Doctors in Unite Statement: Government guidance on shop opening and return to work is unsafe

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. 

Ventilation

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.

BAME staff

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.

Social distancing

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.

Face coverings

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.

Conclusion

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.

References

  1. Estimated to be 17,000 new infections per day by the MRC Biostatistics Unit on 5 June 2020. https://www.mrc-bsu.cam.ac.uk/now-casting/
  2. https://www.gov.uk/guidance/working-safely-during-coronavirus-covid-19
  3. https://www.medrxiv.org/content/10.1101/2020.04.04.20053058v1.full.pdf
  4. https://science.sciencemag.org/content/early/2020/05/27/science.abc6197
  5. https://www.pnas.org/content/early/2020/05/12/2006874117
  6. https://wwwnc.cdc.gov/eid/article/26/7/20-0764_article#tnF1
  7. https://wwwnc.cdc.gov/eid/article/26/8/20-1274_article
  8. https://www.latimes.com/world-nation/story/2020-03-29/coronavirus-choir-outbreak
  9. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/886668/COVID-19_Infection_prevention_and_control_guidance_complete.pdf
  10. https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2931142-9

Doctors in Unite Statement, 10/06/2020

COVID-19: the lack of safe PPE will be this government’s legacy

As the number of cases of COVID-19 in the UK continues to rise it has become increasingly clear that there is a dire shortage of appropriate PPE for health and social care workers.

There have been repeated assurances from the government that there is plenty of appropriate PPE. However it is widely reported from the front line that PPE is in very short supply, and that what is available does not adequately protect from infection. Deliveries do not arrive and hotlines that have been set up do not work. 

In desperation many health and social care workers have taken it upon themselves to source their own equipment from DIY stores, and some have made agreements with local secondary schools to make visors on 3D printers. This situation is wholly unacceptable.

Doctors in Unite de­mands transparency from the government about the real state of affairs with respect to the current reserves, on-going production and distribution of PPE. Health and social care workers are working long hours in stressful conditions in response to the COVID-19 pandemic. The government owe it to us to be honest, and acknowledge our very real and widespread experience with shortage of appropriate PPE and explain to us why it is lacking.

It is the duty of the employer to ensure that the working environment is safe for employees. As a trade union we contend that the current situation in health and social care with respect to COVID-19 and PPE is not safe for either patients or workers. We believe that health and social care workers should not work without appropriate PPE, as to do so endangers the worker and the patient. We do not believe that health and social care workers, including porters and cleaners, should inadvertently carry infection from one patient to another through lack of disposable equipment.

Research has shown that while approximately one in five will suffer severe symptoms, and approximately one in twenty may die, the vast majority of the population will suffer a mild illness – some so mild that they are unaware they are infectious.

We must therefore assume that everyone is infectious and protect ourselves accordingly. Failure to do this will result in health and social care workers becoming infected en masse, and unavailable for work in large numbers. This will put greater strain on the NHS and social care than already exists. It will result in patients becoming infected by health and social care workers. Consequently, and disgracefully, some patients and workers will needlessly die.

We demand that industry is immediately repurposed to produce appropriate PPE in adequate quantities to properly protect staff. At the very least this should be long sleeved gowns to cover all clothes, gloves, plastic overshoes, a mask (preferably FFP3, since coughs and sneezes are also aerosol generating events) and eye and face protection for all workers in the community. Critical care workers would need considerably greater protection. 

We demand to know where this equipment is being produced, in what quantities, and when and how it will be delivered to the front line. 

If the government will not give us this information we can only assume that the PPE is not available. Given that at the time of writing we are still to feel the full force of the pandemic in the UK, this would demonstrate a total abdication of the government’s responsibility to keep the population safe.

We reject any accusation that we are engaging in political point scoring. We believe that it is the duty of the trade union movement to draw attention to the harmful effects of government policy and to demand that the population (workers and patients) receive proper care. 

Failure to draw attention to damaging government policy now will only lead to far worse consequences in later months, when the full force of COVID-19 has hit, when people have seen their relatives refused critical care because there are not enough ventilators for everyone, and there is not sufficient staff to look after them. People will quite rightly ask why the trade unions and professional organisations did not speak out.

It has been recently reported1 that in 2016 then Secretary of State for Health Jeremy Hunt, now chair of the Health Select Committee rejected stockpiling of PPE for health and social care workers on the ground of cost. It is clear that the health of the nation has been put firmly behind the strength of the economy in terms of government priority.

Dr Jackie Applebee 

Chair, Doctors in Unite

Dr Rinesh Parmar

Chair, Doctors’ Association UK

Dr Gary Marlowe 

Chair, BMA London Regional Council (signing in a personal capacity)

Michael Forster 

Chair, Health Campaigns Together

John Puntis and Tony O’Sullivan 

Chairs, Keep Our NHS Public

Professor Wendy Savage 

  1. https://www.theguardian.com/world/2020/mar/27/advice-on-protective-gear-for-nhs-staff-was-rejected-owing-to-cost

Demands in response to COVID-19


The challenge of coronavirus requires a radical response. We will overcome this virus, but current legislation falls short – much more must be done. We demand:

Full PPE

This must include FFP3 masks, visors/protective spectacles, fluid resistant gowns with sleeves and gloves for all health and social care workers dealing with patients and service users who have or are suspected to be infected with COVID-19. This is vital to prevent staff going off sick en-masse leaving no one to care for patients.

Widespread testing

Whole population testing for COVID-19 is essential, with particular attention paid to health and social care workers. Isolation and follow up of identified cases with rigorous contact tracing is crucial.

Laboratories in hospitals

Full pathology laboratories should return to hospitals. Cuts and privatisation of labs have reduced the capacity for testing so that when they are needed the system cannot cope.

Public control of private hospitals

Private health care facilities must be taken under public control and made available to assist the NHS in caring for ill patients.

Public control of industry

Key industries must be taken under public control and repurposed to manufacture equipment that is essential to deal with the outbreak of COVID-19, such as PPE, ventilators and antibiotics. 

An end to needless competition

The protection of intellectual property rights for key equipment such as ventilators must end, so that companies can collaborate to produce them. There is no place for the pursuit of profit and competition between companies during a national crisis. 

Support for staff to work remotely 

Guidance on confidentiality and data security should be rapidly produced. Investment in IT should take place to enable all those who need to work from home to do so. 

Protection and recompense for retired workers returning to work

Retired workers returning to the NHS deserve the proper provision of PPE and COVID-19 testing. Older people are more vulnerable to the virus, and will need thorough protection. 

Full pay when self-isolating

All UK workers who are off sick or self isolating due to COVID-19 should be paid as if they were in work. No one should be under financial pressure to work when government advice is that they should be at home. Previous record of days off sick should not be an impediment to this principle.

Universal basic income

Universal basic income must be made available for all in line with the living wage for the period of the crisis. This would be in place of all other benefits, universal credits or employment support.

Retraining for the newly unemployed

Those who have lost their jobs should be offered free retraining in roles that support our society and infrastructure during the pandemic. This could include medication delivery, care work, and supporting the socially isolated.

Universal access to essential services

Everyone should to be able to access the essentials that they need, including food and shelter. The homeless should be accommodated in empty hotels and houses. Supermarket stocks should be centrally managed and provisions distributed so that everyone can have what they need. 

Proportionate, time limited emergency laws subject to regular review

While being clear that everyone must be able to access what they need, there is a fine balance between ensuring equity of distribution and infringements of people’s reasonable rights and liberties. All new legislation that curtails civil rights must be limited in scope, be regularly reviewed, and should include a sunset clause.

Comprehensive support for vulnerable health groups

Services for the homeless and those who suffer from substance misuse must be maintained. These are vulnerable groups who are at high risk of complications from COVID-19 infection. They are often hard to reach and should be provided with phones so that key workers can maintain contact while working remotely.

Comprehensive social care

Disabled people are vulnerable and their needs must be properly met. They are at particular risk if their carers become unwell. Those who have accepted personal budgets are particularly at risk. Services must continue for them in all circumstances. 

An end to overseas charging

NHS eligibility checks for migrants leads to them not accessing healthcare as frequently. It is vital that during a pandemic, everyone gets the care they need. Charging overseas visitors for NHS care must be stopped and the legislation that allows this abolished.

Extended rent and mortgage payment holidays

Suspend rent and mortgage payments for all NHS and social care staff. No health or social care worker should be anxious about living costs. Many are at risk of losing household income if their partner loses their job. The current three month mortgage holiday should be extended to at least six months.

Psychological support for health and social care workers

Psychological support services should be provided at no cost for NHS and social care staff caring for patients during the period of the pandemic crisis.


We the undersigned support these demands and urge their adoption by the government as quickly as possible:

Living together, staying apart: self-isolating in a shared house

Like many people in the UK, I live in a house of multiple occupation (HMO). We make an improvised family of five. Three of us work in the NHS: one junior doctor on a geriatric ward, one junior doctor on a psychiatric dementia ward (me) and one working in administration. The other two are finishing off their studies as mature students.

Last week, we went into self-isolation as my housemate in admin had developed a fever and cough the week before. It was a strange time, none of us became ill as a result but we had to make big adjustments quickly at a time when the country was still getting its head around the emerging pandemic.

Now that we are going back to work, I am actually more anxious about how this will affect the health of our patients and of each other. While my other doctor housemate will likely be working with patients who have COVID-19, my patients in psychiatry are highly vulnerable if they contract the virus. If one of them does, it will be hard to contain the spread, as we cannot force patients to stay in their rooms if they wish to wander. The last thing I want now is to pick up the virus at home and bring it to my patients.

There are around 500,000 HMOs in England and Wales. People who live here tend to be young single adults choosing HMO living because it is a more economically viable and social option.

HMOs present a challenge in controlling the spread of disease. Apart from the fact that people are living closer together and sharing communal spaces, there is also housemate etiquette that can make it challenging to use the space in a harmonious way. Social distancing is understandable when going to the shops, park or to visit friends, but to change behaviour within the home is a change in behaviour that asks much more of us. When you share a bed and eating spaces with other people, where do you draw the line in this time of social distancing?

To answer this, I have tried to compile some simple tips for minimising the spread of disease in the home:

Wash your hands as soon as you come in. The alternative to this is rigorous washing of front/back door handles and keys. I think it is more achievable to make sure that hands are washed after this, especially if you have just been shopping.

If you have been working in a clinical environment, try to change your clothes at work or as soon as you get home. I am also going to leave a change of clothes at work to make this easier. If you will be working in areas with covid-19 then ask for scrubs to help protect yourself and others.

Have your own mug/glass/bowl/cutlery and wash them well after use. This minimises on washing up and means there won’t be any accidental cross contamination.

Have your own assigned tea towel/towel in the kitchen and bathroom. Slightly more tricky as it can result in there being also of fabric everywhere. Hand washing is all very well, but drying hands on a contaminated cloth will only re-contaminate them. If you don’t have endless supplies of paper towels (which we definitely don’t) then an individual towel will help.

Shared meals mean less people in the kitchen at once and it’s great not to have to cook every night. Practice hand hygiene in preparing meals. Communal living can still be isolating at times and shared meals are the perfect opportunity to check in on everyone.

Daily clean of: cupboard, door and appliance handles, light switches and taps. Any surface that is going to be used by multiple people could be a source of spread. The number of times a day to clean is not evidence-based, just realistic!

Physical distancing not social distancing: enjoy each other’s company from a safe distance and combat loneliness! Ultimately, if unwell people in your house are well looked after, this will allow them to stay isolated and make them feel cared for.

Rachel Hallam is a junior doctor and member of Doctors in Unite

COVID-19: A GP’s Perspective

As I write we are at the beginning of the pandemic in the UK. We still have relatively small numbers of cases but they are steadily increasing along with, tragically, associated deaths.

There is a very fine line between not fuelling mass panic, which is unhelpful, but also in taking sensible precautions.

Public health messages such as thorough hand washing and minimising touching our faces and each other are very important. This will have some effect in slowing the spread of the virus. However, we only have to look across to Italy to see how it has quickly overwhelmed their health care system, even when they have twice the number of critical care beds per person than we do in the UK.

In my view, our responsibility is to try to slow the spread of the virus, to minimise the pressure on critical care (though of course the pressure is still likely to be huge), and also to demand that the government increases the number of critical care beds as a matter of urgency by requisitioning private hospitals, upgrading existing beds in NHS hospitals and if necessary setting up field hospitals.

This will also require immediate training of NHS staff to look after critically ill patients as there are not enough at present. The last 10 years of systematic underfunding and dismantling of our NHS, along with massive cuts to social care, is now having devastating consequences.

Primary care is where 90% of NHS encounters take place, so it seems obvious that most cases of COVID-19 will be dealt with here. It is important that health workers remain well as far as possible and so are able to continue to treat patients. Unfortunately, personal protection equipment (PPE) that has been issued to GP practices is more or less useless – simple paper surgical masks which do not stop infection.

Many GP surgeries are moving towards a system called Doctor First, where patients are not allowed access to the premises without first speaking to a doctor over the phone. This is to protect staff and other patients from people who may be infectious with COVID-19.

Patients are being advised by the government to self-isolate and sweat it out at home if they become unwell, and to contact NHS 111 if they cannot manage self-isolation. NHS 111 has rapidly become overwhelmed, and there are reports of 12 hour waits for a response.

Understandably patients are not all going to meekly wait at home. Some will either come to our surgeries and demand to be seen or go to A&E, spreading the virus.

There is a debate about self-isolation, closing schools and universities and whether these are the correct strategies. I think it is not possible to say with any certainty yet whether we should or should not adopt these measures. If we do, are we just pushing another peak further down the road? What happens to, for example, children who live in poverty and rely on free school meals, or families where parents have to work to pay their rent? Will such strategies push the burden of childcare for school age children to vulnerable grandparents?

What we can say with certainty is that years of austerity have decimated our NHS, and that despite this NHS staff are, as always, rising to a very difficult challenge. While we wait for a vaccine and more critical care beds, we need to try to slow the spread down.

We should demand:

Immediate requisitioning of private hospitals to increase the pool of critical care beds.

Immediate training of NHS staff who are willing, to help look after critical care patients.

Adequate supplies of proper PPE for all staff on the front line.

Suspension of all non-essential work, for example CQC inspections, appraisals and enforcement of key performance indicators such as QOF and enhanced services. No practice should be financially penalised for dealing with this unprecedented crisis.

Adequate IT and internet connectivity to cope with the rise in remote working.

That sick pay is paid from day one. Staff should not suffer economic hardship for self-isolating or being off sick. Anyone who comes to work who is potentially infected is a danger to everyone else.

Sick pay be extended to those on regressive employment contracts, such as zero hours contracts.

No penalty for those people missing DWP assessments as result of self-isolation.

Provision of centralised primary care type services in each borough for those patients who are too sick just to sweat it out at home, but not ill enough to go to hospital.

Much more testing. We can learn from South Korea, where mass testing is being performed via drive through test stations.

Dr Jackie Applebee is a GP and the chair of Doctors in Unite.