Dr Sandesh Gulhane discusses results from our COVID-19 survey focusing on concerns about shortages of personal protective equipment and how they are affecting the care provided to patients
PPE, FFP2, FFP3.
If I had asked you what all this meant during the fledgling, innocent start to 2020 most people would have wondered if it was an anagram; now almost everybody is an expert. There was controversy surrounding personal protective equipment (PPE) from the very start of this pandemic. Out-of-date stock was being distributed with the original date concealed under an updated sticker. This was questioned and we were then told that this stock had been tested but further details of the test and evidence have not been seen. There has also been a lot written recently about the inadequacy of the PPE on offer to GPs and non-COVID wards. There has never been hair/head protection and the quality of the available eye protection has been poor. A cough could easily cause virus particles to land in your eye. There were no gowns offering full protection but instead a plastic apron that would not look out of place for serving food. The quantity of PPE was also a problem, with many healthcare professionals stating they had not received any supplies at all. The logistics were handed over to the military and supplies began to come in but there are still clear supply issues.
This article reports on a far-reaching and ground-breaking survey, conducted across the UK by Guidelines in Practice, asking primary care healthcare professionals about their experiences now that we appear to have passed the peak of the disease.
The most shocking finding of this survey was discovering that even at this point in the pandemic we are still not supplying our staff with enough PPE:
- 30% of respondents were lacking basic fluid-resistant masks. We have been told that these masks are adequate for non-aerosol generating procedures; our past experience makes us sceptical about this but there are not enough filtering face-piece (FFP) 3 masks available and priority must go to those who carry out aerosol generating procedures
- eye protection is a serious issue—33% of respondents were lacking surgical masks with integrated visors; 32% were lacking full-face shields/visors; and 21% were lacking safety spectacles. In general practice we cannot control if a child coughs into our faces, especially if we are looking down their throat. Pre-COVID I have also had adults cough in my face. We need eye protection that protects us from this and the flimsy spectacles handed out simply do not work
- 7% were lacking aprons but as already discussed, whether these actually provide any additional protection is questionable
- 3% did not have gloves. This is an absolute basic requirement and running out of gloves confers risks from any procedure.
At this stage in the pandemic I would have expected supply chains to be established and this basic PPE to be provided.
This lack of PPE has driven a fundamental change in the way general practice is working. There has been a switch to telephone and video consultations to protect staff from being exposed to COVID-19. This also allows for preservation of low stocks of PPE but the survey results highlight there is widespread concern (over 80% respondents) that remote working could lead to missing serious disease. There has also been a change to the type of work we are doing. The survey found that most practices (75%) are able to deliver 6-week baby checks but many are combining these with immunisations to reduce contact.
Around 70% of respondents felt that medication reviews were sufficiently resourced and achievable—perhaps because most can be adequately done over the phone. The areas that respondents felt were not adequately resourced were mental health and review of chronic conditions. Ninety percent of survey respondents reported concerns that, due to this lack of resource, we will see a deterioration in patients with chronic health conditions and a significant impact on the mental health of patients that will last for years after this pandemic is over. Furthermore, over 80% of respondents were concerned that serious disease is being missed in primary care by delayed patient presentation.
It is also clear that the mental health of staff is going to be affected and there has already been a drive to invest in services to help. This is borne out in the survey with 77% of respondents moderately or very concerned about the impact on the mental health of healthcare professionals. Healthcare professionals have families, loved ones, and friends so it is not surprising that 68% were moderately or very concerned about the risks posed to them and their families. I have recently written an article explaining that I am myself scared and wondering if I am unique in this1 but the results from this survey show that I am not alone.
There is currently an ongoing debate between Public Health England (PHE) and the Resuscitation Council about whether cardiopulmonary resuscitation (CPR) is an aerosol-generating procedure; PHE says it is not an aerosol-generating procedure and trusts can choose what to do but the Resuscitation Council says that it is, and recommends that Level 3 PPE should be donned before undertaking chest compressions.2 At the heart of this debate is the issue of PPE. We have seen from the survey that there is still an inadequate supply and if CPR is deemed an aerosol-generating procedure then full PPE is required, which is simply not available and would take up to 15 minutes to put on correctly. We have heard accusations from Panorama that the severity of the coronavirus was downgraded not because of the science but because of the availability of PPE or lack thereof.3 To qualify as a GP we need to prove that we have undergone an accredited course by the Resuscitation Council; this would lead us to believe they know what they are talking about.
Doctors and nurses go to work every day to help heal the sick and care for the dying. During this pandemic they are risking their very lives to continue working and some have paid the ultimate price for their dedication and have died. We have resorted to asking schools, local businesses, and family to help provide protective equipment to allow us to save others’ lives. This is a disgraceful situation and things must change. We do not want a medal, we don’t want people clapping for us, we want to feel safe going to work and to minimise our risk of dying.
- Gulhane S. Coronavirus: I am scared. View from the ground. Guidelines in Practice, 30 April 2020. Available at: www.guidelinesinpractice.co.uk/your-practice/coronavirus-i-am-scared/455279.article
- Resuscitation Council UK. RCUK Statement on PHE PPE Guidance. RCUK, April 2020. www.resus.org.uk/media/statements/resuscitation-council-uk-statements-on-covid-19-coronavirus-cpr-and-resuscitation/statement-on-phe-ppe-guidance/ (accessed 13 May 2020).
- BBC website. Panorama: has the Government failed the NHS? BBC, 27 April 2020. www.bbc.co.uk/iplayer/episode/m000hr3y/panorama-has-the-government-failed-the-nhs