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The waiting game

Public Health England to release updated PPE guidance later this week

Public Health England is working on updating its guidance on the use of personal protective equipment (PPE) and is expecting to publish the results later this week, Pulse has learned.

The latest guidance says GPs should wear PPE within one metre of patients with possible or confirmed coronavirus (Covid-19) - but this only applies to patients who are symptomatic, meaning GPs are not advised to wear PPE for patients who are asymptomatic. 

The BMA has sought clarification from the Government on what risk doctors are expected to take when caring for patients without adequate PPE, saying they are still receiving widespread reports from doctors around the country who have not received PPE, or who do not feel the PPE they have received offers sufficient protection.

One LMC has told members to implement a 'no PPE, no see' policy for all patients.

The recommended PPE is a fluid repellent facemask, apron, gloves and eye protection 'if there is a risk of splashing or exposure to respiratory droplets', NHS England, Public Health England (PHE) and the Academy of Medical Royal Colleges said in a letter sent to practices, PCNs and trusts at the weekend.

The letter added that although there had been 'some issues' with the supply of PPE, NHS England, PHE and the Academy of Medical Royal Colleges are 'confident' that those who need PPE will be supplied with 'adequate' stock 'in good time'.

But, quoting communities secretary Robert Jenrick, who said on Sunday that ‘we cannot and should not ask healthcare workers to be on the frontline without appropriate protective equipment', the BMA has urgently sought clarification on the current guidance.

BMA consultants committee chair Dr Rob Harwood, said: 'We need clarity from the Government on what it is that healthcare staff should do and, particularly, what risks they should not have to take if they do not have adequate PPE, if they should find themselves in this situation.

'This is about the safety of patients and doctors first and foremost. Doctors are placing themselves at significant risk by treating patients on the frontline and there are concerns that sometimes this is without adequate PPE.'

Dr Yvonne Doyle, medical director at PHE, said: ‘In response to NHS staff feedback about their personal protective equipment, the Department of Health and Social Care; PHE and NHS England and NHS Improvement have looked again at the guidance.

‘Now that Covid-19 is much more widespread, we will carry out a rapid piece of work ensuring the guidance is clearer on which PPE should be worn in different NHS settings.'

‘The Academy of Medical Royal Colleges will support this urgent work.’

A PHE spokesperson told Pulse new guidance was expected later this week. 

In the meantime, some GP leaders have taken matters into their own hands and recommended their colleagues to avoid seeing any patients without PPE.

Berkshire, Buckinghamshire and Oxfordshire LMCs said in a communication to practices: ‘We continue to press centrally for appropriate PPE for all practices. In the meantime, in the absence of appropriate PPE, we support practices in adopting a NO PPE, NO SEE policy and not conducting any face to face consultations without appropriate PPE.’

LMCs chief executive Dr Matt Mayer continued: ‘We draw constituents’ attention to recently published BMA Ethics guidance on PPE8 which makes it clear GPs are under no obligation to risk their own safety and says:

‘There are limits to the risks you can be expected to expose yourself to. You are not under a binding obligation to provide high-risk services where your employer does not provide appropriate safety and protection.’

And more than 20,000 people in three days have signed a petition launched by doctors' wellbeing lobby group EveryDoctor, urging the Prime Minister that ‘every NHS worker, from surgeons to nurses, GPs to paramedics’ needs adequate protection. 

Dr Julia Patterson, who leads EveryDoctor, said: ‘We are not satisfied with the PPE guidelines set out by NHS England and NHS Improvement, Public Health England and the Academy of Medical Royal Colleges on 28.03.2020.

‘The guidance being issued by these bodies does not meet WHO recommendations.’

The Government has been criticised for failing to act fast enought to secure PPE for the NHS frontline battling the coronavirus pandemic.

Global demand for PPE and a ban on export of the products in China is causing constraints on securing additional UK supplies, the Department of Health and Social Care has said.

Yesterday, the Government released a service specification for manufacturers who believe they can provide PPE

The technical specifications differentiate between guidance for examination gloves; gowns; surgical face masks; respirator masks and eye protection.

They come as companies including Mercedes, JCB and Dyson have joined the work to try to meet the UK's impending demand for ventilators and CPAP breathing aids for hospitalised Covid-19 patients.

Current PPE recommendations

Recommended PPE to be used by healthcare workers within one metre of a patient with possible or confirmed COVID-19, including staff working in hospitals, primary care, ambulance trusts, community care settings, care homes:

• fluid repellent facemask

• apron

• gloves

• eye protection if there is a risk of splashing or exposure to respiratory droplets.

Source: NHS England's 28 March letter to practices

Readers' comments (15)

  • Good old nhs england... operating at the speed of light. It's simple adopt the WHO guidelines and get us the proper protection.

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  • Eye protection if there’s a risk of respiratory droplet exposure - well that’s all patients isn’t it?

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  • PPE or not PPE?

    Attempts at blanket testing (Diamond Princess, Vo'Euganeo) suggest over 50% are asymptomatic at point of testing and most of these remain so.
    9.5% of all Italian diagnosed COVID patients are healthcare workers.
    Currently available community prevalence data is hopelessly inaccurate, and actual mortality rate for young patients with no risk factors is likely well below 1%, although several fold more may need ICU care.
    Currently we are told 1 in 4 doctors are absent from work in the UK, mostly due to suspected/dubious household contact for 14 days, therefore unlikely to result in immunity.
    Until this pandemic is beaten (there is no mapped out long term end game in China or elsewhere), then even with ongoing lockdowns, unless PPE is worn 24 hours a day, key workers will have ongoing exposure to positive cold patients and colleagues - half of whom will be asymptomatic.
    Therefore many will eventually contract the virus at some point whether or not PPE is worn in clinical situations, until key worker herd immunity is achieved.
    Half of these contracted cases will have no symptoms and go on working (unless high frequency testing of asymptomatic key workers is introduced) and become immune.
    Most of the other symptomatic half will only be off for one 7 day period (according to UK guidance) after which they will also be immune and return to workforce.
    If exposure is limited to key workers under 50 with no risk factors only a very small number will develop complicated COVID. However, this unfortunate group is probably destined to contract COVID at some point anyway in any other scenario if we accept there are high rates of asymptomatic spreaders.
    This key worker herd immunity will then help protect older key workers who will adhere to strict PPE throughout.
    In the absence of a vaccine, and IF serological data back up that large scale asymptomatic herd immunity is already happening in healthcare workers, then it appears rational for low risk key workers who are cohort caring for COVID-19 patients to be exposed in an unfettered manner. There would be no real benefit in flattening this key worker curve if it means half will be off work for 7 days once versus one quarter off for 14 days again and again.
    I accept that this view would be unacceptable to the workforce and indeed employers and their lawyers, but it is the conclusion the current facts (subject to change) appear to support. Although anecdotal concerns remain over whether initial viral doses encountered during high risk clinical exposure somehow result in disproportionately worse outcomes.

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  • Its time that PHE and NHSE stopped making up "guidelines" based on what equipment is available, rather than what is necessary without supplying any evidence base.

    Even their own guidelines for the same healthcare workers with the same virus a few weeks ago recommended much more stringent PPE.
    Lets be honest, the virus hasn't got any less virulent has it?

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  • what a joke; only it's not funny any more

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  • It’s a two way street & lack of ppe means clinicians can give to patients, not just patients to clinicians! The thought of “hot” clinics with clinicians with inadequate ppe suggests they should be named “Typhus Mary” clinics. Surely it is the frail & elderly who are likely to be seen as they have the most illness & chronic illness, especially when chronic illness doesn’t go away in a pandemic.

    It was once acceptable to set sail on a cross channel ferry with the bow doors open.

    It was once acceptable to clad blocks of flats in highly inflammable insulation.

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  • CoVid 19 becomes non-lethal when it enters U.K. airspace.
    WHO guidelines therefore don’t apply.

    My back eye.

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  • Brandom, I actually completely agree with you. Give fewer clinicians the highest grade PPE to see patients with everyone else supporting in the background.

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  • Brandom 'Most of the other symptomatic half will only be off for one 7 day period (according to UK guidance) after which they will also be immune and return to workforce.'
    No evidence no longer infective at 7 days.

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