Not for the first time in this pandemic, the government is making bold claims and failing to deliver. When the Pfizer vaccine was approved, we were told five million cases would be delivered and used by the year end. In the event, it was less than one million. As my colleagues’ “Worth a Shot” Briefing Paper showed this week, “Britain’s vaccination programme is being hampered by an excessively centralised, command and control approach that has rebuffed help from the private sector, the armed forces and volunteers.” But for once the problem does not lie with our leaders setting out bold ambitions but with our Kafkaesque bureaucracy getting in the way.
The Medicines and Healthcare products Regulation Agency (MHRA) has been blamed for delays but this turns out, according to a release on 8th January, not to be the case. After approving the vaccine, the 1925 Therapeutic Substances Act requires it to test every batch. The manufacturer’s tests are the same as those by the government’s National Institute for Biological Standards and Control (NIBSC) but they only take four days and are conducted in parallel.
On December 31st, Jonathan Van-Tam, deputy chief medical officer, said: “the only thing that is going to slow us down is batches of vaccine becoming available”. He blamed that not on any shortage of the vaccines themselves but of the vials to put them in. When we ordered 100 million doses, it seems no one thought of the vials.
Unfortunately, the health bureaucracy has more inefficiencies. The Sun on 6th January reported that Public Health England did not do deliveries on Sundays. Lucky that the original three man Sage Committee bearing gifts, and guided by the science. did not try to deliver on a Sunday. The NHS front line is short of doctors and nurses but many of the pharmacies and recently retired clinicians who volunteered to help are getting no replies to their applications. According to BBC Look East (7th January), those who are provisionally accepted face 15 hours of online form filling before they can make the first jab. Matt Hancock agreed (House of Commons 7th January) that wielding a hypodermic did not really require proof of diversity awareness or terrorism policy or many of the other 21 tests, but the mid-level NHS manager who appeared on the programme clearly disapproved of their withdrawal and, one suspects, would be in no hurry to do so.
The Prime Minister rightly announced, also on January 7th, that the military would assist with distribution and, because the NHS had been objecting, he had Simon Stevens, the NHS CEO beside him when he said it. “Army logistics chiefs have been brought in to use “battle preparation techniques to help us keep up the pace”, he said. Given the pressure on the NHS to treat the massive surge of new variant cases, it would have been better to turn the whole vaccination programme over to them but that would have been throwing their rattle out of the pram. As it is, the military will simply be advising on the Herculean task of getting the vaccines from Wrexham across our emptied road network to the vaccination centres.
According to the Vaccines Minister: “Working together, day and night, they will ensure our vaccines are going into arms rather than sitting on shelves. UK forces will use techniques borne out of decades of experience of getting things done in some of the toughest conditions imaginable. They’ll bring the bravery and brilliance they shown [sic] in places like Iraq and Afghanistan to these shores.”
The North Norfolk constituents are, on average, the oldest in the country and the number of infections, amongst the over-80s, tripled in December, so it is not surprising that it is yet to have anywhere that can do a jab. It has a hospital in Cromer, and cottage hospitals in North Walsham, Wells and Holt, but none of those have been selected. Instead, vaccination centres at Sheringham and Aylsham should be operational by 15th January.
Then there is waste. The MHRA limits distribution: “Currently the MHRA directions do not allow for the re-distribution of the Astra Zeneca vaccine from the PCN [Primary Care Network] designated site to other practices for administration within the practice.” Similarly for Pfizer. So if there is a surplus, it cannot be taken to another practice that needs it. A practice can take doses to a single care home in its area but if it turns out there is a surplus, it cannot return them to the original PCN designated site nor to another care home nor to vaccinating its own staff or patients in its own area. The unused doses have to be destroyed. [1] Local Medical Committees are restrained in their comments on orders from above but in this email: “We are aware that it is illogical and frustrating, however, this has been determined by MHRA and we need to wait for them to change their directions.”
That was not expected for some time, but in fact the advice was withdrawn the next day!
One should not carp. Huge numbers of good people are doing their level best, under difficult and once-in-a-lifetime circumstances, to treat patients and save lives. Perhaps the most remarkable feature of the first wave was the way front line clinicians simply threw out pettifogging rules and did what needed to be done. In normal times, those changes would have taken committees many years. The NHS may not have too many managers but it certainly has too many people saying “no”. I had to discharge myself from my last two sojourns in a major NHS hospital trust, or I would still be there. The Prime Minister and the Health Secretary may have a clear view of what needs to be done but they still have two major problems: failing to clear Kafka’s action-blockers out of the way and failing to plan well and in good time. It looks like the first of those is beginning to happen but the second remains a problem.
[1] Email from Norfolk and Waveney Local Medical Committee “Oxford AstraZeneca vaccine - movement restrictions”, 6th January.