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  • Roger Kline

Better late than never

At last. We finally have decent guidance on risk assessments from NHS Improvement and NHS Employers that recognises much more needs to be done to protect NHS staff and which recognises the particular toll on BME staff.

As of May 2nd 177 health and social care workers in the UK had died from Covid 19. That is much higher than in Germany, for example, and probably proportionately amongst the highest in Europe. To put it in context it the average number of workers dying from all accidents at work over the last 5 years average 142.

Of those who died, the clear majority of staff (some two thirds of NHS deaths) are from Black and Minority Ethnic (BME) backgrounds

We don’t know what proportion of those deaths and NHS and social care staff illness are directly due to exposure to Covid 19 at work, but there are good reasons to think that a substantial proportion are.


Firstly, the most dangerous area for healthcare staff ought to be Intensive Care Units because they care for the sickest patients with Covid 19, undertake airway management and have high risk of viral exposure and transmission yet in the analysis of the first 119 deaths, not a single doctor, nurse or physio from ICU died – black or white. The analysts suggested this was because they had good PPE and an awareness of the risks shared by staff and managers. In a follow up report on May 5th they found there continued to be no deaths reported amongst staff in anaesthesia and intensive care settings

Secondly, as this analysis of the first 119 deaths concluded “whilst it is not possible to know whether infection occurred at home or at work, the vast majority of the first 119 individuals who died had both patient-facing jobs and were actively working during the pandemic. It seems likely that, unfortunately, many of the episodes of infection will have occurred during the course of work”.

Thirdly, in their follow up analysis, of the first 130 deaths they had data on, they found. “younger female NHS workers (35% of the NHS workforce) may have a mortality rate approximately twice that of their peers who are not-NHS staff”.

Fourthly, it is clear from the repeated accounts of doctors, nurses and healthcare assistants that the failure to have enough PPE, have it properly fitted, or to ensure social distancing was observed at work wherever possible, has been mentioned in many of the individual accounts of deaths.

So we may reasonably conclude that what employers do or don’t do can make a big difference to whether NHS staff are infected by Covid and therefore risk death.

I have discussed elsewhere what employers should have done as soon as it was clear Covid 19 was a pandemic with serious consequences for working practices.

The BMA, the Doctors Association UK, the RCN, the RCM and Nursing Notes have collated many examples where employer acts or omissions have placed staff at risk.

I have received several testimonies of employers failing to provide PPE because they don’t have it, fit PPE properly, ensure social distancing at work or threaten employees who raised concerns. The testimony below from a BME junior doctor working in a High Dependency Unit is typical and he highlights one important aspect of the systemic shortcomings, which I hope are finally improving

“Public Health England’s guidance is that for aerosol generating procedures (AGP) or high risk clinical areas where AGPs are regularly performed e.g. HDU or ITU, staff should wear FFP3 respirators along with long-sleeved disposable fluid repellent gowns, eye protection and gloves. In order to ensure that this equipment is protective to that individual person (i.e. personalised protective equipment) the FFP3 masks has to be “FIT” tested to ensure that the mask provides a tight seal to prevent COVID-19 aerosols from being inhaled by the front line staff.

“As a junior doctor working in HDU, I was “FIT” tested on the different disposable masks, but unfortunately there were no masks available that provided me with sufficient protection. On the “FIT” test algorithm, I should have been offered a reusable mask or a hood; and if neither of those options were available, be re-deployed to a low-risk area and not perform any AGPs. 

“But this was not my reality. 

“I was told by my consultant I would need to carry on working my rota as scheduled because there would be a hood available, so when at the start of my 13 hour shift, I raised it again with the consultant who was then on duty, I was shocked when I was told I was “not a sufficient priority” for a reusable mask or a hood. My consultant explained that these were for the Anaesthetists and Intensive Care consultants, not for me as a junior doctor. I was in disbelief that both my work and my personal health were being belittled by my senior and my request being ridiculed.

“I was left feeling conflicted and confused. Under these extraordinary circumstances I am proud of being a doctor and being able to care for patients who so desperately need our help. Myself and my colleagues are having to face so many unknowns, make incredibly difficult life-saving clinical decisions, deal with the emotional burden of caring for so many dying patients – and do this under the physical pressure of working consecutive long shifts, wearing suffocating masks that prevent us from taking a sip of water.

“But my concerns should not have been ignored. And I am not alone in feeling that way.

“With the pressure-cooker effect of COVID-19, it is BAME staff that are disproportionately facing the pressurising and coercive behaviours from their seniors. We previously knew from the NHS staff survey results that BAME staff report higher levels of bullying and harassment from their seniors compared to white staff. BAME staff are more highly represented in lower-paid positions on the front line in the NHS so they are significantly more exposed to the virus. Staff who are bullied are less likely to raise their clinical concern about care, less likely to admit making a mistake for fear of being blamed and less able to provide compassionate care for their patients.

“Eventually when I was in the process of being re-deployed I was asked a question by my consultant that I have heard other redeployed staff have been asked: “in a decade’s time would I be proud of my contribution to COVID-19”. But over history we have repeatedly failed to acknowledge BAME contribution within the NHS – reflected in the decision to yet again recognise Florence Nightingale over Mary Seacole in the naming of the Excel Centre. My contribution had already been minimised and deemed “not important” enough to be given the correct PPE.” 

Fortunately this junior doctor tells me he has so far come to no harm. But the fear, disillusionment, illness and potential death such treatment risks is extraordinarily serious.

There are finally some serious signs of improvement in the NHS response but no sign of improvement in the outrageous treatment of social care staff in care homes and providing personal services in homes.

The most recent data shows how crucial cutting transmissions of Covid-19 to health and social care workers. Epidemiologist Anne Johnson (UCL) reports that

“Half of all new infections reported last week were among healthcare workers. This has now become the leading edge of the spread of the disease.”

If that is the case, then protecting NHS staff is not only crucial for staff but for the wider population.

The wave of tragic deaths amongst health and social care staff has to stop. The evidence strongly suggests that what employers do makes a crucial difference.

Let’s make sure that happens despite the continuing shortcomings of Ministers.

Footnote. Health Service Journal reports “Public Health England has (4th May 2020) made new changes to its guidance on the use of face masks as “a pragmatic approach for times of severe shortage”. PHE on Sunday updated its guidance on the use of certain facemasks facing “acute shortages”. The new advice states that FFP2 respirators can be worn without fit testing in lieu of surgical masks in non-surgical settings…….The update came as trust procurement leads reported receiving substandard face masks from national stocks over the weekend”, although a PHE spokesman told HSJ that this had not caused the change to guidance.”

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