The Chief Executive of, The Royal Wolverhampton NHS Trust will present on the Trust’s response to Covid-19 and their plans for the future.
Minutes:
Dr Jonathan Odum, Medical Director of, the Royal Wolverhampton NHS Trust gave a presentation on the Trust’s response to Covid-19. The Medical Director stated that there had been a number of preparatory meetings in the weeks leading up to the pandemic in the UK. The first confirmed case with Covid-19 at the Trust was declared on Saturday, 7 March 2020. Following the first confirmed case, the Trust setup their Silver and Gold Command meetings. The Silver and Gold Command meetings were attended by multi-disciplinary partners from within the Trust and elsewhere in the City. The Silver Command acted as the Operational Command for running the issues related to the pandemic within the organisation. The Silver Command meetings were held three times daily. The Gold Command acted as oversight and strategic management. Initially these meetings took place daily and were Chaired by the Chief Executive of the Trust. Eventually the Gold meetings were reduced to three times per week and as necessary.
The Medical Director remarked that during the course of the pandemic the Trust felt they had superb relationships with Partners within the City. He made particular reference to the good relationships with Public Health England, Public Health Wolverhampton and other teams within the Local Authority.
The Medical Director stated that Wolverhampton had higher Covid-19 cases per 100,000 during the course of the pandemic than the England average. This trend was the same across the Black Country. He commented that early on in the pandemic it was clear that some patients had Covid-19 but had not tested positive for it from a swab test. They were however treated in exactly the same way. Early in the testing regime there had been a significant false negative rate and also some people could be positive and then later test negative. To date 914 patients had been admitted to the Trust with a positive Covid-19 test result. According to the slide, 44.59% were female and 55.41% were male. At the peak of the pandemic the Trust had in excess of 300 people being treated for Covid-19 within the organisation. The length of stay for each person was significant. The Medical Director described the demographics of the 914 patients that had been admitted to the Trust with a Covid-19 positive test result. 70% of the patients were classified as White-British. A breakdown was given of the ethnicities as follows: -
White British – 70.49%
Black Caribbean – 6.89%
Asian Indian – 6.01%
Not Stated – 9.51%
Asian Pakistani – 1.09%
Asian - Any Other Background – 0.55%
Black African – 1.97%
Black - Any Other Background – 0.77%
White – Any Other Background – 0.87%
Other – Chinese – 0.22%
White – Irish – 0.33%
Other – 0.87%
Mixed White/ Black / Caribbean – 0.44%
The first Covid-19 positive death at the Trust was reported on 8 March 2020. 282 people with a Covid-19 positive swab result had died at the Trust to date. 300 had been reported to the Covid National Reporting System because on the Medical Certificate Cause of Death, if Covid-19 had been included as a cause of death from the 25 April 2020, these had been reported. There had been some cases where it was believed the person had Covid-19 but had not tested positive. This was probably due to the testing system not being as accurate in the early days of the pandemic. People over the age of 65 were much more likely to die of Covid-19 when they had been admitted to the Trust. He presented a slide on the ethnicity of the 282 people who had died that had a confirmed Covid-19 test result. The breakdown was as follows: -
White British – 70.21%
Black Caribbean – 8.87%
Asian Indian – 6.38%
Not Stated – 9.22%
Asian Pakistani – 1.77%
Asian Any Other Background – 0.71%
Black African – 0.71%
Black Any Other Background – 0.71%
White Any Other Background – 0.71%
Other Chinese – 0.35%
White Irish – 0.35%
The Medical Director remarked that during March, April and May 2020 there was a much higher death rate at the Trust than in a normal year. The higher excess death rate was down to Covid-19. They were not seeing excess death rates in any other disease groups. The Trust had carried out a number of Mortality reviews for Covid-19 deaths. None of the deaths reviewed were classed as avoidable. They were about to commence an out of hospital (community) review of deaths during the pandemic, the results of which could be reported back to the Health Scrutiny Panel in due course. The Trust were also undertaking a review of mortality due to possible Healthcare Associated Infection (nosocomial infection / Hospital Acquired Infection).
The Medical Director talked at length about the risk assessments in place at the Trust. Initial risk assessments had been put in place for all staff deemed vulnerable to Covid-19 exposure including health risks and pregnancy, these were completed in March 2020. When it had appeared, there was some disproportionate impact, with Covid-19 more likely to have a poor outcome for those from a BAME (Black, Asian and Minority Ethnic) background, the Trust included it as a risk factor in the risk assessment. A system wide risk stratification tool had been put in place. All staff at RWT had received the risk assessment framework, with a mandate for staff across the organisation to complete it and discuss the results with their line manager so mitigations could be put in place. Redeployment and social distancing had been put in place for high risk individuals. The matter had been taken very seriously by the Trust.
The Medical Director presented a slide on what had worked well at the Trust during the pandemic. The Staff at RWT had responded magnificently to the Covid-19 pandemic. The redeployment required to manage the situation had been substantial. All the rotas had been completely redone to ensure there was the correct provision. Digital innovation had been utilised to maintain business within the organisation. The use of Babylon (Digital Health System) had been very helpful. Virtual appointments and sessions had been undertaken.
The Medical Director stated that maintaining PPE (Personal Protective Equipment) provision during the course of the pandemic had been very difficult. PPE had been managed centrally by the Government Department for Health and Social Care. There had been daily issues in managing PPE and shortages. The Trust had redeployed 30 staff to work on internal production of protective visors. As of the date of the meeting the Trust had made over a quarter of a million visors. He paid tribute to the staff who had participated in the redeployment. During the peak of the pandemic over 20,000 were being made per week. They had supplied other Trusts with the visors, who had experienced shortages. They were now continuing to make a minimum of over 3,000 per week in preparation for a potential second wave of Covid-19. The Chief Executive of the Trust commented that early on in the pandemic they had become acutely aware of the UK’s reliance on China for provision of PPE. The UK did not have the manufacturing capacity for the quantity of PPE required for the pandemic.
The Medical Director remarked that an area that had worked particularly well was the fact that the Black Country Pathology Service was on site. They had been able to use the laboratory for Covid-19 swab and antibody testing. The national testing process for managing testing had not been helpful in their view.
The Medical Director made reference to the very good sickness rate across the Trust compared to other NHS Trusts in the West Midlands region. The highest sickness absence rate for RWT at the peak of the pandemic had been 16%. The sickness rate for the Trust at the date of the meeting was at approximately 4%. Emotional and psychological support had been put in place for staff, including the provision of “Wobble Rooms” (Time Out Areas). An onsite Supermarket had also been provided for the staff.
The Medical Director presented a slide on impediments and challenges during the pandemic. PPE and ventilators had been a massive challenge on a local and national level. The Trust had been able to use their anaesthetic machines and so had been able to cope. Constant changes to national guidance had also been a challenge. In one week, there had been seven national guidance changes in relation to Infection Prevention, which had been challenging and confusing for Trust staff. The initial turnaround time for swab testing results had been slow, with up to 14 days delay in some cases. This had caused some issues with patient placement. Once testing results were brought in house to the Black Country Pathology Service in April 2020, the time reduced to circa four hours.
The Medical Director stated that the discharge to Care Homes had been a very significant issue partly related to the clarity of guidance at the outset. It was a very different position now but had been very challenging at the start of the pandemic. The Palliative Care Team would be in agreement that restricted visiting was an absolute necessity. It was however a very stressful and emotionally demanding time for patients and their relatives. The Trust had used digital technology to try and help.
The Medical Director commented that the ITU (Intensive Therapy Unit) Ward had been expanded. They were carrying out works to improve the infection prevention measures. The Trust were carrying out significant surveys and events in relation to Covid-19 to determine the psychological effects on staff. Some individuals would require significant help and were likely to be suffering from PTSD (Post Traumatic Stress Disorder). The Psychological and Emotional Wellbeing Support Team were providing the support. As a consequence of the pandemic significant hospital business had not been undertaken, such as work with cancer patients who would have suffered. Restating services would be slow and complex due to the infection prevention measures required.
The Medical Director presented a slide on the preparations for a second wave of Covid-19. Refurbishment work was underway to change the ICCU (Integrated Critical Care Unit) open plan layout to three separate areas in preparation for a second wave in order to hold different groups of patients depending on their Covid-19 status. There were two new wards with a 56-bed ventilator capacity. A bid had also been submitted for ten additional ICCU beds. An Occupational Health Test and Trace process would spot outbreaks amongst staff promptly. There would be an increase in Medical and Junior Doctor support at night. 316 volunteers had been trained (Staff – 156 and External – 160). They had been trained on bed making, laundry management, infection control, PPE and hand hygiene.
The Chief Executive of the Trust commented that on Sunday, 8 March 2020 he had decided in conjunction with the Director of Public Health that general visiting to Trust sites should cease immediately. His biggest personal regret was visiting did not cease for a further two and a half weeks as he had been pressured at a high level, not to halt visiting. He believed that not enough recognition had been given to the fact that the Black Country was just behind London in the pandemic trajectory. He estimated, although he would never be able to know for sure, that up to 25 deaths from Covid-19 may have been prevented within Wolverhampton if general visiting at the Trust had ceased on the 8 March 2020.
The Chief Executive stated that 250 ventilators had been delivered for use in Birmingham and the Black Country from China. They had not been fit for purpose as there was only two levels for oxygen control. This had been a particular low point for staff who had been promised more ventilators only to receive some that were unusable in a UK clinical setting. The country had not prepared for the pandemic as well as it should have done, preparations should have started earlier on a national level in December 2019. The Trust had the foresight to order some full hoods in the January, which were now next to impossible to obtain due to the huge demand. He paid tribute to the Trust’s staff and the staff within the Council’s Public Health team. There were however a number of mentally damaged Trust staff, who had to cope with unprecedented deaths in Intensive Care, some of which had not worked in the unit before. The Trust were doing everything they could to help these members of staff.
The Chief Executive thanked the Chairman of the Health Scrutiny Panel for his support throughout the pandemic. A conference call had taken place with him and the Vice-Chair of the Panel approximately every two weeks for a large part of the duration of the pandemic.
A Member of the Panel complimented the Medical Director on his presentation and the useful and important information that had been relayed. He commented that the ethnicity statistics of the 282 Covid-19 deaths given by the Medical Director tallied with the local ethnicity of Wolverhampton from the 2011 census. He commented that it was critical to keep up the preparations for a second wave of Covid-19 within the City. Where social distancing was not being maintained in the City, enforcement teams should take strong action.
A Member of the Panel commented that one of her son’s had been receiving concerning reports from Italy throughout February. She asked why the Chief Executive of the Trust, thought the UK had not responded to the Italian experience quickly enough. The Chief Executive responded that they were fortunate to have employed a number of Italian Consultants who had returned to Italy. The Trust were therefore able to receive direct information from Italy about the situation. The Trust were able to learn directly from the experiences in Italy, at a time when the Trust were not receiving information directly from the UK Department for Health and Social Care. What had caused them alarm, from the information they had received from Italy, was the lack of treatment options for Covid-19. He commented that worldwide there was only four major suppliers of medical equipment. There had been numerous problems with trying to secure extra ventilators and he did not find the fact that the supply of them was taken on at a national level helpful. He had recently been informed that one of the suppliers of the antibody testing kits was reducing their supply to the UK by 40%. This was because they were an American company and the kits were now needed in the USA. This was a classic example of the vulnerability of health systems worldwide.
A Member of the Panel complimented the excellent partnership working that had taken place amongst health partners during the course of the pandemic. She paid particular tribute to the work of RWT and the Council’s Public Health Team. She hoped that messages were going to the Department for Health and Social Care and Public Health England with the concerns that the Trust had about the national response. The Chief Executive of the Trust confirmed that he had raised his concerns at a high level including some of them with Simon Stevens, the Chief Executive Officer of NHS England. He did not wish to point all the blame at NHS England though, many of the problems had resulted from too much reliance on China for essential medical equipment. The difficulties with not permitting visitors had been partially mitigated by the purchase of hundreds of IPads to allow families to see their sick relatives via virtual means. Considerable effort had been put into the Trust’s Bereavement Service during the pandemic.
The Director for Adult Services commented that at the weekly meetings with the MPs, they had raised concerns about any key points during the course of the pandemic. He emphasised the importance of local control of actions.