So can you start by saying your name and what your current position is?
So I'm Andrew Brent and I'm an infectious diseases and medicine consultant at
Oxford University Hospitals and I'm one of the deputy chief medical officers.
Okay. So going back to the very beginning, how did you first get interested in medicine and decide to be a doctor?
So I, I, I, I considered medicine as one of several things as I was in my later years at school.
And by the lower sixth, I pretty much decided I wanted to do medicine.
I didn't have a lot of experience of it. I, I come from sort of two rather big families and I did have one uncle.
I do have one uncle who was an orthopaedic surgeon, but I hadn't had any direct exposure to medicine.
So I prepared my in those days UCAS form to apply for medicine.
And and then he very kindly organised for me to spend a week doing some experience to see medicine.
And I spent that week in a hospital in the north.
And after a week there, I don't think I'd met a single positive doctor.
I'd met quite a lot of people who were, I think, fairly frustrated with their careers.
I'd heard a lot about the negative aspects.
The most enthusiastic doctor I'd met was probably someone who was, in retrospect, clinically depressed, but had given me some time.
And and I came away from that probably rather serious.
A 17 year old not quite sure it's what I wanted to do after all, and decided not to apply for medicine.
And I ended up going to Cambridge to read natural Sciences with a with a bent on physics, which had been my favourite A-level.
So so it was a false start for medicine.
I then spent a large chunk of my year off working in India,
a proportion of which was doing some sort of very basic health care assistant type work in Calcutta.
And during the course of that year, I never really let go of the idea of medicine.
And I realised at the end of that time that actually I did want to do medicine and I did want to do it for what I saw then as all the right reasons,
I couldn't change immediately. I did a year of natural sciences and then I was fortunate.
It was a process of sort of internal replication to to get a place for medicine the following year.
So I then transitioned from natural sciences to medicine, and I did my undergraduate in in Cambridge,
and then I came to Oxford for my clinical and then I pursued my postgraduate training mixture of here and abroad.
I one of the key reasons I went into medicine was an interest in the developing world.
I'd grown up in the tropics, in East Africa, the Middle East, the Far East,
and that was a really large part of my driving interest, I think thinking about health in the context of development.
And for that reason I chose infectious diseases and flirted briefly with paediatrics but decided I liked my adult patients too much to give them up.
I was fortunate during the course of my training to spend two periods of my contract fellowships working at the Wellcome Trust,
Oxford Centre, the Kenya Medical Research Institute in Kenya.
And and and so I returned from my second stint there in 2011, 2012,
and towards the end of my training in infectious diseases initially to a university post.
But then in 2015 I took up a substantive NHS post in infectious diseases and general medicine in Oxford,
and in 2018 I became the clinical lead for infectious diseases.
And so I was the clinical lead for infectious diseases.
When COVID arrived at the end of 2019, early 2020.
Yeah. So at what point did you become interested in alongside and grow, excuse me,
in getting involved in hospital management or health services management that were very good question and very, very belatedly.
And actually COVID had no small part to play in. All right. Well, we can talk about that later if it happened, if it's a post-COVID thing.
So what sort of infectious diseases that you tend to see practising in Oxford?
I mean, clearly infectious disease is a huge problem in the developing world,
but I think this is probably part of the problem we had with COVID is that it's it's it's a bit apart from for small children,
it's a bit sidelined in Western countries where all the focus is on cancer and heart disease and so on.
Yes, it's very interesting actually. It makes up a much larger burden of presentations to both primary care and and hospital than one might realise.
Of course, many of those things particularly in primary care, are.
The sorts of infections that don't present a very big risk to the population and or even to the to the individual.
And so they're managed simply in hospital as part of the sort of emergency caseload that presents to hospital infection plays a very large part,
you know, common infections, pneumonia, urinary tract infections, gastrointestinal infections.
And most of that in most parts of the country is dealt with within the sort of general medical sphere,
although there are variations in models across across the country.
The that there is, however,
a lot of quite complex infection and and that has has only increased in its complexity as medicine has increased in complexity.
So you know the increasing complexity of surgical procedures and the complications thereof, which often include or might include infection.
And more and more patients are on immunosuppressive medication,
which which comes with risks of opportunistic infections which present differently
from the way that infections might present in you or I with with good immune systems.
And so there's there's there's a there's a need for infection expertise in managing those.
And and then of course there are the sort of traditional infectious diseases.
So whilst the burden in this country of things like HIV and TB might not be what it is in parts of the developing world, actually,
you know, we've got a cohort of several hundred patients with HIV whom we look after and we look after patients with TB.
And there are some areas even in Oxfordshire that have had know quite significant incidence of TB and some important outbreaks.
And even in the last few years there are other parts of the country and in the parts of
London where the incidence of TB is similar to that in high incident incidence countries.
So, so so another important part of our core business in infectious diseases is looking after patients with those,
if you like, traditional infectious diseases. And we also look after patients returning from other parts of the world.
So the returning traveller and that might be with the number of infections,
we have a steady stream of people who've got malaria, imported malaria and other diseases like typhoid.
And then really important element of this, though rare but very relevant to the context in which COVID arrives,
are high consequence infectious diseases. So you can broadly divide high consequence infectious diseases into two groups.
You've got highly pathogenic respiratory infections.
So that would include things like SA's, obviously the Corona virus, Murs, Middle East Respiratory Syndrome,
another Corona virus, very important part in the story of of COVID and the vaccine development.
And as you know, but also other infections like viral haemorrhagic fever.
So things like Ebola, Lassa fever, Crimea, Congo haemorrhagic fever and so forth.
And so because there is a small risk that patients returning from areas where these infections might be,
the epidemic are endemic and we within infectious diseases, have to have systems in place to safely manage those suspect cases.
And there are case definitions which are defined nationally and and which we follow.
And we've really been pretty rigorous at this. I think it was always something we did even in my training,
but I think we got really quite professional at doing it in in about 2014 with the West Africa Ebola epidemic.
And this is it to do with isolating isolation from each other, wearing full PPE for health care workers?
Well, absolutely right. So if you have a patient who comes back from an endemic area with potential
exposure and meets the clinical criteria for management as a suspected case,
then you need to manage them very safely. And absolutely, that's it's about isolation.
It's about having a pretty appropriate hospital estate to manage them in in terms of the pressure management of those rooms to to limit infection.
And it's about the personal protective equipment, but also not just about the equipment itself,
but about the processes with which you manage that in terms of how you put it on,
most importantly, how you take it off, because that's the highest risk bit of your contaminated, how you work together and teamwork.
It's buddying when you go in and really quite well established protocols.
By the time we get to 19 2 to 2019 about how we manage those cases of suspected high consequence infectious diseases.
So quite a broad range of infectious infectious diseases.
And, you know, I guess we're lucky in Oxford that we've got a quite a big department.
We have a large number of trainees and the size of the department partly reflects
the fact that many in the department have a very portfolio which includes a.
Teaching and research and contributions to the clinical work.
So lots of in-house expertise, which again is not irrelevant to indeed into the to the landing of a pandemic.
Absolutely. Thank you. So let's let's get to Kobe.
Can you remember how you first heard about it?
And how concerned were you when you heard those first communications that it might become something big that would involve you in a major way?
So it's hard to put my finger on exactly when I heard.
But I think I was aware in late December.
I subscribe to an email service called Pro Edge, which gives you lists of potential or emerging epidemics in parts of the world.
And and it came up in premiered, I think, in late December 2019 and it hit the BBC news at some point.
I think it was probably early January, but it might have been late December.
I don't recall exactly when, Certainly by sort of the end of the first week of January,
we were we were getting the first communique, Public Health England Communications,
about what was then known as Wuhan novel coronavirus,
and that was on the back of the identification of the virus in early January in China as a novel coronavirus.
But at that stage, the messages were that there was no evidence of human to human transmission.
There was no evidence that any health care workers had been infected.
Of course, that story evolved very, very rapidly over the over the following few days and weeks.
And and at that time, of course, this was considered a high consequence infectious disease.
And so and that was the framework in which all of our work and interaction and preparations for COVID began.
The period of sort of January through to early March was a very busy one.
And it's in retrospect now sitting here in 2023, it's slightly difficult to disentangle the exact timing of all of those threads.
But certainly in January we were already managing suspected cases.
I recall that we work quite closely with university partners and and so we're in regular
communication and with the local health protection Unit and Public Health England.
And there was a group of Chinese students who were visiting the university from Wuhan and were who were then quarantined in a Travelodge.
And we were alerted that we might have to look after those and investigate them if any of them got respiratory symptoms, which some of them did.
So they were among some of the first suspected cases that came in.
And, you know, when they come to hospital, regardless of the severity.
Absolutely. And this is one of the things that changed very rapidly in the following weeks,
because initially we were admitting actually very well people with minor symptoms treat treating
them and managing them as a potential high consequence infectious disease with all that PPE,
they were staying in hospital several days, sometimes because there was a wait to get the tests back.
And we can talk more about that. And there was there was already quite a lot of alarm, I think, in the community at this stage.
I remember one of the things that we one of the referrals was someone in Bicester Village who'd seen
someone Chinese and was really worried that they might have that they might have this horrible virus.
I've interviewed several Chinese researchers who encountered hostility and really made them
change how they felt about being in the UK very much because I can well understand that.
I remember that. I remember that that sense in those early days very well.
And in late January that we were in contact with the local public Health England,
a number of British nationals were repatriated from Wuhan back to our Brize Norton.
And so we were on I remember being on stand by in case in case we needed to admit them.
They they were then all transferred up to Merseyside to a specialist area and supervision.
And I think that made the news at the time as well.
So, you know, these these are little milestones in what was what was day to day, a very, very busy time.
I remember the last weekend of January.
So having just looked at the diary segments, I mean, Saturday, the 25th of January,
we were invited by friends to a Burns Night and that was the last sort of proper night out for a very long time.
And I'd been invited to give the toast to the lasses.
And and that was all about or at least had featuring prominently in that because I'd been on call all day in the hospital was Wuhan virus,
because actually the lion's share of the time I spent that day was dealing with suspected cases.
So by that time we were already very, very busy dealing with suspected cases, although no confirmed cases at that time.
And again, still all as a as a as a high consequence infectious disease during January.
And there was a lot of communication with partners in Public Health England,
with the ambulance service with whom we had to build really quite rapid lines of communication,
but also collaborate and and also with academic colleagues, many, you know, many in the department.
And and I think all of us were feeling that what we could see about the the epidemiology of this evolving virus was looking increasingly worrying.
Back in those days, it was possible to have pretty much kept on top of the literature because it was very small.
Of course, that burgeoned and later became impossible. But but actually everything that was coming out,
we were devouring and trying to learn from it and I think could see that that that this is something we had to keep our eye on.
And on the 4th of February,
we have a weekly lunchtime seminar on the Tuesday and we have invited speakers across the range of infectious diseases and pre-COVID.
It was always in person and it's since become virtual like many things.
But on the 4th of February we gave over that session to talk about the Wuhan virus, as I think it was still called.
Then it changed its name at some point due to COVID or SARS-CoV-2.
And and that was an interesting session, firstly, because I think that the data that was.
Presented with suggesting that this virus did appear to meet some of the important epidemiological
requirements in terms of the R number of and and mortality of a potentially pandemic causing infection.
But it was also interesting because there was a wide range of views in the way that that was received in the room.
And, you know, on the one hand, there was some anxiety and and in general, this was seen as quite serious.
But there were some voices in the room who saw this discussion as irresponsible and alarmist.
And so even within infectious diseases at that time,
I think there was there were the it took a while, I think, for it to sink in completely everywhere.
And there's still haven't been any you ever, you know, No, there were no UK cases yet.
But by that and I think from memory, I think late January there were some cases outside China and Singapore and South Korea.
The US cases were very early and in Spanish an epidemic took off and of course Italy, which will come to an end,
but we were at that time really focussed on evolving our pathways and this was literally something that happened day to day.
And my I was very grateful to my colleagues.
I think there was a real departmental recognition that this was something that we had to think about and plan for,
and therefore we had to create some time and space for it. So one of my colleagues very kindly took over.
I was on general medicine at the time, took over my general medicine and released me to give some headspace to this.
And, and, and that was really essential to be able to maintain communication and work
with the team on the ground and and actually listen to everybody in the team.
Because as I said, we're so lucky to have a fantastic and very broad expertise in the department and then informed to some extent by,
you know, what was evolving nationally, although in most cases slightly ahead of that and put together our own protocols and pathways.
So we were, you know, our pathway initially for managing patients with a suspected high consequence infectious disease was,
you know, these were usually sporadic cases we would bring. We would liaise closely with the ambulance.
You need a specialist ambulance to bring them to hospital. We had a separate pathway through the hospital.
It came in through a back door on the ground level and then a separate lift to bring them up to the to the ward.
And and so we were doing that initially this became very busy.
And, you know, we were colleagues on calls, became managing these cases till nine, ten at night.
And, you know, I mean, amazing to think back and just think how people just stepped up.
I mean, this was quite a lot of extra work very quickly. And I can't remember any complaints in the department.
Everybody just pulled a pulled their weight. And this was, again, before any lockdowns or anything was happening.
But it was really just a fantastic can do attitude.
That process became difficult to manage at such a high volume.
And so it evolved and it evolved organically.
There was a there was a national strategy to roll out things called Corona pods,
which were essentially to put these little temporary buildings in the hospital ground where people could turn up and telephone and say,
I'm here and get a test. And and that sort of happened. But before that and and and in parallel with that, we were developing our own system.
I remember one weekend, one of my colleagues, Tony Woodrow, who's now the Infectious Diseases Clinical lead, was on call.
And and we'd been we'd started saying, well, actually some of these people are really well, they don't need to come into hospital.
Let's test them. And if they if they can safely self isolate at home and it was a checklist to do that actually we can test them and
and then let them go and then instead of them bring him up to the ward and testing them and taking that back down,
we'd sort of taken them out. We've got a space downstairs where we were testing them.
And then, you know, I think, Charlie, that we can actually board. What's the point of getting out the car?
Let's just swap you in the car. And actually, so drive by testing evolved, you know, really quite quickly.
And of course it evolved in parallel in several other places and became a really important part of the way that we did testing nationally.
But you still aren't getting results for 48 hours or something at that stage.
Well, 48 hours, if you were lucky. The way that testing started initially was it was it was all centralised by public health England.
It was all. On in Colindale and initially they were doing a PAN coronavirus PCR,
and then if that was positive, they were doing further tests to look for for the novel virus.
And that initially would make it would take another 24 hours.
Although as the volume of testing increased across the country, that turnaround time actually increased to up to five days.
So so and that happened really quite quickly.
We could talk a little bit, I think, be nice to reflect on it little bit later about because maybe some of us within Oxford,
we had the expertise to do that kind of testing. Well, I think I think that is one of the lessons that we can draw from this.
But I'll come back to that, I think, because I think, you know, it's part of the team and we we then realised that,
you know, where we were doing this at the John Ratcliffe Hospital.
It wasn't the ideal state to, you know, there was nowhere very easy for people to park, certainly not for a higher volume.
And so we, we then rearranged things and we set up a separate testing hub at the Churchill Hospital in what had been our old infectious diseases ward.
And that was a really fantastic collaboration with the Community and Oxford Health Trust and and working with partners.
They lent us some staff, so we were able to set up testing.
We were helped by some medical students who and medical students stepped up in many different ways to help with this, but who learnt the ropes.
And and so we set up a separate testing system there with patients.
So, you know, possible patients, those who needed testing,
who met the criteria could come and drive part, be tested and and safely come in a separate entrance,
be swabbed and come out and say that because they self-refer or would they know they they were they
these were these were usually referrals through either public health England or general practice.
Right? To us. Yes. But that became, you know, we we probably we managed, you know,
several hundred or 600 or so people before we then devolved that that model to Oxford Health who who took it over and ran it for a lot longer.
And and again, of course these things then then evolved further as national testing evolved in different places.
We we also had a model of community testing.
So not just asking people to come up, but actually people who were we looking and we triaged as to whether it's good to test them in their homes,
depending on how well or otherwise they were and how how able they were to come up to hospital,
if they could come up to hospital because they could drive or they and they could they could come up safely,
then that was a plan A But for those who couldn't, we we developed a model to go out into the community.
And I well remember the first time we did this, it was so, so we had to create you rotas.
These were staffed by our consultants and but mainly by our registrars.
And again, I think we've been fantastically lucky to have such a big department because of course, this all started when, when it all started.
And during all of this time this was all just within infectious diseases.
And we were it wasn't yet affecting the rest of the hospital.
And although the communications had gone out about suspected cases and so forth,
and but we we teamed up with the ambulance service who gave us a car and a driver,
and then we went out with the ambulance service to do testing in the community.
And that first evening I was with one of the registrars, just wanted to make sure that the process was working.
And so we we were very quiet.
The first part of the evening we had no referrals, which was slightly quieter than the evenings before.
And, and so we went and we made some films about how to essentially filming the process.
We actually went back to her house and did it all there so that we could film to
train other people who were going to be doing it and as a training resource.
And then about 9:00 we got a call from public health to say that there was an inmate in prison put into prison who needed testing, who was from it,
just been transferred back from Thailand,
had been in prison in Thailand and had some respiratory symptoms and was in a cell with someone else with a history of asthma.
He was having an asthma exacerbation and would we go there and do the testing?
And that was an experience. And so we drove to Bullingdon Prison.
Of course, you've got to leave all your and all your belongings as you go in phones and everything in the locker.
So we were off grid for for for a few hours and we met with the prison staff and the prison governor who was, I think, understandably concerned that.
What he didn't want to do is create unrest in the prison. There was still there was a lot of fear about this.
And. And then we we turned up and the prison staff for him, of course, this was this was all very new.
I mean, if you can imagine long sleeve gowns and gloves and masks and, you know, we traipsed through into into the prison.
And the prison, not surprisingly, looked like a prison.
And, you know, you like I will have a vision of what that looks like in from from television and other sources.
And and we went in across the cell and we tried to keep a low profile.
And the prisoners were all obviously in their cells. And each of those doors has a has a window which had a a metal shutter on the outside.
And there was a little bit of a standoff with the prisoner who didn't really want to be tested.
And and so it wasn't quite an altercation, but we had to do quite a bit of persuasion.
And and the registrar I was with absolutely fantastic.
But, you know, fairly diminutive compared to this huge bare chested prisoner who was, you know, and not doing anything to not look intimidating.
And and and while while we were having this conversation and.
And again, it was another education for me. But one of the prisoners in the level above managed to tear off the hands of the sheets.
Explain to me what they're doing by that, by the prison officers with us.
And then they use that to under the door, over the door to pass things between the rooms like teabags or toilet paper or other things.
But they put it over the top of the door and then managed to use it to open the shutter on the outside so that he could see what was going on.
And and so they started to look out and then they stopped.
And then there was a little bit of banter and, uh, and then sort of corona and corona virus.
And then you could hear this being taken up by other and then, you know,
within a few minutes there were 200 odd prisoners banging on their doors, shouting Corona, Ebola, corona, which was a fairly surreal context.
And they were the two inmates whom we had to to swap were also not pleased because it gave them a I guess it was tension that they didn't want.
Yes. But we we were able then to to test them into and then to get away.
Both of them were negative. And I think that, you know, in a sense, it's a it's a good example of.
How in those early days, actually some of our case definitions for testing really hadn't quite kept up with with what was happening globally.
And so, you know, probably being in a Thai prison was a relatively safe place to be, actually, I suspect.
But here we are. And we used to have weekly teleconferences, national teleconferences.
So and they were led by Keith Willett, who is the director of the response.
And and, you know, we would talk about the SITREP nationally and then present solutions, you know, in terms of patient pathways.
That kind of pods was a good example in terms of testing and etc.
But it always felt as though and this is no criticism actually, because I think that I think it's inevitable,
but it was felt like it was addressing problems that we'd solved one or two weeks before because, of course, the situation was evolving so quickly.
But, you know, we were lucky. We were well resourced department with a lot of internal expertise and and had had therefore the
opportunity to do things that many district general hospitals wouldn't wouldn't have had the chance to do.
We had our first case around the end of February or early March.
I forget the exact date. It was linked to one of the returning groups from skiing in Italy at that half term.
We know in retrospect that probably thousands of introductions separately into the UK around that time, but no case definitions at the time.
We're still talking about China and had slightly extended to include Taiwan.
There was something that was slightly surreal about it and.
By March, we were going into our first peak and actually thankfully as a hospital, I think we were quite well prepared.
We've been fortunate in that respect. We'd been able to see what was happening in China and we we had a teleconference with Doctors Hospital in Wuhan,
which was very helpful in terms of learning,
you know, the generosity with which people gave up their time and shared things, I think internationally was was phenomenal.
Similarly, we arranged through colleagues a similar catch up with colleagues in Lombardy in Italy so we could try and understand,
we could see what was unfolding in Italy. And so again, the severity of the situation at this point was, was very clear.
Um, but, but we were also lucky that we had slightly more time than, say, London.
So, you know, we could see the wave coming through London and also learning from that.
And there were lots of WhatsApp groups and, and, and we were all sharing information, but we had a little bit more time to prepare.
And so and thankfully we were in a in a reasonably good place.
Um, you know, I mentioned that colleagues recognised the importance of creating some time for planning, which was I think important.
And my colleague Katie Jeffrey, who's the director of Infection Prevention and Control,
set up a COVID incident management group in late January, which she and I co-chaired and which became it was a daily event.
It happened first thing in the morning and with wide representation across the hospital.
And actually that became a really, really important forum for listening to people's concerns and ideas and also sharing,
you know, the situation, the SITREP and and the plans.
And I think I mean, communication was absolutely fundamental to this.
And I think that was one example of, you know, one of the things we did, I think, very early, which was which was really good, we had.
But you can always do more. Yes. And did you have systems set up to detect any transmission that was happening within the hospital?
So. Well, one of the challenges was that that we were obliged to follow the national case definitions.
And the national case definitions were a little bit behind where they needed to be.
And we were we we had we could only we were only allowed to test through the national testing.
And you know, I've already explained that was of limited capacity and you could not test if you didn't meet the national case definition.
So again, we'll come back to that because I think this is one of the really valuable areas
of lessons to learn for when inevitably we next have something like this.
I think the other reason why we were really well prepared is that our executive and get engaged really early and seriously with this,
the chief medical officer set up a COVID steering group. They co-opted expertise onto that group.
And and so there was a sense that the that the leadership were really taking this seriously right from early on.
And I you know, I think all of us involved were very grateful to that.
And so you had a sense of being on the front foot rather than I think.
Yes. I'm not sure You know, I'm not sure front foot is necessarily was the word.
I mean, there were there were huge challenges. And, you know, I think that we were relatively well prepared compared.
And that's partly out of luck in terms of our existing capacity and partly because of the timing.
You know, we had if we'd been in Lombardy, would we have been that prepared?
No, I don't think so. So we had that opportunity to to see what was what was coming our way.
Um, but that time allowed us to put together, you know, lots of the detail that you need.
So, you know, our clinical protocols, treatment, escalation plans, you know, we had a whole,
this whole piece of work around resuscitation and how do you say you can't just do what you've always been doing?
So the layers and layers of detail, occupational health, how do we look after our most vulnerable?
And some of this was obviously informed by by national guidance, but that was also evolving very rapidly within infectious diseases.
And the infection prevention control team, you know,
we were providing pretty much 24 hour seven support and advice for for all the other specialities and,
you know, in lots of different ways in terms of, you know, answering continuous questions and also some bespoke,
targeted extra engagement sessions to help support specific areas like anaesthetics, for example, and by this time in.
So I suppose we've got to early March or so.
Was the hospital Still trying to see as many patients in those other specialities as it as it would have done previously had?
Yes, at this stage. At this stage. At this stage, you know, the rest of it was sort of business as usual in terms of the rest of the activity.
Although, you know, it was very clear to many of us that there was going to come a time when we couldn't do it.
And that time was very, very rapidly approaching, not least because we had to organise reorganise the hospital.
And so I think, you know,
one of the themes that came out of that was the sort of teamwork that that that allowed that to happen, which was phenomenal.
And I think the single most positive aspect of the whole.
COVID experience. I hadn't experienced anything like that in my career to date, and it's really a positive.
But the impact was as you lead to profound, you know, because we then did have to stop doing some things.
You know, we had to redeploy staff to areas sometimes that they were very unfamiliar with and understandably, you know, would have had some anxiety.
But again, the the attitude with which staff did this was phenomenal at all cadres.
You know, Universe University colleagues stepped in and helped in the medical side.
Medical doctors went to areas they weren't familiar with.
The nursing staff, you know, did a lot of that, you know, really difficult lifting and and but really,
again, phenomenal tribute to their dedication that everybody just got on with it.
We had to stop a lot of elective work. So, of course, you know, we're now dealing with some of the consequences of that.
Um, I think we were relatively lucky in Oxford that we were able to because our the Churchill Hospital,
we have most of our elective cancer work is happens is a separate site.
We were able to continue most of our cancer opportunity and in fact help other hospitals in the locality and in terms of cancer work.
So so I think some areas of service we did manage to protect to some extent, but nevertheless there was a huge impact on on other services and.
The impact is on staff. Understandable fear. We mustn't forget that this is before vaccination,
and it's very easy now to forget that this was a an infection which demonstrably had a high mortality and people were dying, you know.
Clinical staff were dying. We know that people had seen that in the media before it arrived in the UK and it was happening already in the NHS.
And of course, unfortunately some of our colleagues sadly died as well.
And of course, it was having a massive impact on patients. We were you know, we were seeing, you know.
A volume of of illness and mortality that probably none of us have have seen before or since.
And did you yourself get involved in doing any of the intensive care work?
Not in intensive care, but I worked in infectious diseases.
Yes. And the within infectious diseases, we provide daily advice to intensive care of the management of the patient.
So there's usually an intensive care ward around. And no, in normal world we go round from bed to bed with the team and review every patient.
But of course things were completely reorganised within COVID,
so we had to first of all expand the number of intensive care beds very significantly and that involve procurement of ventilators and and,
and, and space.
But also we had to reorganise the intensive care unit so that some became covered and some were non-covid and, and the COVID intensive care units.
We minimised the number of people we went in there.
So one's role as an infection doctor advising on those patients actually then became slightly remote.
So we would meet them in a room that was separate and we would run through the patients and talk about it.
But it was, you know, it probably didn't make a major impact on the quality of the advice that we were able to give.
But it definitely had a very different feel at that stage.
And, you know, initially it sort of felt like COVID could be anyone or anywhere.
Yes, I sort of said that the testing took a while to catch up on and and so we didn't know.
We could only test those people who met the case definition. We were waiting quite a long time for the results to come back.
And so anyone who had a fever or respiratory illness, you know, could be COVID.
And we had a traffic light system for triaging the likelihood of COVID and but they would
be on your infectious disease ward if they weren't severe enough to go into intensive care.
Now, very quickly, we very quickly initially, yes, but for a very short period.
And then we exceeded the capacity of the intent of the infectious diseases wards amongst these patients.
So, you know, I remember I forget exactly when it was, but in one of those in the early part of that wave with infection control colleagues.
Thinking.
Actually, we need to know what the situation is in the hospital and with the support of the infectious diseases team and the infection control team.
We audited one afternoon. Every single patient in the hospitals to work out what to traffic, light them to work.
And we literally had maps of the hospital with beds in them and we were putting stickers on it as it so that we could see what's the situation,
because of course we didn't have electronic systems to tell us coded on them. You know, this was all evolving very, very quickly.
And then and that was, you know, around the same time as we were reorganising into as we really got a plan to do into COVID wards
and and and cohorting patients who had COVID might have COVID and we didn't think had COVID.
And and again, we we had some clues and we all became very familiar with the clinical pattern of disease with time.
And, you know, some of that we were learning from the literature and from talking to those doctors in Wuhan and in Lombardy.
But it was a pattern of illness in terms of.
The clinical presentation. But also in terms of radiology, we all got used to saying, well, yes,
there is a typical changes on the chest x ray and everyone was, you know, an expert, you know, within a few weeks.
Similarly with the blood tests, we started to recognise that blood clots were an important complication that, you know, evolved over time.
So so it was it was a period of really rapid learning as an organisation, but also clinically, individually and in teams.
And each peak, of course, was different. So that first peak, it was really rapid, it was new.
We, we had limited tools. We didn't yet have any treatments.
Research was an important part of it because of course recovery, recovery and trial was started.
During that time. We had a really vulnerable population because no one was vaccinated.
And there was that, you know, really high mortality. Mortality was lower than the average.
But nevertheless, you know, it was it was a disease which which took its significant toll.
What sort of percentage?
So I think I think in our ICU cases, our mortality was in the high twenties as compared to national mortality in the early thirties.
But I know it's a long time since I've looked at data centres, so so I'd have to remind myself exactly.
But, but you know, it was, it was a really but the nurses were seeing patients dying.
Not just everybody was seeing the patients dying.
And sometimes, you know, spouses were dying within days of each other, you know, on different wards in hospital.
And I think anyone who wasn't touched by that emotionally was, well, I suspect that there was nobody wasn't touched by that in a way,
even though for many, I suppose it would it takes quite a long time.
And I think we're seeing that played out now that in some ways it's easier when you just get on with it.
And in that sense, I felt very lucky to be able to do something.
You know, Of course, lockdown then happened and for many people they were stuck at home.
And I can't think of anything that would have driven me more mad than feeling being at home and feeling unable to do something.
And I think there were lots of people who felt in that situation. So in some ways it was a huge privilege.
And although we were all working incredibly hard, there was an adrenaline, quite a long lasting boost of adrenaline that kept everybody going.
And that teamwork, I keep coming back to it, but that really was phenomenal.
And then within that there, as we went into the spring and the summer, it was glorious weather.
And I can remember some of those weekends, you know, where I got my phone on me and I asked answer questions and, and it always be things to do.
But actually just being able to spend that time outside, I you know, I remember some really very precious family time in that time as well,
which maybe all the more so because it was contrasted with what was going on on the weekend.
And we all also had to think very rationally about what the risks to our to us personally were.
Yes. Especially when you're in a leadership role and you are taking people to your you're supporting other people to look after these patients.
Again, an infectious disease, we are relatively privileged because we've been used to the concept of looking after patients with high consequence
infectious diseases when it was delegated for about from a high consequence infectious disease and PPE change.
That, of course led to other anxiety.
And, you know, and that was a and that played into how people felt a little bit about things.
And so being able to think sort of rationally through the numbers in terms of, well, yes,
my risk of dying is if I get COVID is probably about twice the risk of dying and getting out of bed this morning.
Well, actually, you know, I'm not worried about my very small risk of getting out of bed this morning.
So but but, you know, for everyone and of course, depending on your your age and your background, those risks were a little bit different.
And there was a, I guess, a degree of introspection that everybody had.
I mean, you knew situation, you were obviously a relatively young, very healthy person.
But on the other hand, you were working in an environment where the risk of there might be virus floating about was quite high.
Yeah, you weren't secluded in the way the rest of us were. That's absolutely so.
So I think that it forced lots of reflection, which, as is often the case, takes a while for people to process.
And I think I think that that's not irrelevant to the way that the workforce
is is is feeling and processing things even now and not just in healthcare.
Of course, by the second peak we were starting to see the benefit of.
And so we we knew that steroids worked from recovery. And so this July was it not to the them?
I can't remember. If I'm really honest, I know we were kind of led to this in August.
And I think I think it probably was late in the year I would have to go back.
Okay. So it was the ultimate. Yes, This was that second peak.
The, um, was actually one of the biggest peaks.
We had about 350 patients in the hospital and the but we could we could already see some of the effects of the treatment in steroids.
So it was tangible at the bedside. What we knew from the clinical trials, again, still pre vaccine and I think in our models evolved too.
So we one of the really important things we did was we set up a service called COVID Care at home,
and that was initially we tried to set something up with primary care.
I think that's quite complicated because primary care is quite disparate.
It's and and it was clear it was going to be difficult to do that quickly.
So working with Dan Larson, who leads our acute hospital at home service and make it upended as the chief medical officer and who gave us her support,
we were able to really very rapidly set up the care homes.
So essentially from making a saying, yes, just do it, we were able to do that within a week and have a and have a service.
And I you know, I can't think of any other service that's been set up quite that quickly for quite the volume that it then started to manage.
So this was seeing patients and then either hospital avoidance so that we we discharged them home or like allowing patients to leave hospital early.
So discharge support and facilitation.
And it was really in some ways the service was uniquely helpful for COVID because what we knew and this was particularly the case pre-COVID,
was that the illness was often biphasic.
So there'd be often be a an initial sort of highly viremia phase that was a bit like flu and then a secondary deterioration that might happen,
you know, anything from towards the end of the first week up to a couple of weeks.
And it was that during that deterioration that patients might become very hypoxic, low oxygen levels and could die suddenly and patient.
You know, people did die in their beds. And, you know, even from again,
I remember vividly those descriptions from Lombardy of people turning up and looking at looking actually quite well, but having oxygen saturation.
So which should normally be in the high nineties that were in the sixties and you
know it was a term happy hypoxia that was that was that was used to describe it.
And so the principle of the model of keeping care at home was to identify patients who might be having that deterioration.
So they had an oxygen saturation monitor at home and they were encouraged to check their
oxygen saturations twice a day and both at rest and doing a brief period of standardised
exercise and and which is just sitting to standing for a minute and then to record it
and we would find them and once or twice a day depending on their risk category and,
and check how they were and if necessary we could go into their home and review them or we could bring them up to hospital and you know, as that.
And that was supported by a group of specialist clinicians.
So Dan Larson was really key in integrating this into acute hospital home.
But infectious diseases, respiratory doctor sort of contributed to the multidisciplinary team that that reviewed these
patients virtually and and ensured that we were providing them with the care that they needed.
And actually that evolved quite complex medicine. So, you know, not just managing the sort of acute COVID things,
but managing all their other medications and their diabetes and other things
that particularly as we as we push the boundaries a little bit of this where,
you know, we started giving blood things at home and and and for selected patients, once we got the recovery trial data,
some steroids and and even oxygen in certain cases where where we're able to deliver that and it made sense to try and do so.
And in fact even later on, some of the new modulator therapy was given in the community using that example.
So and this is a terrible question to throw in at this point, but is it cheaper to do that than to have in the hospital?
And I think the debates around about the pros and cons of that, the economic pros and cons are probably still being had?
Yeah, I mean, I think I'm just wondering whether it's a model that could be rolled out for the different kinds of.
Well, it's a it's a it's a the the hospital home model is a model that has been and is and continues to be rolled out.
And there's a lot of interest in it. You know, we've sort of transitioned from the model.
This is a little bit of a of a of a tangent, but it's worth answering.
So 20 years ago, everybody would come in the front door, they'd get admitted.
They stay in hospital for a bit. There wasn't the same huge pressure on discharge.
And and and so length of stay we're probably, you know were longer.
Gradually what's happened over the over the last couple of decades is that that length
that length of stay has really reduced and that's because occlusions have got.
Well, probably partly because some treatments have got better.
But clinicians got increasingly comfortable with managing risk and actually recognise the harm of patients being in hospital for longer.
And we've got more agile at supporting those discharges and recognising the benefits of being in your own home.
We've also developed a whole new sort of service model called same day emergency care,
which and we've got a whole unit that does that within within medicine and,
and, and that's been phenomenally successful,
especially when you can bring with that the resource you need for rapid diagnostics, you know, scans and other things.
And many of those patients then managed ambulatory pathways.
So they might be brought into hospital for for investigations,
given some treatment brought by the next day or a couple of days later, depending on their clinical needs.
So so the quick answer to your question is yes, there's you know,
there's a whilst there were some quite specific things about COVID in that secondary
deterioration that made the oxygen saturation monitoring particularly useful,
that broadly the the acute hospital home model is one which has a very definite role within that provision.
Yeah. And and I think, you know, there's nationally there's there's there's been a very concerted effort to try and build that post-COVID, I think.
It's not the case that you can. It's like everything from COVID to every other respiratory illness.
I think there was something quite specific about COVID that made that useful.
And and and actually now with vaccination and the other treatments that are available, we don't really have a need for that.
The amount of illness we're seeing is is a lot less.
We've essentially stood it down as a as a completely separate service that we can still do that if we need to.
And because we don't tend to see that biphasic illness in the way that we were seeing it before.
So again, it doesn't automatically translate to pneumonia or other respiratory diseases.
Um, but you know, so we, we set this service up really rapidly and actually for me it had reminiscences of,
of what was happening in the research space as well.
So um, I'm one of the ethics committees and we were doing what we'd actually done in the West Africa Ebola epidemic back in 2014 and onwards,
where instead of the normal process of ethical approval of studies, which, you know, takes many months,
we were being asked to approve studies like the kind of the COVID vaccine trials very quickly.
So we were, you know,
things would being done by email or with bespoke meetings to deal with things which which allowed the process of institutional approval to,
um, to proceed much, much more quickly. And of course was fundamental to the way that the research found out.
And it was, it was, it was very nice to see some of those, some of that, um,
agility happening in the health service as well in terms of setting up new services.
And I very much hope we will be able to maintain some of that because it can be frustrating, you know,
trying to sometimes set things up and we the, the led predominately by the respiratory team a similar sort of model.
We set up a long COVID clinic because of course that's the other part of things.
And again, you know, as infectious diseases, we were contributing to that, to that and to that model early on as we have benefited from that.
Right. And we all try to learn from that actually, because within infectious diseases,
partly for historical and other reasons, and we manage, um, chronic fatigue syndrome and the,
and, and so I had some experience in that and there are some similarities to the,
to the Post-viral fatigue and other symptoms that that Long-covid has.
And I think my hope and I don't know whether I'm less optimistic now,
but my hope really was that the burden of long COVID in the worries about it would bring in
the resources to really start to understand that disease much better and hopefully bring,
you know, translate some of those understanding and benefits to other people who've got chronic fatigue syndrome.
I think, you know, that's ongoing and I'm not at the coalface of that,
but it would be nice to think that we might learn something that's got wider benefits from that.
And then, of course, you know, the vaccine was rolled out and that's a whole other story which you're very familiar with.
And and and others can tell much better than I.
But but, you know, that, again, made a fundamental difference to the clinical presentation.
Yeah. And because, you know, patients who were vaccinated were by and large getting much less severe illnesses.
We knew from the vaccine studies, but of course there were those that were not vaccinated.
And again, in those early days where we haven't got quite the repertoire of, um.
Treatments that we've we've got now.
We were still seeing some people who were not vaccinated, who were quite a significant minority of people who were not vaccinated,
who who who were very severely ill and in some cases died.
And that was very difficult. And, you know, some of the conversations with with those individuals were were interesting and difficult at times.
And in many ways, I see them as victims of of of a lot of mistrust and misinformation that's out there.
And did they I mean, it's I don't know if you were able to have that level of conversation,
but did they have deathbed conversions to see that terrible.
Well, it wasn't always that bad, But but yes, certainly as a new vaccination was, I think,
rightly a part of the conversation with people, because, of course, you can get infected more than once.
And so it's really important to address.
And I so I did talk to and to the is, you know, it means it is new, whereas it might be me.
And so I know so I did so I did talk to a number of patients about it and I'd say there was a variety of responses.
Some people were very clear that they didn't want to have anything to do with it.
There were others who expressed regret because they were unwell.
I remember very clearly one man, and I guess this also goes to sort of the heart of the social dimension to this who who had not been vaccinated and
and said I wasn't vaccinated because my wife is such an anti-vaxxer I didn't want to cause trouble in my marriage,
you know, and and but, you know, clearly his instinct had been to to get vaccinated.
And so I think we had glimpses of of the way that this was affecting everybody and and and.
And quite deep social levels. That's probably stating the obvious.
And we then had a pipeline of therapies as as the recovery and other trials demonstrated the benefit of additional treatments.
And, you know, outcomes have have obviously improved quite a lot since then and possibly also driven by changes in the pathogenicity of the virus too.
But from a staff point of view, things are also different because, you know, once you've got vaccinated,
staff people feel that much more protected and and you're being able to roll out a vaccine for staff was hugely important.
But so on the one sense there was things were easier because of because of the protection that vaccination afforded.
But the workforce is really really tired. Yeah. And and there are still,
you know huge service pressures so you did I think you said you were going to come back to testing because obviously the situation
with testing changed at some point and testing of the health care workers was something that was obviously going to be an important.
Yes, absolutely. And so we and so testing, testing of healthcare workers sort of happened in, well, two context, really.
So we provided regular testing for healthcare workers before routine lateral flow testing was was available to everybody to sort of take care.
And was that being analysed locally. That's right. So yes, so so this was on the back of, of, of the testing regime that was set up here.
Yes. Derek Crook and colleagues in the university with Katie Jefferies input and the and many, many others.
And on the back of that, there were some important publications around, you know, sort of helping us understand relative risks in different areas.
It's difficult to interpret, you know, completely because of lots of potential confounders.
But actually, I think one of the key messages that came out to me and for others was that in the areas,
you know, one of the areas that we'd worried most about was intensive care.
But actually the risk of infection in that setting was lowest in term in terms of that.
And again, you know, if one ignores to mitigate some of the potential confounders,
that it does actually make sense because often the people that were getting really sick and requiring intensive
care were in that second phase of the illness where the most infectious vari McVeighs had already happened.
And then there was the second immunologically driven phase,
which which led to probably the the the infection risk in that group was less and and I know and of course many of the
precautions were greater in terms of the PPE that was worn and many of them are ventilated so in a closed circuit.
So the process of ventilation is a potentially high risk aerosol generating procedure.
But once you're on a closed circuit, actually the risk should be very small.
So so that was you know, that was interesting and I think really important to give some comfort to people who were working in those areas.
I think, again, I think you can't say it often enough,
but huge respect to colleagues of all colours who who work in these environments and every country and.
So so yes, testing, testing for staff was was was really important.
And then, of course, became baked into what we did in terms of hospital infection control and lateral flow tests at home and so forth.
Um, I just want to touch on the service pressures and then I think it would, you know, might just reflect, we could talk in terms of business.
I think sort of where we are now is we're left with that tired workforce.
And clearly, you know, that's obviously in the news with industrial action and, and and I think very obvious to everybody.
And at the same time, these huge service pressures say we've got very long waiting lists.
There's huge pressure on social care, which is causing the pressure, you know, pressure on hospitals.
And we've we've seen, you know, anecdotally and I think, you know,
borne out some of the data delayed presentations of a number of things with because
we did have reduced health care presentations during COVID for a lot of reasons.
You know, some of those were fear of healthcare as a as a potential risk of infection.
Some of it was a desire not to overburden healthcare.
Some of it was difficulties or different models of access to health care.
And although patients were always encouraged, people were always encouraged to present if they if they were unwell.
And the mental health burden is huge.
And that's being felt not just um, at a in the mental health services which are clearly already stretched and now even more so.
But it's being felt in the acute hospital setting and it's very definitely felt in the emergency department and,
and adds its own toll to the staff who work in those areas and the ward areas.
Um, the but also in the community you know and, and you know the police are having to deal with a lot of this too.
And so so I think there's there's a the health burden is is very wide and and has a very wide impact socially.
We know that during COVID the standard things that we do in terms of preventative medicine were less good.
So people were not monitored for their blood pressure.
People were not being as routinely diagnosed of high blood pressure.
There's, as predicted, you know, high rates of cardiovascular disease and stroke and things as a result.
So the pressure on the acute services is has remained very high and in some cases higher.
But of course, there's all that elective backlog as well. So so that's the situation we're in now.
And I wanted to make sure we did cover how your own role developed as a result of because I mean,
it sounds to me as if a lot of what you were doing to all this was management planning.
Allocation of resources, human and otherwise, thinking of better ways of doing things.
And you hinted earlier that that was what's the reason that you've ended up in these management roles on top of your clinical responsibilities?
Yes. Thank you. And if you'd asked me five years ago, we would have been doing the role I am doing now and have told you.
You add that I love my clinical work and the but a couple of things.
It sort of inspired me to do it both inside and outside work actually.
So I appreciate that I was involved as chair of governance for a local school and as a as a very unique school.
We had a number of challenges to deal with.
It's a European school which which had to change its model post Brexit.
And so I, I found myself working with some fantastic people to to sort of overcome some of those challenges and which,
you know, we've negotiated, I think, very well.
And I've got a huge sense of achievement out of that, which already made me sort of, I guess, reflect on the first of all,
enjoying the challenge of problem solving in that sense and and the strategic challenge and and and the enjoyment of making things happen.
I think so. So that was that was, I think, a very important formative experience.
And then within COVID, as you say, I quite quickly got co-opted into some of the groups that were involved in this.
And and as the clinical lead for the department had to take on a leadership role, as I'd say,
a large part of that was enabling because there were you know, there were, you know, a lot of the things that we developed, you know, it wasn't me.
It was enabling the team to together, but the need to do the skill.
And I hope so. I think and I and I and I again, I found that a very rewarding experience.
And, and there are huge challenges that face the health service.
And I guess I go back to where I started in medicine. I came as in some ways from a.
The public health perspective in terms of thinking about how do we improve health, health care?
And in that time, that was, you know, in the context of the developing world and for family reasons, you know, I'm now based in Oxford, but actually,
I guess some of the motivations of that are not dissimilar in terms of thinking about how can we what can we do better, How can we do it?
Can I have I got a role in trying to do that?
And it's in that context that I applied for and was appointed to my current role and which has been rewarding to me.
So it's been a it's been a journey and in many ways an unexpected one, but not one I've regretted.
And what are the the main route I took to make another pitch about this as well?
But quality improvement seems like a very sort of generic term.
But what are this? The the areas to focus on, the most important areas to focus on.
So as you say, quality improvement is potentially huge. And it is.
And I, I think it also means different things to different people.
Um, classic quality improvement or QE is, is all about trying to improve systems in a sort of grassroots up way.
And actually echoing what I was saying a moment ago,
it's it's a lot of it's about empowering people on the ground who are the experts in their area, in their speciality, in their patients to.
Look for, see and implement improvements.
So some of it's about letting go and creating some some capacity and enabling that to happen so that your your job becomes not just doing your job,
but improving your job with benefits both for the service but also ideally for the staff as well.
You work in that service. So so that's that's what that's I guess that's the nub of, of quality improvement.
And what we are trying to do in there is foster a culture that allows that in terms
of giving people the skills because there are some tools that allow one to do that.
And and it certainly if everybody has a similar understanding of the tools and the approach,
it makes it easier for people to collaborate on those things, but also hopefully shortcuts some of the potential pitfalls.
But of course, you know, there are broader things out that, you know, service wide improvements that need to be made.
And some of those are national challenges like the times we've got with agents and emergency care.
You know, our organisation is under huge pressure, as is every acute trust in the country and many of the challenges will be similar.
The solutions might be slightly different and that's where I guess the key but it comes in in terms of understanding the detail locally.
But some of the solutions are probably common to many of those many organisations.
Sorting out the capacity in social care, for example, would allow us to discharge more patients from hospital when they're ready to be discharged,
which would automatically create more capacity in the hospital to allow patients to flow through the department to create more space,
which commissions the space to be able to see those patients and manage those more quickly.
So there's, you know, there are some lots of interdependencies, some of which sit outside the immediate hospital sphere.
And so then if that answers your questions, it does. It does.
Yes. I think there are some lessons from COVID that it's worth perhaps in the last few minutes, just just sort of reflecting on.
And I think the first thing to say is clearly what happened with vaccination was phenomenal.
And, you know, it's wonderful that Oxford played such an important role in that.
And I think we're very lucky to be embedded within the academic capital that we are.
But it is easy to forget that the NHS dealt with two peaks and some really unprecedented challenges before vaccination came online.
And we were really fortunate, not just with our academic background,
but because of the leadership we had very early and seriously and allowed us to do it.
And, and that teamwork which which, you know, was such a, an empowering and inspiring thing for me,
I think there were some lessons from the national approach, and I sort of hinted that might come back to this in terms of testing.
But I think testing is a really good example. We took an approach which was not universal.
If you look around other countries initially to centralise testing and,
and we and because we centralised it, we also centralised the case definitions for testing.
And around that we also have sort of centralised some, I think, dogma at the time.
So there was a dogma early on that asymptomatic transmission didn't happen, for example.
And then of course you're never going to discover if asymptomatic transmission happens,
if you never test people who've been in contact with someone who's been asymptomatic.
And I think, you know, anecdotally, for example, in Oxford,
we had there was a it was there was an outbreak associated with one of the university choirs.
And I remember the conversations at the time of could we could we test, you know,
there was an explicit recognition about the about could there be asymptomatic transmission.
But they're very clear the only way of getting testing was nationally. And the only way you could do that is if you've met the case definition.
So you didn't see testing didn't happen.
And I just reflect that actually, had we not been quite so dogmatic about some of those things and not centralised it quite as much as we did,
and in fact it turned out that the test they were using centrally wasn't the best test,
and yet partners in the laboratory were crying out from early January to say, Can't we just can't we set up some testing?
And had we not been so committed to centralising things early on, actually we probably learned about those things a lot earlier.
And we may have you know, we may have spared some of the infection and mortality that happened as a result,
you know, would have it would have informed our infection control precautions.
It was it was similar aspects. You know, it's hard to be critical, isn't it, because this thing evolved so, so very quickly.
But, you know, those the case definitions around travel also felt like I could vividly
remember being need with with with people that you thought this could be COVID,
but they just can't remember where they came from now. But I'm talking to one of my ID colleagues was saying we should be able to test this.
I agree, but we can't because they've not know at the moment. Never really extended it to Taiwan.
Yes. So so I think that was frustrating.
And there are some other examples of that. I think, you know, centrally too, it was,
and probably partly because it was focussed initially within the high consequence infectious disease network.
And in fact we sort of became a surge centre in March,
but only just before it was designated as a high consequence infectious disease and probably centrally nationally.
It was slightly slow to realise what was actually happening on the ground and, and how quickly this and this then it exploded.
But then by contrast, you've got recovery and, you know,
I think it's no accident that it was 176 NHS hospitals that delivered the
recovery trial and all the benefit that that has had for patients with COVID.
And and I think for me, that's the single most important lesson to take away from this.
I think we're incredibly fortunate to have our joined up National Health Service.
It has many imperfections. There's lots of things that we could do better.
It could be more joined up in some areas.
But but I think that that the recovery trial clearly provides a model for what we can do and should do in terms of improvements for.
Advancing the cause of research within the NHS.
Because if we could harness that. Capacity and capability for many of the other big questions that we've got and just have the courage to
do that rather than implementing things that perhaps don't yet have the have have a solid evidence base,
I think that would represent in the long term much, much better value for taxpayers money and know the NHS is quite rightly being put at
the heart of the UK Health Sciences Vision and so Life sciences vision and I think.
It's really untapped potential. But we've got some hard work to do to meet that potential, because although we know that.
Conditions want to be involved in research.
And we know that being involved in research is associated with greater job satisfaction and so forth.
We've got to create the time and resource to allow them to do that.
And clearly the service pressures make that difficult. But I think it's part of our medium to long term plan.
That's a crucial. Pillar.
I think it would be really sad not to do. That's lovely.
Thank you very much.