Director of Public Health
.. The Chairman invited the following to the meeting:
· Dr Tamara Djuretic – Director of Public Health, London Borough of Barnet
· Ms Dawn Wakeling - Executive Director, Adults and Health, London Borough of Barnet
· Dr Chris Streather – Group Chief Medical Officer, Royal Free London NHS Foundation Trust
Dr Djuretic presented her slides on the Coronavirus pandemic in Barnet. She reported that Barnet has a high infection rate with currently 1250 confirmed cases. Scientific research showed that around 1% of the population has Covid-19 which would mean there are around 4000 cases in Barnet. The peak of the pandemic had been reached in Barnet by the end of March 2020. At the end of the week beginning 20 April, 277 deaths had been registered in Barnet with Covid-19 as the primary cause. In the last week, there had been only a small number of new cases, despite an increase in testing across the Borough. In Barnet 52 Care Settings had been affected although no new cases or deaths had been reported in the last few days.
Dr Djuretic reported that Barnet had been able to secure a good stock of Personal Protective Equipment (PPE) locally and had also joined the West London Alliance Framework which provided regular deliveries of PPE. Dr Djuretic commented that even though the experience of lockdown had been devastating for everyone, there were some positive outcomes which should be preserved. Self-care had been well promoted and care for vulnerable residents had been provided promptly, including those being shielded and homeless people. The voluntary sector had also stepped up very well. Another positive point was the increase in awareness around infection control.
Dr Djuretic added that further guidance was awaited on social distancing from Public Health England (PHE). Barnet Council would undertake full risk assessments to enable services to be restored to their full functions. Local Authorities had been asked to scale up testing in Care Settings and the introduction of a national portal had been announced just prior to the HOSC meeting, on which Dr Djuretic awaited further information. She noted that she is a representative on the Testing and Contact Tracing National Working Group. Contact tracing was due to commence on 18 May led by NHS Test and Trace and, London, the London Coronavirus Response Cell for incidents in specific settings, with local Directors of Public Health having oversight of this process.
A Member stated he had read that vulnerable people, including those in Care Homes, had been approached by GPs to encourage them to agree a ‘Do Not Attempt to Resuscitate’ (DNAR) Order. This would mean that those patients would not be considered for hospital treatment if they became ill. He awaited a response to an enquiry that he had sent to the Clinical Commissioning Group (CCG). He felt this was a concern considering the large elderly population in Barnet. Dr Djuretic reported that anecdotally all patients, in either care homes or hospitals, who exhibit Covid-19 symptoms are given a choice: one of the questions put to them being about resuscitation. Ms Wakeling noted that she would forward a response to the Member’s question, which she had received late that afternoon from the CCG. This stated that all GPs had been asked to initiate Advanced Care Planning discussions, which were to be led by the patients and their families where appropriate. The National Institute for Health and Care Excellence (NICE) had issued guidelines to all Care Staff about this on 4 April.
Action: Executive Director, Adults and Health
A Member enquired whether GPs are visiting Care Homes in person during the pandemic. She noted that she is aware of Care Home residents who may not have capacity to express their need to see a GP. Ms Wakeling responded that in-person visits from GPs during the pandemic are not standard practice as this poses increased risks. Barnet Council had distributed 100 Ipads to care homes for remote consultations. GPs are also conducting telephone consultations and Barnet Council is trying to ensure that Care Home residents get full access to healthcare. However, Ms Wakeling added that should there be instances where residents would have been better served by face-to-face consultations and had not been offered this, it would be helpful if this could be fed back. Ms Wakeling would ask the CCG to respond to the Member’s question on patients who do not have the capacity or communication skills to ask for a face-to-face GP appointment.
Action: Executive Director, Adults and Health
Dr Djuretic reported that a Member had previously asked about pandemic ‘flu planning. A Pandemic Flu Exercise had taken place on 11 March which was also the date that the Coronavirus pandemic was declared by the World Health Organisation (WHO). This was a partnership exercise involving about 60 people. Its main aims were to test both the internal and partnership ‘commander control’ arrangements. It looked at the communication lines, mutual aid plans and the provision of scientific advice. A report had been drafted about lessons learnt, which included clarifying decision making, following national guidelines and establishing scientific advice. Clarity regarding communication and the importance of transparency had also been discussed. The group had also focussed on updating business continuity plans and considered critical and non-critical services and staff redeployment, which has worked well. Lessons had been learnt on excess deaths planning and voluntary and community sector engagement.
A Member asked whether the learning from this outbreak would be used if there were a second phase. Dr Djuretic stated that there are different clinical features of Covid-19 to what is usually seen in influenza viruses, with the challenge of a possible overactive immune system in some patients and the problems posed by some individuals with the disease being asymptomatic. She added that Dr Streather would cover the clinical aspects of the disease in his update but that the epidemiology of Covid-19 is still not fully understood. Unlike influenza, it appears that children are not usually affected and are not transmitters of Covid-19 and the disease is more prevalent in the elderly. Usually a vaccine could easily be developed for influenza, unlike with Covid-19, and it is unclear whether long-lasting immunity occurs after an episode of Covid-19. The Public Health Team is keeping updated on the national guidelines and ensuring that these are implemented.
Dr Streather responded to questions received from the Chairman prior to the meeting:-
1. How many people with Covid-19 have been admitted to the Trust’s hospitals?
· 1365 over the first four calendar months of 2020: 601 in Barnet Hospital (BH) and 764 at the Royal Free Hospital (RFH). That however is an underestimate of the number of people as testing is not 100% reliable: only approximately 70% of people with Covid-19 will have a positive first swab test.
2. How many people have been admitted for other reasons and contracted Covid-19 in hospital?
· Possibly 44 but these were swab-negative on arrival, then later became swab-positive, but may have had Covid-19 from arrival. Of these 27 patients were at BH, with positive swabs 14 days after admission and 17 patients at the RFH.
3. How many patients had been discharged having been treated successfully for Covid-19?
· 1331: 631 from BH and 730 from RFH.
4. How many have died of Covid-19 in the Trust’s hospitals?
· 312 out of 1365 patients who had a positive swab test had died. This may be an underestimate as some patients had had imaging of the lungs typical of Covid-19, yet were swab negative.
5. How does the mortality rate this year up to the end of April compare with 2019?
· In 2019, 621 people died in the first four months of the year: 271 at the RFH, 349 at BH and one at Chase Farm Hospital (CFH). For the same period in 2020, 1055 patients had died making a total of 434 more deaths, which were most probably attributable to Covid-19.
The Chairman asked whether the number of people attending A&E had reduced since the outbreak of Coronavirus. Dr Streather responded that over the past three weeks patients had again begun to arrive with other diagnoses, but this remained far below the numbers prior to Covid-19, at around 40% of the usual figures.
The Chairman asked about the supply of PPE to the Trust. Dr Streather reported that this had been sufficient, and the Trust had never run out or had to ration supplies. He added that only a small number of members of staff in A&E and the Critical Care Unit had caught Covid-19.
The Chairman enquired whether there is a large backlog of people waiting for treatment due to the outbreak. Dr Streather confirmed that there is, adding that he is involved in work across London to prioritise patients during the recovery phase. There has been centralisation of heart surgery to the Heart Hospital and Harefield Hospital, where the most urgent cases can be treated. Around 250 cancer patients per week are being seen in dedicated London hospitals that have no A&E Departments, so there should be far less risk of them being infected by Covid-19. The next challenge is to increase the number of patients being seen, including those on long waiting lists, such as for cataract surgery and joint replacements.
A Member asked what percentage of the Covid-19 tests produce ‘false negative’ results. Dr Streather responded that about 30% on initial testing currently are false negatives but this reduced with further testing. Symptoms, as well as the test, are considered, and a ‘safety first’ approach is taken with all patients entering hospital.
A Member enquired how this is managed as the public are concerned about mixing with Covid-19 patients. Dr Streather reported that the Trust tries to separate patients at A&E and even those with no Covid-19 symptoms are treated as though they might have the disease. He stressed that it is important that people still attend A&E if they need to. Currently patients are not stopped from walking into A&E though social distancing is maintained. There remains a risk to anyone going in to A&E but with fewer people attending it is easier to maintain good social distancing. Patients who might have Covid-19 are treated with caution on all three of the Trust’s sites.
A Member asked whether the ‘flu and anti-pneumonia injections that were offered for over 60-year-olds two years ago might help protect against Covid-19. Dr Streather responded that this unfortunately would not protect against Covid-19 due to a different bacterium being involved.
The Chairman thanked Dr Djuretic, Dawn Wakeling and Dr Streather for joining the meeting.
RESOLVED that the Committee noted the verbal reports.