Hospital leaders have directly attacked the government for the first time during the coronavirus crisis over the shortage of personal protective equipment (PPE) after a desperately needed consignment of surgical gowns that had been announced by ministers failed to arrive.

In an unprecedented intervention, which hospital leaders privately say is the result of “intense frustration and exasperation”, the organisations representing NHS trusts in England urged ministers to “just focus on what we can be certain of” after weeks of “bitter experience” with failed deliveries.

The NHS Confederation and NHS Providers spoke out amid continuing alarm that shortages of equipment will soon have disastrous effects on the frontline, with representatives of intensive care staff warning on Sunday that the critical shortage of PPE could lead to some people refusing to continue working there.

After the Guardian revealed on Friday [see article below] that doctors and nurses had been asked to work without protective full-length coverings and to instead resort to aprons, cabinet minister Robert Jenrick promised that 84 tonnes of PPE, including 400,000 much needed surgical gowns, would arrive from Turkey on Sunday.

But after that shipment was delayed without explanation [1], hospital chiefs’ frustrations boiled over. “Tens” of trusts are now at risk of running out of gowns over the next few days unless fresh supplies can be found, a well-placed NHS source said.

After previous examples of promises of shipments that either did not arrive or contained the wrong items, NHS Providers – the representative body for hospital trusts – wants ministers including the health secretary, Matt Hancock, to stop talking about expected deliveries in public and only announce them once they have arrived.

Shipments trailed in advance that do not arrive increase anxiety among frontline staff and make it harder for hospitals to plan how best to keep their doctors and nurses from getting infected, bosses said.

“We have, over the last 24 hours, seen an unhelpful focus on one individual consignment coming from Turkey. We are told that this consignment is still stuck in Turkey with no certainty, at the time this comment was issued, on how many gowns, if any, will leave for the UK, [and] when,” said Chris Hopson, chief executive of NHS Providers.

“Given the current uncertainties over gown manufacture and supply, due to global shortages, we suggest that any future announcements on what gowns might be available for delivery, when, just focus on what we can be certain of.”

“Bitter experience in recent weeks has shown that promised consignments of gowns cannot be relied on until they come, are checked and found to contain the right kit,” he added. “For example, a consignment of 200,000 gowns that arrived from China last week actually contained only 20,000 gowns. This follows previous instances of consignments of gowns being mislabelled and failing safety tests.”

Trust leaders privately admit that they are desperate to acquire more full-length waterproof surgical gowns. Hospitals have expressed gratitude to local vets, fire brigades, police forces, councils, DIY shops and builders’ merchants after being forced to ask them to hand over their stocks of gowns. One received 2,000 from a nearby veterinary supply firm.

On Friday Hancock told MPs on the Commons health and social care select committee that 55,000 more gowns were due that day. They arrived as expected and were distributed to hospitals over the weekend. However, NHS officials pointed out that, with hospital staff in England using 150,000 gowns a day, they constituted barely eight hours’ supply.

London hospitals are getting through 30,000 to 40,000 a day and major teaching hospital trusts, such as Addenbrooke’s in Cambridge and University Hospitals Birmingham need to use 3,000 to 4,000 each day, such is the demand caused by the pandemic.

Niall Dickson, chief executive of the NHS Confederation, which also represents hospital trusts and other NHS providers, said the non-arrival of PPE from Turkey was “very serious” and made a difficult situation worse. “It would have been better had the government not made the announcement in the first place,” he said. “We know shipments in this supply chain are unreliable and even when they do arrive they are not always what is expected. In future the NHS will expect announcements when supplies have arrived, not promises about what may or may not be delivered.”

Echoing Hopson’s concern, Dickson added that unfulfilled promises from ministers about PPE caused problems.

“We accept that this is difficult for everyone, but we now need action, not words. There was already a loss of confidence and real anxiety across the NHS and care system around PPE supply. This will have been further eroded by what has happened this weekend. It will not be restored until we have a stable supply chain and certainty that staff will be given what they need when they need it. At the moment we are a long way from that point.”

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As the number of NHS staff who have died from coronavirus rose to 77, Dr Chaand Nagpaul, leader of the British Medical Association, said: “This really is a matter of life and death. In what is an incredibly challenging time, doctors and healthcare staff should feel as equipped and supported as they need to be able to deliver care for patients. Instead, they are left fearful for their own health and safety – this is shameful.”

The Intensive Care Society, Faculty of Intensive Care Medicine, Royal College of Anaesthetists and Association of Anaesthetists joined a growing medical backlash against new PPE guidelines issued by Public Health England on Friday. In a joint statement, they said concern about lack of PPE was so great that some doctors may decide not to take the risk of treating infected patients.

They said that, given the flaws in PHE’s advice, “We think clinicians should carefully evaluate the risks before taking a decision about whether to provide care, and should discuss a decision not to provide care with a colleague.

“If shortages continue or worsen, our members will face increasingly difficult decisions. This will involve balancing the safety of patients against their personal safety and that of other staff, those they return home to after work, and patients they may treat in the future.”

The Department of Health and Social Care said: “Adequate supply of protective equipment is an international issue facing many countries during this global pandemic. Our stockpiles and planning have allowed us to deliver nearly 1bn pieces of protective equipment to the frontline so far. We continue to work around the clock to give the NHS and the wider social care sector the equipment they need.”

Denis Campbell Health policy editor

• The Guardian. Sun 19 Apr 2020 19.56 BST Last modified on Mon 20 Apr 2020 00.05 BST:
https://www.theguardian.com/society/2020/apr/19/hospital-leaders-hit-out-government-ppe-shortage-row-escalates-nhs

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NHS staff told ’wear aprons’ as protective gowns run out

Exclusive: U-turn on original guidelines of full-length waterproof gear for high-risk procedures.

NHS bosses have asked doctors and nurses to work without protective full-length gowns when treating Covid-19 patients, as hospitals came within hours of running out of supplies.

The guidance is a reversal of Public Health England (PHE) guidelines [2] stipulating that full-length waterproof surgical gowns, designed to stop coronavirus droplets getting into someone’s mouth or nose, should be worn for all high-risk hospital procedures.

In a significant U-turn, PHE advised frontline staff to wear a flimsy plastic apron with coveralls when gowns ran out, in a move that doctors and nurses fear may lead to more of them contracting the virus and ultimately putting lives at risk. The PHE announcement on Friday evening came shortly after the planned move was revealed by the Guardian. Meanwhile:

Nearly 15,000 people were confirmed to have died from coronavirus in UK hospitals, with the total rising by 847 on Friday to 14,576. After a peak of 980, fewer than 900 deaths have been recorded in hospitals for six days in a row.

Only 21,000 tests were carried out – some of them duplicates – putting the government far short of its goal of 100,000 a day by the end of the month.
The health secretary said Britain would restart tracing the contacts of people with coronavirus symptoms, having stopped in early March.

The government set up a vaccines taskforce to help the development, rapid production and introduction of a vaccine.

The government confirmed that 1bn items of personal protective equipment (PPE) were to have been delivered across the UK by this weekend – but hospitals and care homes continued to suffer shortages, in particular of gowns. More than 50 frontline healthcare workers have died amid fears a lack of PPE is leaving them exposed.

Prof Keith Willett, who has been leading NHS England’s response to the coronavirus crisis, helped formulate the new PHE guidance, which is being sent to all 217 trusts in England.

It sets out options for what frontline staff should do when they cannot access gowns. They include hospitals that still have gowns lending each other batches of them, wearing coveralls – one-piece items of personal protective equipment (PPE) that cover the whole body – and using plastic aprons as alternatives.

It confirms that wearing “disposable, non-fluid-repellent gowns/coveralls with a disposable plastic apron for high-risk settings and aerosol-generating procedures [such as intubation] with forearm washing once gown/coverall is removed” is one of the alternatives staff should deploy once gowns run out.

In total, PHE set out three alternatives to using the high-spec fluid-repellent gowns that are now in short supply.

The second of those also involves staff using “reusable (washable) surgical gowns/coveralls or similar suitable clothing (e.g. long-sleeved laboratory coat, long-sleeved patient gown, industrial coverall) with a disposable plastic apron for aerosol-generating procedures and high-risk settings with forearm washing once gown/coverall is removed”.

Under the third option, hospitals should conserve supplies of fluid-repellent gowns by using them only during aerosol-generating procedures and surgery.

A source had told the Guardian: “The new guidance will say ‘this is what you do if you don’t have any gowns’. Wear an apron instead – that will be the new policy for the foreseeable future, though the medical organisations will go mad about that.”

Gowns are vital for frontline staff dealing with Covid-positive patients because, alongside an FFP3 face mask, visor or goggles and two pairs of gloves, they make up the full PPE which PHE says is necessary to minimise the risk of infection from intubating patients being put on a ventilator.

Advising staff to use aprons instead of gowns carries the risk of a major confrontation with staff groups. The Royal College of Nursing last week made clear that nurses should refuse to treat patients if they were not happy that the level of PPE available would protect them properly. The British Medical Association, which represents doctors, has also warned that doctors’ lives are being put at risk by stocks of PPE having reached “dangerously low levels”.

Shortages of gowns in hospitals in England are far worse than Matt Hancock, the health secretary, has admitted, hospital bosses claim. “We are tight on gowns. That is the pressure point at the moment,” Hancock told MPs on the Commons health and social care select committee in an evidence session on Friday morning.

He said: “We have another 55,000 gowns arriving today and we’re working on the acquisition internationally of more gowns, but it is a challenge. This follows changing the guidance 10 days ago which increased the advice on the use of gowns but also said that they should be used for sessional use rather than for individual patient use ... And it is a big challenge delivering against that new guidance and we’re doing everything we possibly can.”

He could not guarantee that every hospital would have the supplies needed to tide it over this weekend.

Hancock had sought to reassure MPs by stressing that 55,000 more gowns were due to arrive on Friday. However, those equate to about eight hours’ supply because the NHS is currently using 150,000 gowns a day.

There were only “several tens of thousands” left in the NHS’s reserve stockpile, sources said on Friday. “Gowns have in effect already run out,” one said. “The situation is so serious that some trusts will run out today and others over the weekend.”

Ed Davey, the acting leader of the Liberal Democrats, warned that PHE’s downgrading of the advice on PPE could result in more lives lost. “Changing official guidance on protective equipment from gowns to aprons translates to increased risk to frontline staff, at a time when the death toll from Covid-19 is already rising for frontline workers. This is intolerable,” he said.

“The health secretary’s repeated reassurances the supply of protective kit for staff was under control now look totally threadbare. Matt Hancock should have been completely candid about the level of personal protective equipment but is now fast losing the public’s confidence as the reality of severe shortages becomes clear.”

At least 50 doctors, nurses, midwives, porters and other NHS staff have died from the coronavirus so far, the Guardian has established.

PHE is braced for a backlash from medical and nursing organisations. However, some senior figures in NHS England were “exasperated” about PHE’s earlier stipulation that staff in high-risk Covid-19 environments should wear full PPE, including a gown, and regarded that as “excessive”.

NHS leaders and Hancock have been desperately trying to find a solution to the lack of gowns since the Guardian first highlighted last week an internal memo from NHS bosses warning hospital chiefs that “there are no immediate stocks of gowns due in the national supply chain over the next few days and we are unsighted on when further deliveries will be made”.

More than a week later, they have been forced to draw up the controversial new guidance, which is a tacit admission that shortages are set to continue.

NHS Providers, which represents trusts, said hospitals would implement the new guidance. “The supply of clinical gowns is now critical, and it is now clear that some trusts will run out of fully fluid-repellent gowns,” it said.

Saffron Cordery, the organisation’s deputy chief executive, said: “Trusts and the National Strategic Reserve have very carefully managed the last remaining stock and trusts have helped each other wherever possible. They have used the remaining stock of coveralls as alternatives to gowns and have been deploying their gown stock very carefully.

“We understand the new recommendations … are aligned with World Health Organization guidance on the use of PPE when it is in short supply.

“Trust leaders will now implement this plan wherever needed and will therefore use the highest possible level of alternative protection equipment such as a fluid-retardant, as opposed to fluid-repellent, gown combined with an apron.”

The British Medical Association (BMA) said using aprons instead of gowns would increase the risks run by frontline staff. Dr Rob Harwood, chair of the BMA’s consultants committee, said: “The health and social care secretary admitted he couldn’t guarantee that supplies of gowns wouldn’t run out this weekend, and now this illustrates the dire situation that some doctors and healthcare workers are finding themselves in.

“If staff are now told to use aprons in the place of gowns, this directly contravenes the evidence and guidance from both Public Health England and the World Health Organization. Guidance that’s there to help keep healthcare workers and their patients out of harm’s way.

“Too many healthcare workers have already died. More doctors and their colleagues cannot be expected to put their own lives on the line in a bid to save others, and this new advice means they could be doing just that. It’s not a decision they should have to make.”

A spokesperson for the Department of Health and Social care said: “New clinical advice has been issued today to make sure that if there are shortages in one area, frontline staff know what PPE to wear instead to minimise risk. This has been reviewed by the Health and Safety Executive, and is in line with WHO and CDC guidance on PPE use in exceptional circumstances.”

Dr Susan Hopkins, the Covid-19 incident director for PHE, said: “The UK PPE guidance continues to recommend the highest level of protection for health and social care teams treating Covid-19 patients. PPE is currently a precious resource and it is crucial that everyone that needs it has access to the right protective equipment. That is why we have worked with the NHS and [Health and Safety Executive] to suggest ways that they can maximise the resources they have available.”

Denis Campbell Health policy editor

• The Guardian. Fri 17 Apr 2020 18.52 BST First published on Fri 17 Apr 2020 16.48 BST:
https://www.theguardian.com/world/2020/apr/17/nhs-staff-to-be-asked-to-treat-coronavirus-patients-without-gowns

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