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Good morning and welcome to my patient safety weekly email covering the US election result*, lockdown 2.0, nosocomial infections and staff safety alongside vaccine news. On the non-Covid side we also come back to maternity safety and how to get shot of lawyers after a fascinating select committee session on Tuesday. Interrogating the lockdown data I’m in no doubt that the Prime Minister had little choice but to introduce the second lockdown and wish it could have happened earlier. But that doesn't mean the data used to persuade the country was up to scratch, and the graph we all saw on Saturday suggesting 4,000 deaths a day was heavily criticised by me and other MPs at the Science and Technology Select Committee session with Sir Patrick Vallance and Chris Whitty. When we have so much more knowledge about the disease, get people into hospital more quickly and have treatments like dexamethasone why are we facing a daily death rate four times that in the Spring? Err it turns out the two key advisers to the PM don't think we are, as the very next slide demonstrated with daily hospital admissions projected to be just a quarter higher than the spring. Which rather begs the question as to why they showed the slide if not to frighten people, as Labour MP Graham Stringer challenged them. It turns out the 4,000 figure came from an Oxford/PHE study that itself had already been reduced by more up to date data. Bottom line: the case they were making was strong enough without needing this kind of overstatement. As ever the point was best made by Professor David Spiegelhalter. Nosocomial infection continue to rise. Charts published by SAGE last Friday show a spike at the start of October in the proportion of patients displaying symptoms more than 7 days after hospitalisation. When it is broken down by hospital the numbers are even more alarming with some hospitals having nearly half their patients as people thought to have picked up the virus on site. Overall the figure for the NHS appears to be 18% of COVID hospital patients having caught the virus at their hospital which is frankly shocking, especially when we got it down to virtually 0% in late August/early September. We could have been forgiven (perhaps) for not understanding the dangers of asymptomatic transmission in the Spring but we have no excuse now. And the only answer is... Weekly NHS Staff testing which despite repeated prodding from me, Chris Hopson, Sir John Bell and many others has still not happened. I called for it again in my question to the Prime Minister on Monday and although he wouldn't give me a date Sir Simon Stevens appeared to ride to the rescue on the Today programme (at about 0825) saying it would happen within 6 weeks according to a letter from Chris Whitty. That is good news to a degree...but means we will not have introduced it until after this second wave has peaked and how many lives will be lost as result? And it is not just outsiders who have been calling for this: SAGE said on 21st September that “regular testing of staff should be seen as a priority if infections continue to grow” and back in July Chris Whitty told the Health and Social Care Select Committee “If there was a big surge I would be absolutely in favour of going for regular testing, even in advance of knowing the optimal frequency.” An additional worry is that the brilliant Sarah Jane Marsh, who was coordinating the plans for NHS staff testing amongst other things, has now moved back to her day job so we have no idea who is in charge. Staff absences One concern about weekly testing is whether false positives might mean many staff wrongly told to self-isolate. False positive rates are now extremely low on PCR tests (less than 25 per hundred thousand according to John Bell) but this can always be addressed with a second confirmatory test. But the opposite problem is now happening: tens of thousands of NHS staff are off sick related to COVID-19 which could have been prevented with earlier testing and isolation. Some trusts are now on 40-50% staff absence. You get my point on staff testing? I will belt up. Wise use of lockdown There are other things we need to do during this lockdown period as I mentioned in my speech to parliament on Monday. The most important is to fix the contact tracing system: first get more people into the system (we’re only finding about 1/3 of those the ONS says gets the virus each week); then find their contacts more quickly (only 60% of contacts were found and less than half of in person tests got results back within 24 hours); and thirdly ensure more people isolate (currently only about 20% who need to are doing so). Biting the bullet by putting local authorities in the driving seat for contact tracing is one answer. Another is to pay the wages of people asked to isolate - far cheaper than picking up the pieces when they go on to infect many others. Finally, we need to spend the time building a mass population testing programme to be delivered by the spring. The trial of mass testing in Liverpool is very welcome but the light at the end of the tunnel would be a date to do this everywhere, every month. We are not actually that far off it - testing would need to be quadrupled from its current capacity, but we have already done that in the last three months. Full marks to the Tony Blair Institute for Global Change for identifying this as a way forward in an excellent report. To vax or not a very revealing session on the issue of vaccines and treatments. Kate Bingham, who chairs the UK's vaccine taskforce, told the Select Committee she was at least 50% confident that a vaccine would be approved and distributed to all vulnerable members of the population by Easter/early summer. Maternity safety Away from Coronavirus the Health and Social Care Select Committee held the second session of its inquiry into maternity safety. This focused on the impact that the current system of litigation has on safety, learning, and family experiences. Darren Smith, who sadly lost his son Isaac in 2012, told us in very moving testimony that he felt compelled to take legal action as it was the only way to secure an apology from the hospital. My biggest worry is that litigation has a chilling effect on doctors, making them nervous about speaking out openly in case what they say is used subsequently to prove clinical negligence. But without clinical negligence families do not get compensation - so they are driven into a highly adversarial showdown. There is a better way...and it is in Sweden, where Dr Pelle Gustafson explained their system offers candour, an explanation, an apology and compensation. Of 18,000 claims a year only 20-25 go to court and their neonatal death rates are half ours. If we could match them 1000 more babies would survive a year here. Two UK experts, Dr Jenny Vaughan and Dr Sonia MacLeod questioned whether the principal of tort law where you seek to apportion blame was appropriate for maternity cases and gave strong support for the Swedish model. Dr Sonia MacLeod suggested we look at New Zealand who have also had success on this front switching from a negligence based system to one that looks at avoidability. The time taken to deal with cases reduced from 5 months to 13 days when they made this switch meaning families got their explanations, apologies and compensation much quicker. Lots to take in from this session but clearly Sweden and New Zealand are models worth exploring more. Stat of the week 27,136 NHS staff were absent from work last week because of Coronavirus related issues. Jeremy Hunt *just kidding
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