A Duty of Care?

Readers may have noticed that I get irritated rather easily. The latest object of my ire is the journalists who ask such dumb questions at the government's daily press briefings. This leaves me with some sympathy for the two stooges either side of the minister of the day, who are there partly to show the  government is "following the science" when they mean they are paying attention to what the particular scientists they have appointed are telling them, there often being a range of views in the scientific community on any particular issue that hasn't yet been fully understood (and even sometimes when it has). Not to say that's an unreasonable approach. After all you pick the "right" people for the jobs and then you can ask them questions: you don't necessarily take their advice at face value.

So back to those journalists questions. Why so irritating? I suppose because the answer is often either obvious or can't possibly be known yet. The particular case in point over the last couple of days has been the hoo-ha over the numbers of deaths in care homes and the community.  Under pressure, yesterday's medical stooge said that the aim was to try to get the ONS data for all deaths reported on a more timely basis. I'm not sure this would be the best use of resources. After all, deaths in the community are reported at varying times after the date of death depending when the death certificate is registered. Unless or until you set up a totally new method for collecting it from doctors instead of registrars. So any attempt to gather data on a daily basis will fail and will be subject to retrospective correction.Which brings me to the other point. While the total number of deaths is important and each one represents a loss to a family, the thing that matters for government policy and decision making is the trend. As around 90%* of the covid-19 deaths are occurring in hospitals you don't need the precise daily total to take decisions, especially since the whole approach is based on the capacity of the NHS to cope. Therefore it is hospital admissions and intensive care load factor that matters, not the total number of deaths.
        *Though in Scotland it seems it's different - 25% of fatalities have been in care homes and 13% in the broader community

For the decision about whether to tighten or release restrictions it doesn't matter a jot whether our data directly compares with that of France, for example. What matters is that our data is consistent. The relevant comparison with other countries is the gradient of the curve, not whether we are above or below France or Italy at the same stage as the data will inevitably have been gathered in a different way and small differences in the totals will be meaningless.

I imagine it has been drummed into the various ministers and experts not to say that, at least not in that way, as they would then be panned for appearing heartless and implying that the other deaths "don't matter".  But, as even hospital deaths are not always reported promptly, especially at weekends (we learned the other day that a death on a Sunday might not, in some cases, be reported until the Wednesday) I have been wondering for some time why they don't use a rolling three day total to smooth out these reporting timing issues. I guess that, behind the scenes, there are lots more graphs which ministers see. They may feel that anything other than the simplest presentation is beyond public comprehension, but that swaps one problem for another. And even smoothie "dishy" Rishi Sunak with his excellent presentational skills seemed, to my ears, to get tangled over a statistic yesterday. I suspect he read out something from the autocue that he hadn't challenged because, as he said it, it made no sense, referring to the cumulative total of hospital deaths so far being part of the now falling number of patients currently in hospitals.

So am I saying the deaths in care homes don't matter? No I'm not, but I'm wondering why these issues weren't raised by the journalists three or four weeks ago if they care so much about it. Any readers (and I know there are several) who have or have had elderly relatives in a care home or who require care at home will no doubt like me have thought about how difficult things will be for those vulnerable folk. And also for the now almost equally vulnerable people looking after them if the people in their care get covid-19.

So I'm not going to accept that the world has just woken up to this issue. My now departed uncle, before he briefly went into a nursing home, had carers coming in to his house several times a day for an extended period. Before we went into lockdown I said to Mrs H "Roy would have been a sitting duck" because there was a rotating cast of carers and social distancing isn't possible in the context of personal care.

If you were going to fully "shield" these people their carers would have to have been in isolation with them. Some folk caring for a family member have done exactly that but in general it is not a practicable approach. In a care home context staff would have had to live in, where there was accommodation available, or be isolated by some other means. Probably not practicable to any degree. And surely that is the test: to use the phrase from health and safety legislation what is "reasonably practicable" a phrase which, in such law, implies a prior assessment of the risk and the costs of potential mitigations.

Mrs H and I are grateful that our relatives did not live long enough to experience the stress of this situation. I can't imagine trying to reassure a person with dementia who, confronted with a carer in a face mask, becomes startled. Which, in many cases doesn't just mean frightened but violent. We were always grateful for the care provided by the staff at various care homes, working under considerable difficulty even under normal, pre-covid-19 conditions. To expect them to do any more than the best they can in theses circumstances would be unreasonable. This is a disease that has much higher potential for old people than the young (aren't we relieved it's not the converse?) and it was obvious from the outset that there will be a heavy toll in care homes. The average length of stay in a residential care home before the usual one way ticket out in a wooden cardigan (a phrase we learned from a nurse at such a home) used to be about 15 months. It will be shorter for nursing homes. There is a reason: the individuals are generally very old, frail and more likely than not they have dementia at least to some degree (after all, everyone with marbles tries the damnedest to stay out of one). Many of those people have an extremely poor quality of life and would not live for very long. I struggled at the outset to see what could be done to protect care homes - and I still do. I salute those who work there and, personally, I would not expect them to take unreasonable risks with their own health, which might mean scaling back normal standards of care.

One of the problems for care homes is protective equipment, where the government is struggling with the problems of scale, which will be familiar to many engineers especially those with a process industry background. Just because you can do something doesn't mean you can do it on a hundred or a thousand times larger scale, at least not like clicking your fingers. PPE now needs to be distributed to 58,000 locations instead of two hundred odd hospital trusts. With hindsight the contingency stocks should have been held more widely across the country and probably at many of the locations were they are now needed. Perhaps this requirement, stemming from the speed of progression of the outbreak, should have been identified in advance. Quite possibly it was but it was but on risk grounds it wasn't thought necessary.

Of course, while the government is the means of last resort here, the care homes are privately run. We will learn in time whether they decided they needed contingency supplies of PPE and other equipment. After all it wasn't just governments who were warned about possible pandemics.  And these concerns aren't new. In the 1990s the concern was avian, or bird, flu - H5N1 I think. The directors of the company I worked for became convinced that this risk was sufficiently real to hold large contingency stocks of tissues and handwash. This wasn't just out of concern for employees: they saw a potential commercial advantage if the company could come through an outbreak in better shape than competitors. "Those who aren't ready will go bust" I can remember being told as we got swamped with supplies for which we had to find storage. A year or two later we were told to run down the stocks, which saved us having to worry about those that had been filched, or just diverted into use as normal supplies. And therein lies part of the problem: checking that stocks are still there, in good condition etc would have to be done. Perhaps care homes could and should have had adequate supplies for several weeks, though such provisions of materiel aren't necessary for a standard flu outbreak.

Which leads us to preparedness and the exercise to check out NHS readiness called Cygnus and run in 2016 by Imperial College (yes, those guys again). The NHS reportedly "failed" this test, which is not as damning as the journos make out. Such exercises are usually failed, the reason you do them is to identify weaknesses. I am reminded of my time in the nuclear industry where we had big emergency exercises on each nuclear licensed site, witnessed by observers from the regulator, on an annual basis. The year I had charge of a team and facility with two baby nuclear reactors I was committed to being at another site on the day, about which I wasn't too unhappy as the exercise was going to be based on a hypothetical incident in our building, one of many on the site, which would have meant all sorts of restrictions on the working day. Some of my people would have taken part in the exercise, run by the site management. So when I got back to the office the next morning I asked my PA, a redoubtable and highly competent lady, how the exercise had gone, expecting she would have some idea, if only from gossip. "Not too well" she said "two people died". I chuckled and said that I hoped these were imaginary casualties in the exercise and not for real. She looked briefly worried and said she wasn't sure. I laughed louder and said "I think I'd have heard if they were real but you'd better get Malcolm (who was my safety officer) round to tell me about it". It was indeed the case that two of my chaps had been handed cards during the exercise saying, effectively, "you're dead, sit there and shut up".

The team in charge of the emergency response, working from a building a couple hundred yards away had struggled to identify what scenario was unfolding based on the alarms they had been told had gone off and other indications. They never got to grips with the incident in which a fork lift truck driver had suffered a theoretical heart attack, ramming a drum containing lightly radioactive liquid which had set off the alarms and led to the building being evacuated. A person in protective gear was sent in. He was given a card which said "a drum has fallen on you - you're dead" and the fork lift driver was then told he had expired before help arrived. Meanwhile the incident controllers struggled with whether to send in more rescuers, potentially exposing them to risk, and were given more information which was deliberately confusing. Time was called before they understood what had supposedly happened. Lessons were learned - that was the whole point. I never saw an exercise in which they weren't, even if the conclusion was that the incident had been handled well.

So I draw no particular conclusion from the fact that the NHS failed Exercise Cygnus. The correct question is what was done to follow up. Which might mean actual actions being taken but in some cases might involve assessment and judgements that the necessary actions aren't cost effective given the risk. Some reports say the exercise was "ignored", though that can't be the case as there is also evidence that various authorities did take some action as a result of the exercise. And it's not automatically the Health Secretary (at the time it was Jeremy Hunt) who is to blame if the NHS did ignore it as the NHS, at least in principle, was given operational independence about 8 years ago, a bit like the Bank of England was given by Gordon Brown in 1997. Which hasn't freed it from political interference of course. But all this is for later, there are more important things to be doing right now.

I think I'd start by inviting journalists not to try to get the government to compromise the quality of the data it is getting by changing the basis for it in mid air. I'm not sure yet how well the government is doing - for the most part getting an act together after a slow start in January and February I feel - but I think the journalists are having a nightmare. My number one target - Hugh Pym of the BBC who was clearly given a low profile job that wouldn't lead to much exposure because he wasn't up to economics, politics or foreign affairs. None of which would matter if it wasn't always the Beeb whom they invite to ask the first question. Why?

PS Pym and the BBC asked first again tonight of course. Hancock did ok, journos not as bad as on some days. I'd have preferred more frankness on some points but he knows that would lead to a media storm.