Efficiency and effectiveness in a COVID-19 crisis, we need to do much better next time

This last 12 months has been somewhat disruptive for most people and businesses, in the true sense of the word. Many people in their daily lives, or companies trying to continue working, have had to embrace change. Some have done it just to survive but many have done it to try and help solve this crisis as quickly as possible.

At Cambridge Clinical Labs we decided early on that our experience and expertise could help provide valuable testing capability to support the UK Government. We were (and still are) a UKAS 15189 accredited clinical laboratory specializing in oncology and virology, listed alongside approximately 119 other accredited virology labs on the UKAS online register. In February, when the crisis really started to unfold, we, like many other labs in the same situation, tried to contact Public Health England, the NHS and other governmental bodies to offer our services. On the whole these offers were totally ignored. It was a very frustrating time for labs. The German response was very clear, to use as many labs as possible as quickly as possible. By the end of March they were doing up to 500,000 tests per week, we were struggling to do 100,000 per week. Germany had decided to go with a decentralised approach using as many suitable labs as possible throughout the country. This turned out to be very effective and very efficient. The UK’s approach, driven by Public Health England was to maintain a centralised approach to testing, under PHE, with only around 12 labs doing the testing. This was obviously frustrating the UK Government at the highest levels because it was clear that when Matt Hancock said we “would be doing 100,000 tests a day by the end of April”, this was not a wish but a challenge. So what was the UK’s response, bring in the other labs? No, far too obvious, let’s set up brand new “Lighthouse” labs to do mass testing. So yet again we will reinvent the wheel!, These labs “borrowed” equipment from existing academic and NHS labs, effectively preventing them from doing testing. They had to recruit staff, quite a lot from the labs they had appropriated the equipment from. They had to train the new staff, set up new processes and procedures, validate the testing and then start working at these “megalabs”. Clearly not the most effective or efficient way to get to mass testing in my and my colleagues opinions (I am not getting into the argument about significant financial contracts to a couple of diagnostic companies who were actually diagnostic manufacturers and not experienced at running clinical labs, that’s for a different day).

Meanwhile the rest of the labs were still fighting to get any attention. In April 2020 CCL joined the Covid Volunteer Testing Network. A group of self-minded labs who just wanted to help solve the testing crisis. Having critical mass worked well and by early May we had some DHSC contracts to help with Care home and outbreak testing and at CCL these are still in place (at least until the end of January), and then contracts were very short term and often renegotiated leaving gaps in service provision (which proved critical in the Care Home sector).

So, what happened early on and why was our response so poor? You can blame Government, but let’s try and identify whereabouts in this monolithic organisation the inefficiencies exist.

Most high-level politicians rely on information provided by the scientists on the various committees (Cobra, Sage etc). Fundamentally I have no issues with these. Scientists will always disagree with each other and consensus is sometimes a difficult thing to achieve, but overall, I don’t think we’ve done too badly in the science field in understanding this virus and its impact. Whether politicians have always followed that guidance is another thing, but they have to deal with lots of other consequences not just “following the science”. However, I will point the finger directly at one body – Public Health England. I personally believe their preparedness and response to this crisis has been abysmal, and let me justify that statement with some facts:

In Sept 2019 PHE published their “Strategy for 2020-2025”. Page 27, Section 6 is entitled “Effective responses to major incidents” and it states: Ambition -To ensure that the UK health protection system is integrated, resilient and able to prepare for and respond to all major hazards. Aims - a refreshed plan for handling an influenza pandemic. So where was the plan and where was the resilient response? – I would suggest nowhere to be seen.

The head of PHE at the time was Duncan Selbie who was appointed to the role on April 1st 2013 when it evolved from the Health Protection Agency. Reuters did a very nice article on the now Professor Selbie (not sure where the title came from as can’t see that he has any Science qualifications), see here. So where was he when all the others were behind the lecterns every day telling you what the plans were – noticeably absent. Reuters pointed out that when Prof Selbie was elected he joked that when he took his then ￡185,000-a-year job in 2013 that his public health credentials could be fitted “on a postage stamp”. But he was tasked with heading a government agency with a mission to prepare for and respond to public health emergencies. PHE will now be wound down and replaced, meanwhile Duncan Selbie has a now been elected as the next president of the IANPHI (International Association of National Public Health Institutes). Clearly this agency was neither prepared for or had a resilient response to the COVID-19 pandemic. You have to have an organisation that is fit for purpose and has the quality of staff in place who CAN make decisions to save your, and everyone else’s life.

Now let’s move onto more recent events – vaccines and vaccinations. Luckily the vaccine development and manufacture has all been done by experienced commercial companies but with regulatory oversight, if somewhat fast tracked. However, the situation which arose regarding who is eligible for giving vaccinations was the perfect example of bureaucracy over common sense. Individuals, such as retired doctors and dentists, were required to complete 18-10 online courses before they would be authorized to give vaccinations (see here), some of them completely unsuitable for the task in hand, such as “preventing Terrorism”. Why was this allowed to happen and has anything been done about it? Who in their right mind would not look to come up with the slickest, quickest authorization process? You literally cannot make this up!

The “Government” in the broader sense of the word believed that the UK had a poor diagnostic industry, they stated that in news bulletins. They did not seem to be able to clearly differentiate between testing labs, diagnostic manufacturers and pharmaceutical manufacturers. They only saw PHE, NHS and Academic labs doing testing, they ignored other commercial labs. They employed diagnostic manufacturers ad pharmaceutical companies to set up new labs, totally ignoring the obvious existing academic and private labs capabilities. Was this under the counter deals or just incompetence, maybe the post Covid investigations which are undoubtably coming may answer that question.

You can also start to ask other questions: With such a vast civil service why were so many consultants brought in to help, such as those from Deloittes and KPMG? Was it as some have suggested “jobs for the boys” or basically that we need better people with better skills managing our extensive bureaucratic processes?

The Government also utilized the armed forces, especially when logistics were a problem, for example for NHS PPE shipments and now for the role out of vaccines. That can’t be a ”jobs for the boys” situation but it is clear that our Civil Service and other government agencies just cannot cope in a crisis. You could ask why weren’t the forces automatically brought in as part of the pre-planned response as they are the specialists in a crisis? It constantly felt that Government were being reactive to developing mini-crises with little forward planning.

So where does that take us for the future? It is obvious to most of us who work in this field that COVID-21 could be just around the corner or it could be TB-23 or Ebola-24 or potentially many others. We do need to be much better prepared, with a real plan for action to mobilise against a naturally occurring epidemic or pandemic but also against a potential infectious bio-warfare attack against the UK. The response would need to be very similar. We need to have an effective and efficient response next time, not shackled by ludicrous bureaucracy. It needs to be efficient and effective. We need to learn from our mistakes this time and not repeat them. I’m not looking to proportion blame but identifying areas for vast improvement, and I personally think that it should be driven by the commercial and scientific communities, not bureaucratic government agencies.

I want to start a discussion and I look forward to your comments