly important in super-spreader events;
Aerosols can carry virus much further than 2m indoors;
Temperature, humidity and air circulation (fresh air exchange rates) significantly affect stability and transport of droplets and aerosols and therefore transmission;
Close proximity of workers on the production line doing physically demanding work and therefore breathing heavily also facilitate transmission. (Other studies have pointed to rapid “line speeds” as an additional contributing factor);
Early quarantine of possible contacts is essential to limit spread;
Shared accommodation and transport did not play a significant role in this outbreak; the common factor was working together on the factory floor under these conditions;
Improved ventilation and airflow, installation of filtering devices, and use of face masks are required to reduce the infection risk in these environments, and in other workplaces which have enclosed indoor spaces.
Large secondary outbreaks can occur from an initial outbreak in a factory. Press reports indicated an increased number of cases in the surrounding community as well (but this may have been due to increased testing).
There is a need for surveillance testing in high risk environments like food processing plants, given the large number of super-spreading events which have occurred in them.
In addition to measures like hygiene, social distancing and temperature monitoring, multi-lingual information campaigns, compulsory face masks and rapid access to testing are important.
Inspection by regulatory authorities is important to ensure compliance.
While there have also been numerous outbreaks in the hospitality sector, especially linked to pubs, the workplace appears to have now become the frontline in the battle against Covid-19, both here and across the EU.  
5. Growing evidence and consensus around aerosol spread
Aerosol scientists, mainly in the US but also in Australia and elsewhere, and here in the UK (e.g. Professor Catherine Noakes at the University of Leeds, who sits on SAGE), have been convinced for some time that aerosol spread is a major route of transmission. In July, 239 scientists wrote to the World Health Organisation (WHO) asking it to recognise airborne spread and amend its guidance. WHO did shift its previous rejection of the idea and said aerosol spread “cannot be ruled out”. Since then there has been further evidence, including the successful culturing of live virus from the air up to 4.8m from infected patients in hospital rooms. (A surprising and concerning finding was that the rooms had fairly good ventilation rates as well as UV light air sterilisation, but live virus was still able to be cultured from the air.) 
Meanwhile official documents from SAGE have referred to aerosol transmission on a number of occasions,   and some professional associations’ guidelines now include advice on the risks of aerosol spread; for example, the Primary Care Respiratory Society says that routine assessments of patients by means of spirometry should be avoided due to the risk of droplet and aerosol spread. 
Aerosol spread is officially recognised in Germany and Japan and recently the French employment minister, Elisabeth Borne, stated that compulsory mask wearing from 31 August in France, “reflects a growing scientific consensus that the virus is transmitted not only in big drops projected when a person coughs or sneezes, but also in smaller ones suspended in the air breathed out by infected people that accumulates in enclosed spaces”. . Nicola Sturgeon spoke of the risk of aerosol spread in schools in Scotland on 24 August, stating her government was considering face coverings for secondary school students in communal areas. 
In the US a number of institutions are actively looking at ventilation requirements in indoor spaces, using CO2 monitors as a proxy measure for adequacy of ventilation, and the addition of portable air filters to make indoor spaces safer, including in schools and universities. A clear and practical article on this from the University of Colorado is at reference .
6. Workers and local communities are being scapegoated for factory outbreaks caused by airborne spread
We have seen in Leicester and other areas of the Midlands, accusations that outbreaks in factories have been due to workers and/or local communities failing to observe social distancing measures. There has been racist scapegoating of Asian communities, blaming them for local spikes in infection caused by factory outbreaks (in the Leicester garment factories for example), which very likely have involved airborne transmission. We have seen a social media post about the Greencore workers saying, “I don’t feel bad for most of the staff. The Eastern Europeans never followed regulations like distancing and not mixing in large groups in lockdown in March onwards. They don’t care.” The role of airborne spread needs to be understood, and communicated to all concerned during these outbreaks. Ignorance of how Covid-19 spreads is leading to victim-blaming of people who become infected, when attention should be directed to employers, public health officials and government for solutions.
It is notable that in many of these large outbreaks, workers are poorly paid and are on insecure short-term contracts. Many receive only Statutory Sick Pay; as a result they have had to rely on food banks, and some have lost their homes as they could not afford to pay rent. All workers forced to take time off due to having Covid-19 or having been a close contact of an infected person should receive full pay while isolating. Not doing so is inhumane, and is obviously also self-defeating, as some workers will go to work like those who were made to do so at Greencore while awaiting test results, and thereby compromise efforts to curtail the outbreaks. The government’s recent derisory offer of £13 per day for workers having to isolate is clearly wholly inadequate. It has been described as “a slap in the face” by a Council leader, and also only applies to areas with already high infection rates. This is clearly wrong, we want to prevent infection rates going up, not reacting when they have already become high. A proactive, preventive approach is needed.
7. Epidemiological studies
We believe it would be also be very helpful if detailed epidemiological studies, like the one done in the Tonnes meat packing plant, could be conducted in future outbreaks here in the UK, to better understand and learn from them. Hopefully some are being done but we have yet to see any of these.
8. A trade union programme
Employers must recognise airborne spread as a covid-19 risk and take action to assess and minimise risk.
Improved ventilation and airflow, installation of filtering devices, and use of face masks are required to reduce the infection risk in these environments, alongside other safety measures against Covid-19.
Trade union supervision and control of workplace safety.
Weekly surveillance testing on site of all workers, including management, in addition to easily accessible testing for anyone with symptoms or in contact with Covid-19.
All workers forced to take time off due to having Covid-19 or having been in contact with it should receive full pay while isolating. No-one should have to work while awaiting test results for symptomatic or contact testing.
9. Doctors in Unite
We are a national doctors’ trade union within Unite the Union; our members include working and retired GPs and hospital doctors and dentists from a range of specialties, as well as public health doctors and non-medical public health specialists, from across the four nations of the UK. We are party to the BMA negotiating machinery by virtue of an agreement with the BMA dating from 1950 and are the only medical trade union recognised in local government. We have been involved throughout the pandemic, both in our day jobs, and also raising issues around PPE, “Covid-safe” workplaces and campaigning on the critically important requirement for locally based ‘Find, Test, Trace, Isolate and Support’ services run by the DPH in each borough.
We will also continue to lobby for a change to official guidance around transmission of Covid-19, although with the abrupt axing of PHE this may be difficult.
We believe easing of the lockdown, and the active encouragement to return to work, is premature and unsafe given the high rate of ongoing infection1, that the R0 value is very close to, and in some areas is above 1 and the test, trace and isolate system is months away from being properly functioning. In addition, the return to work will disproportionately expose lower paid and BAME workers to increased risk of Covid-19 infection, the very groups who have already been hit so hard by this deadly disease.
The return to work however is being implemented by the government and indeed further plans are to be announced shortly, so it is important to look at the guidance. There is separate guidance for schools which will not be discussed here, however the general principles will apply to schools too.
The government’s guidance for 8 sectors of the economy, “Working safely during coronavirus”2 gives us serious cause for concern. It fails to take into account the way Covid-19 transmission occurs indoors, the time spent in enclosed spaces and the need to ensure proper ventilation. The very high risk faced by BAME staff is not mentioned. The guidance also downplays the importance of face coverings as well as weakening the 2m rule, making it advisory rather than a requirement. There is frequent use of the phrase “whenever possible” throughout the guidance, creating uncertainty and allowing room for employers to choose whether or not to implement the provisions. There is sensible advice in the guidance, such as the need to carry out a risk assessment of the workplace, on home working and on handwashing, use of sanitisers and cleaning and disinfection. However these do not make up for the many deficiencies, which will result in people who work in offices, shops and other enclosed work places up and down the country, doing so in unsafe conditions and being exposed to Covid-19.
Indoor transmission of Covid-19
Apart from early “super-spreader” events outdoors, transmission of Covid-19 is essentially an indoor phenomenon3, both through droplet spread and microdroplet aerosol spread4. The 2m rule is of limited value: if people occupy the same enclosed space for any length of time, and ventilation does not meet required standards, aerosolised viral particles from an infected individual can spread through the available space and may be breathed in by anyone occupying that space. A single cough can project over several metres, tens or even hundreds of millions of viral particles into the air5 and will contribute to the creation of an “aerosol rich environment” in an enclosed space. The longer people occupy this space the greater the risk of inhaling sufficient viral load to get infected. Even if strictly observed, the 2m rule will not offer sufficient protection in this situation.
A number of studies have shown that enclosed indoor environments can result in high levels of transmission.6, 7, 8 They show one or two infected individuals can lead to a large number of other people being infected, even if they are several metres away from each other.
The consideration of ventilation in the guidance is inadequate and vague, and fails to take into account the challenges of making indoor spaces safe from Covid-19. It does say face-to-face meetings should be held “outdoors or in well-ventilated rooms whenever possible.” There is no mention of ventilation however in relation to workplaces and workstations, where large numbers of workers will spend most of their day.
Improving ventilation is mentioned in the government’s guidance for transport operators, as follows: “Organisations should consider how to increase ventilation and air flow. Where possible, transport operators and businesses should ensure that a fresh air supply is consistently flowing through vehicles, carriages, transport hubs and office buildings.” Once more we see “where possible” and there is also a distinct lack of detail about the technical requirements for effective ventilation to eliminate this highly infectious new pathogen from public transport provision. This will not lead to safe conditions for travel for the public.
Organisations with ventilation systems are advised to check them to see if they require servicing or adjustment “for example, so that they do not automatically reduce ventilation levels due to lower than normal occupancy levels. Most air conditioning systems do not need adjustment, however where systems serve multiple buildings, or you are unsure, advice should be sought from your heating ventilation and air conditioning (HVAC) engineers or advisers.” There is no technical guidance here about type of ventilation required, and issues like the number of air changes per hour etc. And what of premises were there is no ventilation system?
The absence of guidance on ventilation is all the more surprising given the detailed advice on this from Public Health England: “Covid-19: Infection prevention and control guidance”.9 While this is written for health care settings and much of the detail is not applicable, the facts of known asymptomatic spread of Covid-19, the aerosol route of transmission of the virus, and the ongoing high level of community infection mean that all indoor spaces are a potential hazard. The general principles of this guidance should therefore apply to all indoor spaces, but they do not appear to have been considered, apart from that stated above.
Nowhere in the guidance is the very high risk from Covid-19 for BAME people mentioned. Death rates are 4 times as high for some BAME groups, yet section 2.1 in the guidance for shops, on “Protecting people who are at higher risk” makes no mention of this. The risk of dying from Covid-19 for people with diabetes, (included in the “clinically vulnerable” group of the population requiring extra protection) is exceeded by that for people of a BAME background. This cannot be right, and as long as serious risks like this are not addressed, the current high death rates will continue.
There is over-reliance in the guidance on the 2m rule to keep workers safe, and as we have said, throughout the guidance this is weakened by the phrase “where possible”. Where 2m distancing is not possible employers should “manage transmission risk” by among other things, “using back-to-back or side-to-side working whenever possible”. Sitting side-by-side or back-to-back will not prevent people from breathing in aerosolised virus, as the studies clearly demonstrate, and people do not rigidly stick to one head position, they move around and turn especially when speaking to those around them. This weakening is consistent with the constant drip feeding in the media suggesting that the 2m rule is not really essential, compromising the social distancing message overall still further.
A recent study in the Lancet showed that reducing distances is associated with increased risk: infection risk doubles when the distance between people is halved from 2m to 1m10.
The government’s recent about turn on the wearing of face coverings is welcome, as belated as it is. However, the advice on face coverings in the return to work guidance almost seems to be designed to put people off from wearing them: “There are some circumstances when wearing a face covering may be marginally beneficial as a precautionary measure.” Again, this is reproduced throughout the guidance documents.
We recognise there will be some areas and job roles, and for some individuals, where it is not practical or advisable, but face coverings should be worn everywhere in the workplace as a means of source control for transmission of Covid-19, unless there is a demonstrable reason not to do so.
Duration of time, activity levels and size of work space
These three further risk factors for indoor transmission are also not considered in official guidance. The longer the time people spend together in an enclosed space the greater the risk of inhaling sufficient virus to become infected. Similarly, the smaller the space the greater the risk. In addition if people are highly active, for example through physical exertion leading to heavy breathing, or laughing or shouting, excretion of virus is significantly increased from infected individuals, adding to risk of infection in an enclosed spaces.
Official guidance on return to work is inadequate and will leave very many people exposed to risk of infection with Covid-19. Making workplaces safe in the era of Covid-19 is nigh impossible given the scale of changes required with ongoing high levels of viral transmission in the country. The only way to keep people safe at work is to drive down transmission to much lower levels and have in place a reliable and highly efficient test, trace, isolate and support system. Current government plans are very risky and threaten to drive a second wave of the pandemic in the UK.
On the 7th May, Doctors in Unite expressed its full support for the National Education Union’s five tests before schools could take in more children and colleges re-open. In brief, these tests were:
Far lower numbers of COVID-19 cases
A national plan for social distancing
Testing, testing, testing
Whole school strategy for testing in the event of infection
Protection of the vulnerable
However, it is now expected that primary schools will accommodate many more pupils from the 1st June, although the prime minister has acknowledged that some will need more time for preparation. The government anticipates that England’s schools are likely to be fully reopened by September this year, while only year 10 and 12 – pupils in their first year of GCSE and A-level studies – will be able to meet their teachers from 15th June.
Although numbers of coronavirus patients are falling, on 28th May there were still 1,887 new cases recorded. One cause of considerable anxiety is that plans to reopen schools more widely have failed to address the increased risk to BAME pupils and staff. Early figures on COVID-19 showed that 35% of almost 2,000 patients in intensive care units were black or from another minority ethnic background, despite BAME people making up only 14% of the population.
On a positive note, there has been a huge and welcome rise in the number of teachers becoming union members, and many parents also remain concerned about safety and are skeptical of government reassurances. Two recent opinion polls showed that 60% of parents were not prepared to allow children back to school. Teachers have rightly been critical of the government for being fixated on a date rather than focusing on ‘how’ schools are to manage the return of pupils.
In fact, government thinking on schools is difficult to fathom not least because the scientific advice on which it is based is still not being made fully public. This issue prompted Sir David King, previously the Government’s Chief Scientific Advisor, to set up an independent Scientific Advisory Group on Emergencies. The Independent SAGE takes a refreshingly honest and open approach, welcoming critique and public discussion, and includes a broad range of scientific specialists. It’s second report is a model of clarity and deals with the question of schools.
The report begins by stating: “The issue of schools reopening during COVID-19 does not just have implications for pupils; it also has knock-on effects for adult staff, parents and the communities and locality from which pupils come from”. Schooling is absolutely essential for children, but must be balanced against the risk to themselves and others. The report also asserts: “We believe that decisions on school opening should be guided by evidence of low levels of COVID-19 infections in the community and the ability to rapidly respond to new infections through a local test, track and isolate strategy. There is no clear evidence that these conditions are met. Until they are it is not safe to open schools on June 1”.
Unfortunately ‘tracking and tracing’ systems are only just now becoming operational and there are likely to be many teething problems not least because of a very top down government approach and the involvement of the private sector. Local initiatives such as in Sheffield are providing both a model approach and important lessons, but have already demonstrated that simply asking contacts of cases if they would not mind self isolating for two weeks is unlikely to work unless the teams actually have the authority to insist. While the government is already thinking ahead to possible financial penalties for those who do not comply with a polite request, they would be better providing financial support at the level of wages rather than the derisory statutory sick pay that is a disincentive for people to stay at home.
There are many things that could be done to ensure children’s education is re-established by preparing school environments for social distancing, and providing better hand washing and toileting facilities. All schools are different and teachers have the necessary insights here. Local knowledge, including rates of infection is essential to inform decisions and some schools will be able to open to greater numbers of pupils more quickly than others. The role of local public health officials is also hugely important and is only now being acknowledged. The development of an effective ‘track and trace’ system is both essential for an easing of lockdown and clearly some weeks if not even months away.
The education unions have put out a joint statement to call for the Government to step back from the 1st June and to work with unions to create the conditions for a safe return to schools. The key elements are fully supported by Doctors in Unite and are as follows:
Safety and welfare of pupils and staff as the paramount principle
No increase in pupil numbers until full rollout of a national test and trace scheme
A national COVID-19 education taskforce with government, unions and education stakeholders to agree statutory guidance for safe reopening of schools
Consideration of the specific needs of vulnerable students and families facing economic disadvantage
Additional resources for enhanced school cleaning, PPE and risk assessments
Local autonomy to close schools where testing indicates clusters of new COVID-19 cases
Dr John Puntis is the co-chair of Keep Our NHS Public, and a member of Doctors in Unite
Dr Ron Singer is the vice-president of Doctors in Unite and was the chair during its centenary in 2014. He joins the podcast today to talk about the utility of trade union membership during the coronavirus pandemic.
It is an insult for the government to claim that a life assurance pay out of £60,000 to the families of a health or social care worker who dies of COVID-19 in any way compensates for the loss of life.
Despite their protestations that they “will do whatever it takes”, this again shows the scant regard the government has for frontline workers.
It follows the abject failure to ensure that staff are properly protected at work, and a testing and contract tracing regimen that is too little, too late. The government has now neglected to correct historic inequalities in the provision of death in service benefits.
On April 27th Matt Hancock announced the £60,000 payout. But the conditions that go with it are an insult to those who are lost and those left behind.
One of the criteria is that the deceased must have been in work within two weeks of developing symptoms.
We do not yet know enough about COVID-19 to be able to confidently state that the longest period from exposure to symptoms is fourteen days.
Many health and social care workers do not qualify for full death in service benefits. These include people who have opted out of the NHS pension scheme due to an inability to afford contributions, or because their jobs have been outsourced to the private sector.
GP locums who die on a day they are not in work, and retired health and social care workers who have generously returned to work during the pandemic are also not eligible for the full amount.
Widowers will also only receive a pension based on their spouses membership of the pension scheme after 6th April 1988.
Families of those with less than two years membership of the pension scheme will receive no short term pension or long term adult dependants/child’s pension.
Full death in service benefits should extend to all health and social care workers regardless of bureaucratic caveats. The criteria that the deceased must have been in work two weeks before developing symptoms should be dropped.