11. Submission by Mr Stanton

Mr Stanton: My Lady, thank you for this opportunity to address you. I appear on behalf of the British Medical Association and the National Pharmacy Association. These organisations are represented separately and I will be delivering their submissions separately, starting with the British Medical Association, which I will refer to throughout as the BMA.

The BMA is a trade union and professional association that represents the interests of doctors in the UK. It has more than 176,000 members, which is over half of all registered doctors. This is the first time the BMA has sought to address you at a hearing and it does so now to emphasise the tremendous impact on the pandemic on doctors and their patients, to offer some observations on areas for inclusion within the scope Module 3., and to request clarification about the Inquiry’s intended approach in respect of issues that are common to multiple modules.

I would like to preface these submissions by making clear that the overwhelming priority of the BMA’s members is to ensure that they provide the best possible care and treatment for their patients. During the pandemic, doctors and other healthcare staff worked tirelessly to safeguard the nation’s health and care for those in need, often at great personal cost to their physical and mental health.

As you will be aware, the BMA conducted its own review into the pandemic and published its finding within five significant reports. The second report, published in May 2022, explores the impact of the pandemic on the medical profession and includes the following passages within the introduction. They read:

“At the beginning of 2020 the medical profession in the UK was struggling. Doctors were overworked and overstretched, with many considering leaving the Health Service altogether. Stress-related sickness absence rates were high and workforce planning was inadequate. The idea of having to work harder still and in more dangerous conditions seemed impossible, and yet that is exactly what doctors have had to do for the past two years since the Covid-19 pandemic arrived.

“The experience of the pandemic among medical professionals remains varied. Some have had their livelihoods affected, many their health, and most their morale. Each experience has been unique and, in some cases, influenced by their ethnicity, gender or disability status.

“There is one word, however, which is used repeatedly by the medical professionals to describe the last two years: devastating.

“Doctors have been left exhausted, demoralised and unwell. UK health services will never be quite the same. While we may be out of the acute phase of the pandemic, largely due to the successful roll-out of the national vaccination programme, doctors’ jobs are not becoming any easier, as they begin to address the mountain backlog of care. Burnout, exhaustion and poor mental health are therefore unlikely to improve overnight, and the intention to leave is high.

“Against this context, a key challenge for health services over the coming weeks, months and years is to ensure that there are enough staff to ensure every patient who needs help receives it promptly.”

My Lady, regarding the scope of Module 3, the BMA’s written submissions identifies some 45 issues for inclusion, and in the time available I will simply highlight four broad areas of concern that recur throughout the issues identified.

They are, first, resourcing capacity and staffing shortages. Prior to the pandemic, the UK’s public health and healthcare systems were understaffed and under-resourced and barely able to cope with pre-Covid levels of demand. Compared to many other OECD nations , the UK entering the pandemic with fewer doctors, hospital beds and critical care beds per 1,000 people, alongside high staff vacancy rates and frequently unsafe bed occupancy levels.

This lack of pre-pandemic resilience and preparedness exacerbated the severe disruption to healthcare delivery during the pandemic and resulted in calls for retired doctors and nurses to return to service, medical students joining the workforce early, and the use of volunteers.

Staff had to be redeployed, often starting new roles without training or adequate supervision. Many elective procedures, diagnostic tests and routine out-patient services were suspended so that staff resources and beds could be utilised for Covid-19 care.

For the BMA it is critical that there is an appreciation and understanding of the lack of capacity and resource within the NHS, public health and social care systems, and of the repeated failures to address the long-standing problem of staff recruitment and retention, which meant that the UK’s health systems were desperately under-prepared, with no spare capacity to deal with the pandemic.

Higher absences among healthcare workers due to Covid-19, self-isolation and Long Covid have compounded workforce shortages, which unsurprisingly impacted patient care and forced remaining staff to take on even more work.

The consequences of these failures are still impacting health services today and there are now over 8.9 million people in the UK on waiting lists for treatment. This figure is from September 2022.

In this context, we heard from counsel to the Inquiry that in March 2020 there were 5.3 million on waiting lists. That’s an almost doubling over the period of the pandemic.

Second, PPE and infection prevention and control. The lack of stock and supply of appropriate PPE to protect doctors and healthcare workers who were exposed to a deadly virus while treating patients is an appalling failure. Even now healthcare workers still do not have access to adequate PPE as a result of continuing inadequate infection prevention and control guidance.

In the early days of the pandemic, shockingly, doctors who purchased their own face masks were prevented from using them , and on some occasions even had them physically removed. Other doctors and healthcare workers were required to use bin bags as protective gowns, had to rely on homemade PPE, or were being offered expired masks, masks they had to reuse or masks that did not fit correctly.

This lack of protection had a profound impact on the medical workforce, including healthcare workers acquiring Covid or Long Covid, and a significant number are still affected now and limited in their ability to work.

Infection prevention and control guidance continues to fail to properly recognise the fact that Covid spreads via the air, and this means doctors and healthcare workers have not and are still not being provided with the right level of protection.

The third area is equalities issues. The BMA encourages the Inquiry to consider inequalities both in respect of the impact on patients and the health and social care worker force. Information collected by the BMA indicates that over 80 per cent of doctors who died of Covid-19 were from an ethnic minority background, and analysis by the Health Service journal made a similar finding, that 94 per cent of doctors who died up to April 2020 were from ethnic minority backgrounds.

In relation to patients, relevant equalities issues will include the impact of pre-existing inequalities on the health outcomes of patients, how inequalities impacted on people’s access to and experience of healthcare, for example, those living in areas of higher deprivation, the impact on people from ethnic minority groups, those without official immigration status, and people categorised as clinically extremely vulnerable.

Fourth area, health and safety issues. All employers are legally required to conduct suitable and sufficient risk assessments to identify risks to which employees are exposed and to identify steps to mitigate these risks and put them into practice. However, during the pandemic doctors and healthcare workers were subject to a catalogue of failures in this area, including the failure to carry out adequate risk assessments, working without adequate protection from infection, inadequate occupational health support, often as a result of lack of capacity, poor testing infrastructure and capacity, inadequate infection and prevention control policies, as highlighted earlier, and working within ageing estates ill-suited to modern needs and without proper ventilation.

Many of these health and safety failures will also be relevant to the Inquiry’s consideration of equalities issues, for example, whether adequate risk assessments would have prevented or mitigated the disproportionate impact of the pandemic on doctors and healthcare workers from an ethnic minority background.

My Lady, the breadth of scope of these issues just outlined means inevitably that the Inquiry will have to examine them across multiple modules and the BMA would be grateful for guidance and clarification from the Inquiry about its intended approach.

In saying this, the BMA fully appreciates the enormity of the task that is faced by you and your team and is in no way critical of the approach taken. The BMA fully appreciates the difficult task of balancing determination of scope, needing to consider sources of evidence against providing direction, and the observations I am about to make will hopefully feed into your considerations in this area.

Taking PPE as an example, which is an issue of various significant and ongoing concern within the medical profession, the clarification provided by counsel to the Inquiry about the extent to which PPE will be examined within Module 3 is welcomed and has provided BMA with some assurance in this area. However, you will be aware that the BMA has also proposed within its written submissions on Module 1 that the lack of adequate and suitable PPE stock and supply should be specifically included within the scope of Module 1 because it is so integral to the issues of resilience and preparedness.

The provisional outline of scope for Module 1 specifically includes consideration of whether lessons were learned from earlier simulations, and the Inquiry will be aware that the recommendations of the simulation exercises, Exercise Alice in 2016 and Exercise Cygnus, also in 2016, included a review of stocks of PPE, the need for pandemic stockpiles in order to ensure availability of sufficient and appropriate PPE, and the development of a whole system approach to the distribution of PPE to health and care staff.

In these circumstances, the BMA’s position is that there needs to be detailed consideration within Module 1 of the apparent failure to implement these recommendations and of the failure to ensure sufficient stock and supply of appropriate PPE more generally.

However, if it is not the intention of the Inquiry to examine these issues within Module 1 then the BMA would be grateful to understand at what stage it is envisaged the failure to ensure sufficient and appropriate stock and supply of PPE and the consequences of this failure will receive detailed consideration, for example, within Module 3 or within a later Government procurement and PPE module.

Similarly, on the issue of resourcing, capacity and staffing shortages, the BMA has noted the recent clarification within the note of counsel to the Inquiry of 14 February, and it has also noted the Inquiry’s earlier indications that Module 3 will investigate healthcare systems, governance and NHS backlogs, that staffing levels and the allocation of staff and resources are within scope, and that Module 3 will be a UK system module and will include consideration of the capacity of healthcare systems to respond to a pandemic.

Notwithstanding these helpful assurances, the BMA would still wish to make clear its position as an organisation that is expert in the delivery of healthcare and public health and one which represents the interests of over half of all practising doctors in the UK, that the lack of resource, capacity and staffing within health services prior to and during the pandemic meant that the adverse impact of the pandemic on patients, doctors and other healthcare workers was and continues to be more severe, including worse outcomes for patients and more serious physical and mental health impacts for doctors and other healthcare workers, than would have been the case had there been better resourcing, capacity and staffing.

The BMA considers that these issues are fully within the Inquiry’s terms of reference and also that they will require some consideration within Modules 1 and 2, because health systems were desperately under-prepared and had no spare capacity to deal with the pandemic and, to a significant degree, this necessitated the national lockdowns.

My Lady, those are the submissions on behalf of the BMA.

Lady Hallett: Thank you very much.

Mr Stanton: In respect of the National Pharmacy Association, which I will refer to as the NPA, the NPA is a not for profit membership body which represents the vast majority of independent community pharmacies in the UK. Community pharmacy is part of primary care, together with GPs, opticians and dentists, and it is most well known as a dispenser of medicines.

However, its role is much broader and includes other NHS and public services, for example the provision of health advice, including sexual health services, advice on substance misuse and travel medicines and health checks.

Community pharmacy also administers millions of flu vaccines every winter, the delivery of over 20 million Covid-19 vaccinations since 2021, and the provision of lateral flow tests.

The type of pharmacies represented by the NPA are family-owned, community-focused businesses, ranging from single outlets to regional chains, as distinct from national chains. Over 50,000 people, including approximately 15,000 pharmacists, work in the NPA’s approximately 5,500 member pharmacies.

The members of the NPA elect members to sit on the national board, with many NPA board members recognised nationally as leading clinical practitioners. The current NPA chair is an officer of the World Pharmacy Council, and other NPA sit on working groups of the NHS and the General Pharmaceutical Council.

Throughout the pandemic, community pharmacies demonstrated great resilience. They not only maintained the core service of the supply of medicines, which involves the supply of around 1 billion prescriptions every year, but they also increase the provision of expert medicines advice, with 98 per cent of community pharmacies reporting increased any enquiries about serious health conditions.

The NPA has collected extensive testimony from its members about the impact of Covid-19, and the following account is typical of the commitment, sacrifice and resilience of NPA members in the delivery of their essential services. It reads:

“My wife and I are co-owners of a single independent pharmacy. We are both pharmacists. When the pandemic hit, it occurred to us that if one of the team became ill or got Covid there was the potential for the whole team to go down and that would mean closure, leaving patients without medication, putting them in turmoil. Our big fear was letting people down. The solution we came up with to keep running and safe was to split the team in half. My wife led one half of the team while the other half of the team isolated at home. Whichever one of myself or my wife was working stayed in a hotel for that week. At the end of the week when I was working, I checked I was symptom-free before going home. Even then the family would go to a separate room and I would go straight to have a shower and put my clothes in a bag. Only then would I come down to the family. We’d spend a day together, then we’d swap. We did that for ten weeks. In 23 years of pharmacy, this has been the most challenging time of my career. It has also been the most rewarding. We’ve not let our patients down. We’ve come through it.”

However, despite this central role in the delivery of NHS care, community pharmacy was often overlooked during the pandemic and it was not given the support that it needed, including pharmacies initially having to source and fund their own PPE, with the NPA and others in the sector having to intervene to secure reimbursement of the cost. Pharmacy workers were not initially recognised as key workers so as to enable their children to attend school while they worked, which again required intervention from the NPA to rectify. There are delays in the provision of Covid test availability for pharmacy teams, which amplified resourcing challenges and, perhaps most inexplicably, community pharmacy was initially excluded from the scheme announced by the Department of Health and Social Care in April 2020 to pay £60,000 when a health or social care worker died from Covid-19 in the course of frontline work. It was only following challenge from the NPA that the scheme was extended to community pharmacy.

Regarding the scope of Module 3, the NPA has suggested within its written submissions over 20 issues including in the following broad areas. First, health inequalities and the needs of vulnerable patients. Here, the NPA suggests that this should include difficulties in accessing medication and the role played by community pharmacy in delivering medicines to large numbers of vulnerable patients in self-isolation.

Community pharmacies have unique insights into the challenges facing vulnerable patients because they are disproportionately located within deprived communities. They deliver health services to communities that need them most, and by doing so community pharmacies play an important role in reducing health inequalities.

In addition, over 50 per cent of the NPA’s membership are from an ethnic minority background, and the NPA as an organisation reflects the diverse background of its membership through a board composition that is generally representative, with eight out of 15 board members coming from an ethnic minority background.

Specific actions taken by the NPA around equalities issues include making the case to the Department of Health and Social Care and to NHS England in March 2020 for the delivery of medicines to vulnerable patients who were shielding. This subsequently led to community pharmacies delivering a significant scheme to support shielding patients through home delivery of their medicines, which required the employment and training of additional staff during the already extremely challenging circumstances of the pandemic.

The NPA also worked closely with the Home Office on the introduction of the Ask for ANI scheme, which gave victims of domestic abuse a way to seek help through their local pharmacy when other services were unavailable, which was voluntary and included providing access to private consultation rooms and undertaking additional training, again on top of already difficult and challenging working conditions, and it collaborated with charities and NHS England to provide Covid-19 vaccines to those with insecure NHS status, such as people without settled immigration status.

The NPA will also suggest in this area that there is consideration within Module 3 of the contribution made by community pharmacy and other primary care providers during the pandemic to the health and social capital of the communities they serve. For example, the extent to which their role as a hub of the community was enhanced during lockdowns when other social contact was unavailable.

The second area relevant to scope to highlight is the impact of medicine shortages and medicine price increases. NPA members had to overcome challenges in the medicine supply chain, including price rises and a shortage as the global medicine supply chain adjusted to the pandemic. There were also local supply challenges as large numbers of patients were transferred on to longer prescriptions, for example a three-month supply versus the previous usual one month’s supply which put acute pressure on supplies.

In Northern Ireland, the Northern Ireland Protocol led to additional difficulties in the sourcing and supply of medicines, including higher costs than in the rest of the UK.

The third area to highlight is the challenge that community pharmacy faced in responding to the pandemic in maintaining staff services following long-term underinvestment.

Here, the NPA suggests that Module 3 should include the circumstances in which pharmacy staff were required to work long hours in extreme conditions with inadequate PPE provision in order to maintain services, and how these conditions were exacerbated by staff needing to self-isolate and workforce shortages across the UK following the UK’s departure from the EU. In many cases the experience of working in these challenging conditions has given rise to stress, fatigue and mental health issues.

The UK’s community pharmacies were in the front line of efforts to limit the impact of corona virus and to keep people well and, as well as handling a massive increase in demand for healthcare advice and medicines, they also continued to provide urgent care and vital support to people with long-term medical conditions.

However, there are now very many at risk of closure due to underfunding and, when the Inquiry turns to its recommendations, the NPA would encourage you to consider how resilience can be built into future plans.

My Lady, those are the submissions on behalf of the NPA.

Lady Hallett: Thank you very much indeed Mr Stanton. Very helpful.

Mr Thomas. I’m sorry you have had to wait and your colleagues have had to wait so long to get on today.