Living on Plague Island

My previous post – It’s airborne – response to Minister for Public Health discussed the impasse in making headway in improving the safety of air in hospitals and other healthcare settings in order to reduce staff sickness and the number of people who get infected, sometimes dying, attending healthcare. The following quote sums up the situation.
IPC say that it’s not airborne, but if it was we would need to wear FFP3 masks. UKHSA say it’s airborne, but that FFP3’s don’t work (they do actually). This era is supposedly one of evidence based medicine!

Since then various strands of activity aimed at trying to achieve change to the IPC (Infection, Prevention and Control) guidance have rumbled on, admittedly without positive results so far.

Firstly we have a new Minister for public health. On 10 February, Ashley Dalton, was appointed to replace Andrew Gwynne who had been sacked. The new Minister has been in post for nearly a month and, at least so far, shows no signs of taking a different line from the previous Minister.

There has also been some continuing correspondence on efforts to try to get those in authority or those with leverage (eg the Covid Inquiry) to take action on air quality issues in healthcare settings (and elsewhere). The rest of this short blog attempts to briefly summarise these developments. Finally there are short updates on the latest evidence on masks and on the potential impacts of turmoil in the organisation of the centre of government.

Air Quality in Healthcare settings – CATA representations

CATA (Covid Airborne Transmission Alliance ) are key advocates on the need for clean air and were core participants in module 3 of the Covid Inquiry. Following various correspondence, Dr Barry Jones on behalf of CATA published a sign off statement and a letter sent to the Covid Inquiry. Then on 3 March the final written submission of CATA ) to the Covid Inquiry module 3 was published on the Inquiry website. The key points can be summarised as follows:

• there is an urgent need for change to the Infection Prevention and Control guidance given that the existing IPC structure has shown itself to be insular, based on outdated science and highly resistant to outside expertise and multidisciplinary working.
• We need an  immediate review by a competent, inclusive and multidisciplinary panel.
• This needs to be transparent and accountable and it is crucial that that  this is  independent and supervised by the HSE.
• CATA argue that the UK needs a governance structure that enables expert professional groups and those most affected in healthcare settings to ensure that on-going decision-making at all levels is in line with actual professional practice conditions and technical and scientific standards applicable to each healthcare discipline and context.
• Robust guidelines are needed on the use of the precautionary principle where there is scientific uncertainty. This was discussed in module three of the Inquiry and had it been adopted would have meant that those responsible for policy would have been required to assume that Covid was airborne and that aerosol transmission was occurring, until it was proven that transmission was not via the aerosol route. This would have meant the adoption of appropriate protective measures eg FFP3’s, power hoods etc that would in reality have saved many lives. The precautionary principle is further discussed in a recent article by Blake Murdoch.

In parallel to this there has been a flurry of activity in response to CATA’s letter of October 2024 to the Chief Nursing Officers across the four nations which raised a number of issues about the claim that the IPC manuals “are subject to continuous review based on the latest evidence on the whole range of infectious diseases”. The letter also raised issues around the failure to ensure that the IPC guidance is based on the latest scientific evidence making the point that the ‘IPC guidance will never be satisfactory so long as it describes surgical masks as “Personal Protective Equipment”.

A reply was received last month which essentially parks all considerations of the case for change until the Covid Inquiry produces its report in next year. This is currently scheduled for 2026 but given that the module 2 report is already six months late I think we need to anticipate delays in both the module 3 report and the final report.

CATA sent a response to the four nations group on 4 March pointing out the inaccuracies of what they claim and ending with the following key hard hitting final paragraph.

Masks work

In addition to good quality air, the use of respirators (masks) is also a key way of keeping safe whilst attending healthcare. A recently published (27 February in the BMJ) paper provides the definitive evidence on the effectiveness of good quality masks. In contrast to the line taken by some officials during module 3 of the Covid Inquiry hearings, this confirms previous robust evidence demonstrating that good quality masks work. However, it adds that they must be continuously worn to be protective. Key points include:

• New research in aerosol science confirms the risk of infection is widespread in health facilities;
• Most guidelines assume risk is only present during close contact or aerosol generating procedures, but studies show intermittent use of respirators is not protective;
• Community use of N95 respirators is more protective than surgical masks, which are more protective than cloth masks, but even cloth masks provide some protection;
• Mask guidelines should be adaptable to the specific context and should account for rising epidemic activity, and whether a pathogen has asymptomatic transmission;
• The main rationale for universal masking during pandemics is asymptomatic transmission, which means risks of transmission cannot be self-identified;
• The precautionary principle should be applied during serious emerging infections or pandemics when transmission mode is not fully understood, or vaccines and drugs are not available. 

These messages clearly need to be acted on in hospitals and healthcare (and other indoor settings) now, as well as being central to planning for a future pandemic.

Turmoil at the Centre

The developments discussed above have taken place alongside major changes in personnel involved in health policy and the NHS as it has become increasingly clear that the new labour government wishes to exercise far greater direct control over the NHS – thus reversing the changes introduced by the previous regime in 2012.

It has been announced that Amanda Pritchard will be stepping down as head of NHS England and will be replaced on an interim basis by Jim Mackey. And in other developments the Medical Director of NHS England, Stephen Powis, will be stepping down from his role as Medical Director and is expected to be followed by many of the senior staff in a major cull.

This all comes soon after it was announced that Dame Jenny Harries will be stepping down from her position as Head of the UKHSA (UK Health and Security Agency).

All of this is happening whilst the government is in the process of appointing a new permanent secretary at the Department of Health and Social Care following the promotion of Sir Chris Wormald to Cabinet Secretary.

It is difficult to work out what all this means for efforts to make healthcare (and other settings) safer. On an optimistic note it might be good news because most of the people currently in post were there at the height of the pandemic and may be fearful of owning up to the mistakes made on airborne transmission and other matters at the time.

On this sunny spring day I would like to be optimistic and think that the arrival of new brooms with a focus on delivery, will lead to a genuine reassessment of what is holding back the NHS and an assessment of the reasons behind high demand for primary health care, and high levels of staff sickness, along with delays in discharge from hospitals due to nosocomial infections and why a section of the population are fearful of attending healthcare. Ideally it will provide an opportunity to look forward and consider what would make healthcare safer for everyone, including patients and staff and deliver savings in terms of reducing demand for healthcare and reducing the length of stays, reducing staff absences and improving productivity – in other words all things that could be helped by cleaner indoor air and other safety measures in healthcare settings .

On this optimistic note I will sign off on this topic until there are further developments.

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Gillian Smith

11 March 2025