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So can you start by saying your name and what your current position is?

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So I'm Andrew Brent and I'm an infectious diseases and medicine consultant at

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Oxford University Hospitals and I'm one of the deputy chief medical officers.

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Okay. So going back to the very beginning, how did you first get interested in medicine and decide to be a doctor?

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So I, I, I, I considered medicine as one of several things as I was in my later years at school.

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And by the lower sixth, I pretty much decided I wanted to do medicine.

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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.

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I do have one uncle who was an orthopaedic surgeon, but I hadn't had any direct exposure to medicine.

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So I prepared my in those days UCAS form to apply for medicine.

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And and then he very kindly organised for me to spend a week doing some experience to see medicine.

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And I spent that week in a hospital in the north.

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And after a week there, I don't think I'd met a single positive doctor.

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I'd met quite a lot of people who were, I think, fairly frustrated with their careers.

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I'd heard a lot about the negative aspects.

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The most enthusiastic doctor I'd met was probably someone who was, in retrospect, clinically depressed, but had given me some time.

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And and I came away from that probably rather serious.

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A 17 year old not quite sure it's what I wanted to do after all, and decided not to apply for medicine.

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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.

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So so it was a false start for medicine.

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I then spent a large chunk of my year off working in India,

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a proportion of which was doing some sort of very basic health care assistant type work in Calcutta.

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And during the course of that year, I never really let go of the idea of medicine.

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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,

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I couldn't change immediately. I did a year of natural sciences and then I was fortunate.

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It was a process of sort of internal replication to to get a place for medicine the following year.

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So I then transitioned from natural sciences to medicine, and I did my undergraduate in in Cambridge,

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and then I came to Oxford for my clinical and then I pursued my postgraduate training mixture of here and abroad.

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I one of the key reasons I went into medicine was an interest in the developing world.

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I'd grown up in the tropics, in East Africa, the Middle East, the Far East,

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and that was a really large part of my driving interest, I think thinking about health in the context of development.

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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.

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I was fortunate during the course of my training to spend two periods of my contract fellowships working at the Wellcome Trust,

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Oxford Centre, the Kenya Medical Research Institute in Kenya.

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And and and so I returned from my second stint there in 2011, 2012,

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and towards the end of my training in infectious diseases initially to a university post.

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But then in 2015 I took up a substantive NHS post in infectious diseases and general medicine in Oxford,

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and in 2018 I became the clinical lead for infectious diseases.

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And so I was the clinical lead for infectious diseases.

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When COVID arrived at the end of 2019, early 2020.

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Yeah. So at what point did you become interested in alongside and grow, excuse me,

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in getting involved in hospital management or health services management that were very good question and very, very belatedly.

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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.

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So what sort of infectious diseases that you tend to see practising in Oxford?

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I mean, clearly infectious disease is a huge problem in the developing world,

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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,

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it's a bit sidelined in Western countries where all the focus is on cancer and heart disease and so on.

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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.

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Of course, many of those things particularly in primary care, are.

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The sorts of infections that don't present a very big risk to the population and or even to the to the individual.

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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,

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you know, common infections, pneumonia, urinary tract infections, gastrointestinal infections.

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And most of that in most parts of the country is dealt with within the sort of general medical sphere,

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although there are variations in models across across the country.

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The that there is, however,

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a lot of quite complex infection and and that has has only increased in its complexity as medicine has increased in complexity.

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So you know the increasing complexity of surgical procedures and the complications thereof, which often include or might include infection.

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And more and more patients are on immunosuppressive medication,

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which which comes with risks of opportunistic infections which present differently

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from the way that infections might present in you or I with with good immune systems.

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And so there's there's there's a there's a need for infection expertise in managing those.

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And and then of course there are the sort of traditional infectious diseases.

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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,

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you know, we've got a cohort of several hundred patients with HIV whom we look after and we look after patients with TB.

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And there are some areas even in Oxfordshire that have had know quite significant incidence of TB and some important outbreaks.

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And even in the last few years there are other parts of the country and in the parts of

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London where the incidence of TB is similar to that in high incident incidence countries.

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So, so so another important part of our core business in infectious diseases is looking after patients with those,

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if you like, traditional infectious diseases. And we also look after patients returning from other parts of the world.

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So the returning traveller and that might be with the number of infections,

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we have a steady stream of people who've got malaria, imported malaria and other diseases like typhoid.

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And then really important element of this, though rare but very relevant to the context in which COVID arrives,

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are high consequence infectious diseases. So you can broadly divide high consequence infectious diseases into two groups.

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You've got highly pathogenic respiratory infections.

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So that would include things like SA's, obviously the Corona virus, Murs, Middle East Respiratory Syndrome,

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another Corona virus, very important part in the story of of COVID and the vaccine development.

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And as you know, but also other infections like viral haemorrhagic fever.

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So things like Ebola, Lassa fever, Crimea, Congo haemorrhagic fever and so forth.

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And so because there is a small risk that patients returning from areas where these infections might be,

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the epidemic are endemic and we within infectious diseases, have to have systems in place to safely manage those suspect cases.

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And there are case definitions which are defined nationally and and which we follow.

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And we've really been pretty rigorous at this. I think it was always something we did even in my training,

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but I think we got really quite professional at doing it in in about 2014 with the West Africa Ebola epidemic.

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And this is it to do with isolating isolation from each other, wearing full PPE for health care workers?

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Well, absolutely right. So if you have a patient who comes back from an endemic area with potential

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exposure and meets the clinical criteria for management as a suspected case,

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then you need to manage them very safely. And absolutely, that's it's about isolation.

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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.

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And it's about the personal protective equipment, but also not just about the equipment itself,

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but about the processes with which you manage that in terms of how you put it on,

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most importantly, how you take it off, because that's the highest risk bit of your contaminated, how you work together and teamwork.

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It's buddying when you go in and really quite well established protocols.

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By the time we get to 19 2 to 2019 about how we manage those cases of suspected high consequence infectious diseases.

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So quite a broad range of infectious infectious diseases.

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And, you know, I guess we're lucky in Oxford that we've got a quite a big department.

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We have a large number of trainees and the size of the department partly reflects

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the fact that many in the department have a very portfolio which includes a.

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Teaching and research and contributions to the clinical work.

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So lots of in-house expertise, which again is not irrelevant to indeed into the to the landing of a pandemic.

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Absolutely. Thank you. So let's let's get to Kobe.

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Can you remember how you first heard about it?

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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?

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So it's hard to put my finger on exactly when I heard.

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But I think I was aware in late December.

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I subscribe to an email service called Pro Edge, which gives you lists of potential or emerging epidemics in parts of the world.

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And and it came up in premiered, I think, in late December 2019 and it hit the BBC news at some point.

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I think it was probably early January, but it might have been late December.

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I don't recall exactly when, Certainly by sort of the end of the first week of January,

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we were we were getting the first communique, Public Health England Communications,

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about what was then known as Wuhan novel coronavirus,

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and that was on the back of the identification of the virus in early January in China as a novel coronavirus.

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But at that stage, the messages were that there was no evidence of human to human transmission.

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There was no evidence that any health care workers had been infected.

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Of course, that story evolved very, very rapidly over the over the following few days and weeks.

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And and at that time, of course, this was considered a high consequence infectious disease.

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And so and that was the framework in which all of our work and interaction and preparations for COVID began.

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The period of sort of January through to early March was a very busy one.

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And it's in retrospect now sitting here in 2023, it's slightly difficult to disentangle the exact timing of all of those threads.

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But certainly in January we were already managing suspected cases.

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I recall that we work quite closely with university partners and and so we're in regular

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communication and with the local health protection Unit and Public Health England.

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And there was a group of Chinese students who were visiting the university from Wuhan and were who were then quarantined in a Travelodge.

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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.

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So they were among some of the first suspected cases that came in.

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And, you know, when they come to hospital, regardless of the severity.

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Absolutely. And this is one of the things that changed very rapidly in the following weeks,

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because initially we were admitting actually very well people with minor symptoms treat treating

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them and managing them as a potential high consequence infectious disease with all that PPE,

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they were staying in hospital several days, sometimes because there was a wait to get the tests back.

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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.

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I remember one of the things that we one of the referrals was someone in Bicester Village who'd seen

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someone Chinese and was really worried that they might have that they might have this horrible virus.

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I've interviewed several Chinese researchers who encountered hostility and really made them

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change how they felt about being in the UK very much because I can well understand that.

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I remember that. I remember that that sense in those early days very well.

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And in late January that we were in contact with the local public Health England,

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a number of British nationals were repatriated from Wuhan back to our Brize Norton.

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And so we were on I remember being on stand by in case in case we needed to admit them.

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They they were then all transferred up to Merseyside to a specialist area and supervision.

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And I think that made the news at the time as well.

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So, you know, these these are little milestones in what was what was day to day, a very, very busy time.

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I remember the last weekend of January.

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So having just looked at the diary segments, I mean, Saturday, the 25th of January,

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we were invited by friends to a Burns Night and that was the last sort of proper night out for a very long time.

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And I'd been invited to give the toast to the lasses.

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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,

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because actually the lion's share of the time I spent that day was dealing with suspected cases.

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So by that time we were already very, very busy dealing with suspected cases, although no confirmed cases at that time.

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And again, still all as a as a as a high consequence infectious disease during January.

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And there was a lot of communication with partners in Public Health England,

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with the ambulance service with whom we had to build really quite rapid lines of communication,

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but also collaborate and and also with academic colleagues, many, you know, many in the department.

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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.

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Back in those days, it was possible to have pretty much kept on top of the literature because it was very small.

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Of course, that burgeoned and later became impossible. But but actually everything that was coming out,

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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.

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And on the 4th of February,

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we have a weekly lunchtime seminar on the Tuesday and we have invited speakers across the range of infectious diseases and pre-COVID.

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It was always in person and it's since become virtual like many things.

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But on the 4th of February we gave over that session to talk about the Wuhan virus, as I think it was still called.

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Then it changed its name at some point due to COVID or SARS-CoV-2.

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And and that was an interesting session, firstly, because I think that the data that was.

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Presented with suggesting that this virus did appear to meet some of the important epidemiological

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requirements in terms of the R number of and and mortality of a potentially pandemic causing infection.

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But it was also interesting because there was a wide range of views in the way that that was received in the room.

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And, you know, on the one hand, there was some anxiety and and in general, this was seen as quite serious.

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But there were some voices in the room who saw this discussion as irresponsible and alarmist.

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And so even within infectious diseases at that time,

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I think there was there were the it took a while, I think, for it to sink in completely everywhere.

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And there's still haven't been any you ever, you know, No, there were no UK cases yet.

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But by that and I think from memory, I think late January there were some cases outside China and Singapore and South Korea.

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The US cases were very early and in Spanish an epidemic took off and of course Italy, which will come to an end,

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but we were at that time really focussed on evolving our pathways and this was literally something that happened day to day.

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And my I was very grateful to my colleagues.

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I think there was a real departmental recognition that this was something that we had to think about and plan for,

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and therefore we had to create some time and space for it. So one of my colleagues very kindly took over.

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I was on general medicine at the time, took over my general medicine and released me to give some headspace to this.

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And, and, and that was really essential to be able to maintain communication and work

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with the team on the ground and and actually listen to everybody in the team.

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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,

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you know, what was evolving nationally, although in most cases slightly ahead of that and put together our own protocols and pathways.

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So we were, you know, our pathway initially for managing patients with a suspected high consequence infectious disease was,

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you know, these were usually sporadic cases we would bring. We would liaise closely with the ambulance.

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You need a specialist ambulance to bring them to hospital. We had a separate pathway through the hospital.

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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.

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And and so we were doing that initially this became very busy.

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And, you know, we were colleagues on calls, became managing these cases till nine, ten at night.

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And, you know, I mean, amazing to think back and just think how people just stepped up.

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I mean, this was quite a lot of extra work very quickly. And I can't remember any complaints in the department.

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Everybody just pulled a pulled their weight. And this was, again, before any lockdowns or anything was happening.

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But it was really just a fantastic can do attitude.

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That process became difficult to manage at such a high volume.

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And so it evolved and it evolved organically.

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There was a there was a national strategy to roll out things called Corona pods,

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which were essentially to put these little temporary buildings in the hospital ground where people could turn up and telephone and say,

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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.

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I remember one weekend, one of my colleagues, Tony Woodrow, who's now the Infectious Diseases Clinical lead, was on call.

197
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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.

198
00:21:15,990 --> 00:21:21,890
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

199
00:21:22,270 --> 00:21:26,520
and then let them go and then instead of them bring him up to the ward and testing them and taking that back down,

200
00:21:26,520 --> 00:21:29,670
we'd sort of taken them out. We've got a space downstairs where we were testing them.

201
00:21:30,390 --> 00:21:34,320
And then, you know, I think, Charlie, that we can actually board. What's the point of getting out the car?

202
00:21:34,320 --> 00:21:38,879
Let's just swap you in the car. And actually, so drive by testing evolved, you know, really quite quickly.

203
00:21:38,880 --> 00:21:45,030
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.

204
00:21:45,090 --> 00:21:48,209
But you still aren't getting results for 48 hours or something at that stage.

205
00:21:48,210 --> 00:21:56,400
Well, 48 hours, if you were lucky. The way that testing started initially was it was it was all centralised by public health England.

206
00:21:56,400 --> 00:22:02,400
It was all. On in Colindale and initially they were doing a PAN coronavirus PCR,

207
00:22:02,700 --> 00:22:10,530
and then if that was positive, they were doing further tests to look for for the novel virus.

208
00:22:11,100 --> 00:22:15,929
And that initially would make it would take another 24 hours.

209
00:22:15,930 --> 00:22:24,710
Although as the volume of testing increased across the country, that turnaround time actually increased to up to five days.

210
00:22:24,750 --> 00:22:26,600
So so and that happened really quite quickly.

211
00:22:26,610 --> 00:22:32,099
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,

212
00:22:32,100 --> 00:22:41,249
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.

213
00:22:41,250 --> 00:22:49,469
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,

214
00:22:49,470 --> 00:22:52,490
you know, where we were doing this at the John Ratcliffe Hospital.

215
00:22:52,500 --> 00:22:58,649
It wasn't the ideal state to, you know, there was nowhere very easy for people to park, certainly not for a higher volume.

216
00:22:58,650 --> 00:23:08,010
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.

217
00:23:09,300 --> 00:23:20,459
And that was a really fantastic collaboration with the Community and Oxford Health Trust and and working with partners.

218
00:23:20,460 --> 00:23:24,270
They lent us some staff, so we were able to set up testing.

219
00:23:24,270 --> 00:23:31,380
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.

220
00:23:31,710 --> 00:23:36,620
And and so we set up a separate testing system there with patients.

221
00:23:36,620 --> 00:23:39,839
So, you know, possible patients, those who needed testing,

222
00:23:39,840 --> 00:23:46,290
who met the criteria could come and drive part, be tested and and safely come in a separate entrance,

223
00:23:46,290 --> 00:23:50,930
be swabbed and come out and say that because they self-refer or would they know they they were they

224
00:23:50,970 --> 00:23:57,450
these were these were usually referrals through either public health England or general practice.

225
00:23:57,450 --> 00:24:04,110
Right? To us. Yes. But that became, you know, we we probably we managed, you know,

226
00:24:04,530 --> 00:24:13,740
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.

227
00:24:13,880 --> 00:24:19,650
And and again, of course these things then then evolved further as national testing evolved in different places.

228
00:24:21,060 --> 00:24:27,360
We we also had a model of community testing.

229
00:24:27,360 --> 00:24:35,639
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,

230
00:24:35,640 --> 00:24:40,410
depending on how well or otherwise they were and how how able they were to come up to hospital,

231
00:24:40,410 --> 00:24:46,920
if they could come up to hospital because they could drive or they and they could they could come up safely,

232
00:24:46,920 --> 00:24:51,990
then that was a plan A But for those who couldn't, we we developed a model to go out into the community.

233
00:24:52,770 --> 00:24:59,280
And I well remember the first time we did this, it was so, so we had to create you rotas.

234
00:24:59,280 --> 00:25:04,470
These were staffed by our consultants and but mainly by our registrars.

235
00:25:04,790 --> 00:25:12,359
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.

236
00:25:12,360 --> 00:25:15,630
And during all of this time this was all just within infectious diseases.

237
00:25:16,140 --> 00:25:19,470
And we were it wasn't yet affecting the rest of the hospital.

238
00:25:20,010 --> 00:25:25,050
And although the communications had gone out about suspected cases and so forth,

239
00:25:25,620 --> 00:25:31,500
and but we we teamed up with the ambulance service who gave us a car and a driver,

240
00:25:31,920 --> 00:25:34,920
and then we went out with the ambulance service to do testing in the community.

241
00:25:35,550 --> 00:25:43,350
And that first evening I was with one of the registrars, just wanted to make sure that the process was working.

242
00:25:43,350 --> 00:25:47,309
And so we we were very quiet.

243
00:25:47,310 --> 00:25:52,560
The first part of the evening we had no referrals, which was slightly quieter than the evenings before.

244
00:25:52,920 --> 00:25:59,520
And, and so we went and we made some films about how to essentially filming the process.

245
00:25:59,760 --> 00:26:03,059
We actually went back to her house and did it all there so that we could film to

246
00:26:03,060 --> 00:26:06,389
train other people who were going to be doing it and as a training resource.

247
00:26:06,390 --> 00:26:20,230
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,

248
00:26:20,580 --> 00:26:22,739
just been transferred back from Thailand,

249
00:26:22,740 --> 00:26:31,379
had been in prison in Thailand and had some respiratory symptoms and was in a cell with someone else with a history of asthma.

250
00:26:31,380 --> 00:26:36,870
He was having an asthma exacerbation and would we go there and do the testing?

251
00:26:37,980 --> 00:26:41,490
And that was an experience. And so we drove to Bullingdon Prison.

252
00:26:41,520 --> 00:26:46,349
Of course, you've got to leave all your and all your belongings as you go in phones and everything in the locker.

253
00:26:46,350 --> 00:26:56,700
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.

254
00:26:57,010 --> 00:27:01,570
What he didn't want to do is create unrest in the prison. There was still there was a lot of fear about this.

255
00:27:02,380 --> 00:27:11,380
And. And then we we turned up and the prison staff for him, of course, this was this was all very new.

256
00:27:12,670 --> 00:27:21,430
I mean, if you can imagine long sleeve gowns and gloves and masks and, you know, we traipsed through into into the prison.

257
00:27:21,430 --> 00:27:23,620
And the prison, not surprisingly, looked like a prison.

258
00:27:23,620 --> 00:27:32,680
And, you know, you like I will have a vision of what that looks like in from from television and other sources.

259
00:27:33,170 --> 00:27:36,639
And and we went in across the cell and we tried to keep a low profile.

260
00:27:36,640 --> 00:27:45,700
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.

261
00:27:45,720 --> 00:27:53,560
And there was a little bit of a standoff with the prisoner who didn't really want to be tested.

262
00:27:53,560 --> 00:28:00,910
And and so it wasn't quite an altercation, but we had to do quite a bit of persuasion.

263
00:28:00,910 --> 00:28:05,830
And and the registrar I was with absolutely fantastic.

264
00:28:05,830 --> 00:28:17,670
But, you know, fairly diminutive compared to this huge bare chested prisoner who was, you know, and not doing anything to not look intimidating.

265
00:28:18,510 --> 00:28:25,040
And and and while while we were having this conversation and.

266
00:28:26,760 --> 00:28:40,050
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.

267
00:28:41,070 --> 00:28:44,790
Explain to me what they're doing by that, by the prison officers with us.

268
00:28:46,000 --> 00:28:54,329
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.

269
00:28:54,330 --> 00:29:02,370
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.

270
00:29:03,090 --> 00:29:07,200
And and so they started to look out and then they stopped.

271
00:29:07,200 --> 00:29:19,410
And then there was a little bit of banter and, uh, and then sort of corona and corona virus.

272
00:29:19,640 --> 00:29:22,520
And then you could hear this being taken up by other and then, you know,

273
00:29:22,560 --> 00:29:31,500
within a few minutes there were 200 odd prisoners banging on their doors, shouting Corona, Ebola, corona, which was a fairly surreal context.

274
00:29:32,220 --> 00:29:45,540
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.

275
00:29:45,560 --> 00:29:51,360
Yes. But we we were able then to to test them into and then to get away.

276
00:29:51,780 --> 00:29:58,080
Both of them were negative. And I think that, you know, in a sense, it's a it's a good example of.

277
00:29:59,450 --> 00:30:08,870
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.

278
00:30:09,650 --> 00:30:17,050
And so, you know, probably being in a Thai prison was a relatively safe place to be, actually, I suspect.

279
00:30:17,520 --> 00:30:25,729
But here we are. And we used to have weekly teleconferences, national teleconferences.

280
00:30:25,730 --> 00:30:31,850
So and they were led by Keith Willett, who is the director of the response.

281
00:30:32,210 --> 00:30:42,440
And and, you know, we would talk about the SITREP nationally and then present solutions, you know, in terms of patient pathways.

282
00:30:42,440 --> 00:30:47,580
That kind of pods was a good example in terms of testing and etc.

283
00:30:47,660 --> 00:30:52,700
But it always felt as though and this is no criticism actually, because I think that I think it's inevitable,

284
00:30:53,450 --> 00:30:59,120
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.

285
00:30:59,300 --> 00:31:08,390
But, you know, we were lucky. We were well resourced department with a lot of internal expertise and and had had therefore the

286
00:31:08,390 --> 00:31:13,910
opportunity to do things that many district general hospitals wouldn't wouldn't have had the chance to do.

287
00:31:16,750 --> 00:31:21,459
We had our first case around the end of February or early March.

288
00:31:21,460 --> 00:31:29,050
I forget the exact date. It was linked to one of the returning groups from skiing in Italy at that half term.

289
00:31:29,770 --> 00:31:37,540
We know in retrospect that probably thousands of introductions separately into the UK around that time, but no case definitions at the time.

290
00:31:37,540 --> 00:31:42,880
We're still talking about China and had slightly extended to include Taiwan.

291
00:31:43,060 --> 00:31:45,860
There was something that was slightly surreal about it and.

292
00:31:48,370 --> 00:31:55,900
By March, we were going into our first peak and actually thankfully as a hospital, I think we were quite well prepared.

293
00:31:56,140 --> 00:32:05,230
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,

294
00:32:06,160 --> 00:32:09,580
which was very helpful in terms of learning,

295
00:32:10,000 --> 00:32:16,390
you know, the generosity with which people gave up their time and shared things, I think internationally was was phenomenal.

296
00:32:17,320 --> 00:32:26,920
Similarly, we arranged through colleagues a similar catch up with colleagues in Lombardy in Italy so we could try and understand,

297
00:32:26,920 --> 00:32:34,780
we could see what was unfolding in Italy. And so again, the severity of the situation at this point was, was very clear.

298
00:32:35,410 --> 00:32:39,819
Um, but, but we were also lucky that we had slightly more time than, say, London.

299
00:32:39,820 --> 00:32:42,760
So, you know, we could see the wave coming through London and also learning from that.

300
00:32:42,760 --> 00:32:51,729
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.

301
00:32:51,730 --> 00:32:58,060
And so and thankfully we were in a in a reasonably good place.

302
00:32:58,650 --> 00:33:05,050
Um, you know, I mentioned that colleagues recognised the importance of creating some time for planning, which was I think important.

303
00:33:05,450 --> 00:33:09,970
And my colleague Katie Jeffrey, who's the director of Infection Prevention and Control,

304
00:33:10,870 --> 00:33:20,130
set up a COVID incident management group in late January, which she and I co-chaired and which became it was a daily event.

305
00:33:20,140 --> 00:33:25,150
It happened first thing in the morning and with wide representation across the hospital.

306
00:33:25,150 --> 00:33:40,480
And actually that became a really, really important forum for listening to people's concerns and ideas and also sharing,

307
00:33:40,900 --> 00:33:44,710
you know, the situation, the SITREP and and the plans.

308
00:33:45,100 --> 00:33:49,389
And I think I mean, communication was absolutely fundamental to this.

309
00:33:49,390 --> 00:33:57,630
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.

310
00:33:57,700 --> 00:34:05,470
But you can always do more. Yes. And did you have systems set up to detect any transmission that was happening within the hospital?

311
00:34:06,040 --> 00:34:16,360
So. Well, one of the challenges was that that we were obliged to follow the national case definitions.

312
00:34:16,540 --> 00:34:21,670
And the national case definitions were a little bit behind where they needed to be.

313
00:34:21,910 --> 00:34:26,410
And we were we we had we could only we were only allowed to test through the national testing.

314
00:34:27,100 --> 00:34:37,180
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.

315
00:34:37,660 --> 00:34:41,069
So again, we'll come back to that because I think this is one of the really valuable areas

316
00:34:41,070 --> 00:34:45,940
of lessons to learn for when inevitably we next have something like this.

317
00:34:47,020 --> 00:34:53,770
I think the other reason why we were really well prepared is that our executive and get engaged really early and seriously with this,

318
00:34:55,420 --> 00:35:00,130
the chief medical officer set up a COVID steering group. They co-opted expertise onto that group.

319
00:35:01,900 --> 00:35:12,639
And and so there was a sense that the that the leadership were really taking this seriously right from early on.

320
00:35:12,640 --> 00:35:16,270
And I you know, I think all of us involved were very grateful to that.

321
00:35:17,050 --> 00:35:20,260
And so you had a sense of being on the front foot rather than I think.

322
00:35:20,320 --> 00:35:25,600
Yes. I'm not sure You know, I'm not sure front foot is necessarily was the word.

323
00:35:25,600 --> 00:35:31,330
I mean, there were there were huge challenges. And, you know, I think that we were relatively well prepared compared.

324
00:35:31,600 --> 00:35:39,909
And that's partly out of luck in terms of our existing capacity and partly because of the timing.

325
00:35:39,910 --> 00:35:43,090
You know, we had if we'd been in Lombardy, would we have been that prepared?

326
00:35:43,100 --> 00:35:47,440
No, I don't think so. So we had that opportunity to to see what was what was coming our way.

327
00:35:48,250 --> 00:35:54,250
Um, but that time allowed us to put together, you know, lots of the detail that you need.

328
00:35:54,250 --> 00:35:58,819
So, you know, our clinical protocols, treatment, escalation plans, you know, we had a whole,

329
00:35:58,820 --> 00:36:04,420
this whole piece of work around resuscitation and how do you say you can't just do what you've always been doing?

330
00:36:04,420 --> 00:36:08,320
So the layers and layers of detail, occupational health, how do we look after our most vulnerable?

331
00:36:08,650 --> 00:36:17,590
And some of this was obviously informed by by national guidance, but that was also evolving very rapidly within infectious diseases.

332
00:36:18,040 --> 00:36:21,480
And the infection prevention control team, you know,

333
00:36:21,490 --> 00:36:28,980
we were providing pretty much 24 hour seven support and advice for for all the other specialities and,

334
00:36:28,990 --> 00:36:37,600
you know, in lots of different ways in terms of, you know, answering continuous questions and also some bespoke,

335
00:36:37,600 --> 00:36:45,040
targeted extra engagement sessions to help support specific areas like anaesthetics, for example, and by this time in.

336
00:36:45,190 --> 00:36:47,230
So I suppose we've got to early March or so.

337
00:36:47,840 --> 00:36:56,020
Was the hospital Still trying to see as many patients in those other specialities as it as it would have done previously had?

338
00:36:56,090 --> 00:37:03,440
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.

339
00:37:03,440 --> 00:37:11,180
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.

340
00:37:11,190 --> 00:37:18,390
And that time was very, very rapidly approaching, not least because we had to organise reorganise the hospital.

341
00:37:19,000 --> 00:37:22,879
And so I think, you know,

342
00:37:22,880 --> 00:37:31,180
one of the themes that came out of that was the sort of teamwork that that that allowed that to happen, which was phenomenal.

343
00:37:31,190 --> 00:37:35,030
And I think the single most positive aspect of the whole.

344
00:37:35,970 --> 00:37:42,240
COVID experience. I hadn't experienced anything like that in my career to date, and it's really a positive.

345
00:37:43,950 --> 00:37:51,029
But the impact was as you lead to profound, you know, because we then did have to stop doing some things.

346
00:37:51,030 --> 00:38:00,089
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.

347
00:38:00,090 --> 00:38:07,890
But again, the the attitude with which staff did this was phenomenal at all cadres.

348
00:38:08,010 --> 00:38:13,280
You know, Universe University colleagues stepped in and helped in the medical side.

349
00:38:13,290 --> 00:38:15,960
Medical doctors went to areas they weren't familiar with.

350
00:38:16,380 --> 00:38:23,670
The nursing staff, you know, did a lot of that, you know, really difficult lifting and and but really,

351
00:38:24,180 --> 00:38:30,870
again, phenomenal tribute to their dedication that everybody just got on with it.

352
00:38:31,500 --> 00:38:36,540
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.

353
00:38:37,020 --> 00:38:43,680
Um, I think we were relatively lucky in Oxford that we were able to because our the Churchill Hospital,

354
00:38:44,250 --> 00:38:47,940
we have most of our elective cancer work is happens is a separate site.

355
00:38:47,940 --> 00:38:55,649
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.

356
00:38:55,650 --> 00:39:06,210
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.

357
00:39:07,310 --> 00:39:12,440
The impact is on staff. Understandable fear. We mustn't forget that this is before vaccination,

358
00:39:12,650 --> 00:39:24,160
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.

359
00:39:26,330 --> 00:39:35,030
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.

360
00:39:35,030 --> 00:39:38,270
And of course, unfortunately some of our colleagues sadly died as well.

361
00:39:41,490 --> 00:39:47,810
And of course, it was having a massive impact on patients. We were you know, we were seeing, you know.

362
00:39:50,490 --> 00:39:59,280
A volume of of illness and mortality that probably none of us have have seen before or since.

363
00:39:59,430 --> 00:40:03,150
And did you yourself get involved in doing any of the intensive care work?

364
00:40:03,540 --> 00:40:08,790
Not in intensive care, but I worked in infectious diseases.

365
00:40:08,800 --> 00:40:18,840
Yes. And the within infectious diseases, we provide daily advice to intensive care of the management of the patient.

366
00:40:18,840 --> 00:40:26,639
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.

367
00:40:26,640 --> 00:40:28,980
But of course things were completely reorganised within COVID,

368
00:40:28,980 --> 00:40:36,930
so we had to first of all expand the number of intensive care beds very significantly and that involve procurement of ventilators and and,

369
00:40:36,930 --> 00:40:39,290
and, and space.

370
00:40:40,560 --> 00:40:49,440
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.

371
00:40:49,860 --> 00:40:52,200
We minimised the number of people we went in there.

372
00:40:52,200 --> 00:40:57,989
So one's role as an infection doctor advising on those patients actually then became slightly remote.

373
00:40:57,990 --> 00:41:01,680
So we would meet them in a room that was separate and we would run through the patients and talk about it.

374
00:41:01,680 --> 00:41:07,319
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.

375
00:41:07,320 --> 00:41:10,680
But it definitely had a very different feel at that stage.

376
00:41:12,000 --> 00:41:17,970
And, you know, initially it sort of felt like COVID could be anyone or anywhere.

377
00:41:18,030 --> 00:41:25,319
Yes, I sort of said that the testing took a while to catch up on and and so we didn't know.

378
00:41:25,320 --> 00:41:30,480
We could only test those people who met the case definition. We were waiting quite a long time for the results to come back.

379
00:41:30,990 --> 00:41:35,190
And so anyone who had a fever or respiratory illness, you know, could be COVID.

380
00:41:35,190 --> 00:41:42,690
And we had a traffic light system for triaging the likelihood of COVID and but they would

381
00:41:42,690 --> 00:41:46,590
be on your infectious disease ward if they weren't severe enough to go into intensive care.

382
00:41:47,040 --> 00:41:51,779
Now, very quickly, we very quickly initially, yes, but for a very short period.

383
00:41:51,780 --> 00:41:56,700
And then we exceeded the capacity of the intent of the infectious diseases wards amongst these patients.

384
00:41:56,700 --> 00:42:11,730
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.

385
00:42:13,800 --> 00:42:14,070
Thinking.

386
00:42:14,100 --> 00:42:20,340
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.

387
00:42:20,760 --> 00:42:29,250
We audited one afternoon. Every single patient in the hospitals to work out what to traffic, light them to work.

388
00:42:29,370 --> 00:42:36,839
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,

389
00:42:36,840 --> 00:42:42,360
because of course we didn't have electronic systems to tell us coded on them. You know, this was all evolving very, very quickly.

390
00:42:42,360 --> 00:42:50,399
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

391
00:42:50,400 --> 00:42:57,060
and and and cohorting patients who had COVID might have COVID and we didn't think had COVID.

392
00:42:58,050 --> 00:43:09,390
And and again, we we had some clues and we all became very familiar with the clinical pattern of disease with time.

393
00:43:09,810 --> 00:43:17,640
And, you know, some of that we were learning from the literature and from talking to those doctors in Wuhan and in Lombardy.

394
00:43:18,600 --> 00:43:21,870
But it was a pattern of illness in terms of.

395
00:43:23,110 --> 00:43:27,489
The clinical presentation. But also in terms of radiology, we all got used to saying, well, yes,

396
00:43:27,490 --> 00:43:33,610
there is a typical changes on the chest x ray and everyone was, you know, an expert, you know, within a few weeks.

397
00:43:34,300 --> 00:43:41,530
Similarly with the blood tests, we started to recognise that blood clots were an important complication that, you know, evolved over time.

398
00:43:42,070 --> 00:43:51,310
So so it was it was a period of really rapid learning as an organisation, but also clinically, individually and in teams.

399
00:43:53,050 --> 00:43:58,930
And each peak, of course, was different. So that first peak, it was really rapid, it was new.

400
00:43:59,500 --> 00:44:03,760
We, we had limited tools. We didn't yet have any treatments.

401
00:44:04,210 --> 00:44:10,720
Research was an important part of it because of course recovery, recovery and trial was started.

402
00:44:10,720 --> 00:44:14,590
During that time. We had a really vulnerable population because no one was vaccinated.

403
00:44:16,000 --> 00:44:20,260
And there was that, you know, really high mortality. Mortality was lower than the average.

404
00:44:20,260 --> 00:44:26,170
But nevertheless, you know, it was it was a disease which which took its significant toll.

405
00:44:26,680 --> 00:44:27,670
What sort of percentage?

406
00:44:28,240 --> 00:44:36,729
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.

407
00:44:36,730 --> 00:44:43,480
But I know it's a long time since I've looked at data centres, so so I'd have to remind myself exactly.

408
00:44:43,480 --> 00:44:48,700
But, but you know, it was, it was a really but the nurses were seeing patients dying.

409
00:44:49,340 --> 00:44:51,430
Not just everybody was seeing the patients dying.

410
00:44:51,430 --> 00:44:57,940
And sometimes, you know, spouses were dying within days of each other, you know, on different wards in hospital.

411
00:44:57,940 --> 00:45:09,400
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,

412
00:45:09,820 --> 00:45:13,149
even though for many, I suppose it would it takes quite a long time.

413
00:45:13,150 --> 00:45:20,290
And I think we're seeing that played out now that in some ways it's easier when you just get on with it.

414
00:45:21,550 --> 00:45:26,290
And in that sense, I felt very lucky to be able to do something.

415
00:45:26,320 --> 00:45:31,750
You know, Of course, lockdown then happened and for many people they were stuck at home.

416
00:45:31,750 --> 00:45:39,010
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.

417
00:45:39,010 --> 00:45:42,729
And I think there were lots of people who felt in that situation. So in some ways it was a huge privilege.

418
00:45:42,730 --> 00:45:52,660
And although we were all working incredibly hard, there was an adrenaline, quite a long lasting boost of adrenaline that kept everybody going.

419
00:45:52,660 --> 00:45:56,680
And that teamwork, I keep coming back to it, but that really was phenomenal.

420
00:45:58,240 --> 00:46:04,840
And then within that there, as we went into the spring and the summer, it was glorious weather.

421
00:46:04,840 --> 00:46:14,829
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.

422
00:46:14,830 --> 00:46:23,260
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,

423
00:46:23,260 --> 00:46:27,750
which maybe all the more so because it was contrasted with what was going on on the weekend.

424
00:46:28,370 --> 00:46:37,330
And we all also had to think very rationally about what the risks to our to us personally were.

425
00:46:37,370 --> 00:46:49,720
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.

426
00:46:49,960 --> 00:46:56,380
Again, an infectious disease, we are relatively privileged because we've been used to the concept of looking after patients with high consequence

427
00:46:56,380 --> 00:47:02,230
infectious diseases when it was delegated for about from a high consequence infectious disease and PPE change.

428
00:47:02,230 --> 00:47:06,309
That, of course led to other anxiety.

429
00:47:06,310 --> 00:47:12,040
And, you know, and that was a and that played into how people felt a little bit about things.

430
00:47:12,040 --> 00:47:20,200
And so being able to think sort of rationally through the numbers in terms of, well, yes,

431
00:47:20,470 --> 00:47:26,020
my risk of dying is if I get COVID is probably about twice the risk of dying and getting out of bed this morning.

432
00:47:26,020 --> 00:47:30,399
Well, actually, you know, I'm not worried about my very small risk of getting out of bed this morning.

433
00:47:30,400 --> 00:47:37,120
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.

434
00:47:37,300 --> 00:47:43,450
And there was a, I guess, a degree of introspection that everybody had.

435
00:47:43,600 --> 00:47:47,350
I mean, you knew situation, you were obviously a relatively young, very healthy person.

436
00:47:47,350 --> 00:47:53,860
But on the other hand, you were working in an environment where the risk of there might be virus floating about was quite high.

437
00:47:54,070 --> 00:47:58,360
Yeah, you weren't secluded in the way the rest of us were. That's absolutely so.

438
00:47:58,360 --> 00:48:07,780
So I think that it forced lots of reflection, which, as is often the case, takes a while for people to process.

439
00:48:07,780 --> 00:48:11,589
And I think I think that that's not irrelevant to the way that the workforce

440
00:48:11,590 --> 00:48:16,540
is is is feeling and processing things even now and not just in healthcare.

441
00:48:16,540 --> 00:48:22,450
Of course, by the second peak we were starting to see the benefit of.

442
00:48:22,740 --> 00:48:31,940
And so we we knew that steroids worked from recovery. And so this July was it not to the them?

443
00:48:32,040 --> 00:48:37,409
I can't remember. If I'm really honest, I know we were kind of led to this in August.

444
00:48:37,410 --> 00:48:41,310
And I think I think it probably was late in the year I would have to go back.

445
00:48:41,320 --> 00:48:44,550
Okay. So it was the ultimate. Yes, This was that second peak.

446
00:48:44,970 --> 00:48:48,420
The, um, was actually one of the biggest peaks.

447
00:48:48,420 --> 00:48:57,780
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.

448
00:48:57,780 --> 00:49:08,040
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.

449
00:49:08,040 --> 00:49:13,290
So we one of the really important things we did was we set up a service called COVID Care at home,

450
00:49:13,770 --> 00:49:18,810
and that was initially we tried to set something up with primary care.

451
00:49:19,740 --> 00:49:23,610
I think that's quite complicated because primary care is quite disparate.

452
00:49:23,610 --> 00:49:28,080
It's and and it was clear it was going to be difficult to do that quickly.

453
00:49:28,470 --> 00:49:40,620
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,

454
00:49:40,620 --> 00:49:44,160
we were able to really very rapidly set up the care homes.

455
00:49:44,280 --> 00:49:50,069
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.

456
00:49:50,070 --> 00:49:57,990
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.

457
00:49:57,990 --> 00:50:11,550
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.

458
00:50:11,610 --> 00:50:14,160
So discharge support and facilitation.

459
00:50:14,640 --> 00:50:23,790
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,

460
00:50:23,790 --> 00:50:25,920
was that the illness was often biphasic.

461
00:50:26,220 --> 00:50:35,040
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,

462
00:50:35,040 --> 00:50:38,490
you know, anything from towards the end of the first week up to a couple of weeks.

463
00:50:38,880 --> 00:50:46,550
And it was that during that deterioration that patients might become very hypoxic, low oxygen levels and could die suddenly and patient.

464
00:50:46,590 --> 00:50:49,829
You know, people did die in their beds. And, you know, even from again,

465
00:50:49,830 --> 00:50:56,909
I remember vividly those descriptions from Lombardy of people turning up and looking at looking actually quite well, but having oxygen saturation.

466
00:50:56,910 --> 00:50:59,309
So which should normally be in the high nineties that were in the sixties and you

467
00:50:59,310 --> 00:51:03,630
know it was a term happy hypoxia that was that was that was used to describe it.

468
00:51:04,380 --> 00:51:12,240
And so the principle of the model of keeping care at home was to identify patients who might be having that deterioration.

469
00:51:12,240 --> 00:51:17,160
So they had an oxygen saturation monitor at home and they were encouraged to check their

470
00:51:17,160 --> 00:51:23,190
oxygen saturations twice a day and both at rest and doing a brief period of standardised

471
00:51:23,190 --> 00:51:30,540
exercise and and which is just sitting to standing for a minute and then to record it

472
00:51:30,540 --> 00:51:34,480
and we would find them and once or twice a day depending on their risk category and,

473
00:51:34,700 --> 00:51:43,020
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.

474
00:51:43,320 --> 00:51:47,910
And that was supported by a group of specialist clinicians.

475
00:51:47,910 --> 00:51:53,069
So Dan Larson was really key in integrating this into acute hospital home.

476
00:51:53,070 --> 00:52:00,570
But infectious diseases, respiratory doctor sort of contributed to the multidisciplinary team that that reviewed these

477
00:52:00,570 --> 00:52:05,250
patients virtually and and ensured that we were providing them with the care that they needed.

478
00:52:05,670 --> 00:52:10,829
And actually that evolved quite complex medicine. So, you know, not just managing the sort of acute COVID things,

479
00:52:10,830 --> 00:52:13,860
but managing all their other medications and their diabetes and other things

480
00:52:13,860 --> 00:52:18,320
that particularly as we as we push the boundaries a little bit of this where,

481
00:52:18,630 --> 00:52:26,220
you know, we started giving blood things at home and and and for selected patients, once we got the recovery trial data,

482
00:52:26,220 --> 00:52:34,800
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.

483
00:52:35,640 --> 00:52:41,610
And in fact even later on, some of the new modulator therapy was given in the community using that example.

484
00:52:41,730 --> 00:52:46,620
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?

485
00:52:47,100 --> 00:52:54,410
And I think the debates around about the pros and cons of that, the economic pros and cons are probably still being had?

486
00:52:54,420 --> 00:53:01,070
Yeah, I mean, I think I'm just wondering whether it's a model that could be rolled out for the different kinds of.

487
00:53:01,080 --> 00:53:07,110
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.

488
00:53:07,110 --> 00:53:10,710
And there's a lot of interest in it. You know, we've sort of transitioned from the model.

489
00:53:11,400 --> 00:53:15,000
This is a little bit of a of a of a tangent, but it's worth answering.

490
00:53:15,930 --> 00:53:19,049
So 20 years ago, everybody would come in the front door, they'd get admitted.

491
00:53:19,050 --> 00:53:22,290
They stay in hospital for a bit. There wasn't the same huge pressure on discharge.

492
00:53:22,740 --> 00:53:27,030
And and and so length of stay we're probably, you know were longer.

493
00:53:27,540 --> 00:53:31,139
Gradually what's happened over the over the last couple of decades is that that length

494
00:53:31,140 --> 00:53:36,540
that length of stay has really reduced and that's because occlusions have got.

495
00:53:36,660 --> 00:53:39,330
Well, probably partly because some treatments have got better.

496
00:53:39,330 --> 00:53:46,200
But clinicians got increasingly comfortable with managing risk and actually recognise the harm of patients being in hospital for longer.

497
00:53:46,680 --> 00:53:53,070
And we've got more agile at supporting those discharges and recognising the benefits of being in your own home.

498
00:53:54,000 --> 00:53:58,500
We've also developed a whole new sort of service model called same day emergency care,

499
00:53:58,950 --> 00:54:03,430
which and we've got a whole unit that does that within within medicine and,

500
00:54:03,780 --> 00:54:08,370
and, and that's been phenomenally successful,

501
00:54:09,930 --> 00:54:15,690
especially when you can bring with that the resource you need for rapid diagnostics, you know, scans and other things.

502
00:54:16,290 --> 00:54:19,290
And many of those patients then managed ambulatory pathways.

503
00:54:19,290 --> 00:54:23,550
So they might be brought into hospital for for investigations,

504
00:54:23,850 --> 00:54:27,719
given some treatment brought by the next day or a couple of days later, depending on their clinical needs.

505
00:54:27,720 --> 00:54:32,610
So so the quick answer to your question is yes, there's you know,

506
00:54:32,670 --> 00:54:37,410
there's a whilst there were some quite specific things about COVID in that secondary

507
00:54:37,590 --> 00:54:41,670
deterioration that made the oxygen saturation monitoring particularly useful,

508
00:54:42,870 --> 00:54:50,190
that broadly the the acute hospital home model is one which has a very definite role within that provision.

509
00:54:50,220 --> 00:55:03,510
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.

510
00:55:06,440 --> 00:55:12,790
It's not the case that you can. It's like everything from COVID to every other respiratory illness.

511
00:55:12,790 --> 00:55:17,470
I think there was something quite specific about COVID that made that useful.

512
00:55:18,700 --> 00:55:28,420
And and and actually now with vaccination and the other treatments that are available, we don't really have a need for that.

513
00:55:28,430 --> 00:55:30,780
The amount of illness we're seeing is is a lot less.

514
00:55:30,790 --> 00:55:35,530
We've essentially stood it down as a as a completely separate service that we can still do that if we need to.

515
00:55:35,980 --> 00:55:42,129
And because we don't tend to see that biphasic illness in the way that we were seeing it before.

516
00:55:42,130 --> 00:55:46,870
So again, it doesn't automatically translate to pneumonia or other respiratory diseases.

517
00:55:47,680 --> 00:55:57,129
Um, but you know, so we, we set this service up really rapidly and actually for me it had reminiscences of,

518
00:55:57,130 --> 00:55:59,980
of what was happening in the research space as well.

519
00:55:59,980 --> 00:56:10,750
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,

520
00:56:10,750 --> 00:56:16,420
where instead of the normal process of ethical approval of studies, which, you know, takes many months,

521
00:56:17,140 --> 00:56:22,150
we were being asked to approve studies like the kind of the COVID vaccine trials very quickly.

522
00:56:22,240 --> 00:56:24,370
So we were, you know,

523
00:56:24,370 --> 00:56:35,350
things would being done by email or with bespoke meetings to deal with things which which allowed the process of institutional approval to,

524
00:56:35,590 --> 00:56:42,850
um, to proceed much, much more quickly. And of course was fundamental to the way that the research found out.

525
00:56:42,910 --> 00:56:47,570
And it was, it was, it was very nice to see some of those, some of that, um,

526
00:56:47,920 --> 00:56:52,090
agility happening in the health service as well in terms of setting up new services.

527
00:56:52,090 --> 00:56:57,459
And I very much hope we will be able to maintain some of that because it can be frustrating, you know,

528
00:56:57,460 --> 00:57:10,060
trying to sometimes set things up and we the, the led predominately by the respiratory team a similar sort of model.

529
00:57:10,060 --> 00:57:14,139
We set up a long COVID clinic because of course that's the other part of things.

530
00:57:14,140 --> 00:57:20,590
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.

531
00:57:20,590 --> 00:57:25,450
Right. And we all try to learn from that actually, because within infectious diseases,

532
00:57:27,160 --> 00:57:33,459
partly for historical and other reasons, and we manage, um, chronic fatigue syndrome and the,

533
00:57:33,460 --> 00:57:39,460
and, and so I had some experience in that and there are some similarities to the,

534
00:57:39,460 --> 00:57:43,510
to the Post-viral fatigue and other symptoms that that Long-covid has.

535
00:57:43,510 --> 00:57:47,680
And I think my hope and I don't know whether I'm less optimistic now,

536
00:57:47,680 --> 00:57:54,370
but my hope really was that the burden of long COVID in the worries about it would bring in

537
00:57:54,370 --> 00:57:59,049
the resources to really start to understand that disease much better and hopefully bring,

538
00:57:59,050 --> 00:58:03,850
you know, translate some of those understanding and benefits to other people who've got chronic fatigue syndrome.

539
00:58:04,660 --> 00:58:09,160
I think, you know, that's ongoing and I'm not at the coalface of that,

540
00:58:09,160 --> 00:58:13,660
but it would be nice to think that we might learn something that's got wider benefits from that.

541
00:58:14,950 --> 00:58:21,159
And then, of course, you know, the vaccine was rolled out and that's a whole other story which you're very familiar with.

542
00:58:21,160 --> 00:58:25,480
And and and others can tell much better than I.

543
00:58:26,110 --> 00:58:29,889
But but, you know, that, again, made a fundamental difference to the clinical presentation.

544
00:58:29,890 --> 00:58:37,180
Yeah. And because, you know, patients who were vaccinated were by and large getting much less severe illnesses.

545
00:58:37,180 --> 00:58:42,040
We knew from the vaccine studies, but of course there were those that were not vaccinated.

546
00:58:42,670 --> 00:58:49,350
And again, in those early days where we haven't got quite the repertoire of, um.

547
00:58:51,230 --> 00:58:53,300
Treatments that we've we've got now.

548
00:58:53,360 --> 00:59:00,510
We were still seeing some people who were not vaccinated, who were quite a significant minority of people who were not vaccinated,

549
00:59:01,250 --> 00:59:05,149
who who who were very severely ill and in some cases died.

550
00:59:05,150 --> 00:59:14,930
And that was very difficult. And, you know, some of the conversations with with those individuals were were interesting and difficult at times.

551
00:59:14,930 --> 00:59:22,970
And in many ways, I see them as victims of of of a lot of mistrust and misinformation that's out there.

552
00:59:23,570 --> 00:59:27,740
And did they I mean, it's I don't know if you were able to have that level of conversation,

553
00:59:27,740 --> 00:59:33,410
but did they have deathbed conversions to see that terrible.

554
00:59:33,810 --> 00:59:40,370
Well, it wasn't always that bad, But but yes, certainly as a new vaccination was, I think,

555
00:59:40,370 --> 00:59:44,929
rightly a part of the conversation with people, because, of course, you can get infected more than once.

556
00:59:44,930 --> 00:59:48,080
And so it's really important to address.

557
00:59:48,410 --> 00:59:55,970
And I so I did talk to and to the is, you know, it means it is new, whereas it might be me.

558
00:59:56,180 --> 01:00:01,940
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.

559
01:00:01,940 --> 01:00:05,050
Some people were very clear that they didn't want to have anything to do with it.

560
01:00:05,060 --> 01:00:08,690
There were others who expressed regret because they were unwell.

561
01:00:09,080 --> 01:00:19,010
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

562
01:00:19,010 --> 01:00:24,020
and said I wasn't vaccinated because my wife is such an anti-vaxxer I didn't want to cause trouble in my marriage,

563
01:00:24,740 --> 01:00:29,389
you know, and and but, you know, clearly his instinct had been to to get vaccinated.

564
01:00:29,390 --> 01:00:38,420
And so I think we had glimpses of of the way that this was affecting everybody and and and.

565
01:00:39,730 --> 01:00:44,740
And quite deep social levels. That's probably stating the obvious.

566
01:00:45,740 --> 01:00:54,610
And we then had a pipeline of therapies as as the recovery and other trials demonstrated the benefit of additional treatments.

567
01:00:55,510 --> 01:01:06,459
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.

568
01:01:06,460 --> 01:01:14,020
But from a staff point of view, things are also different because, you know, once you've got vaccinated,

569
01:01:14,020 --> 01:01:23,350
staff people feel that much more protected and and you're being able to roll out a vaccine for staff was hugely important.

570
01:01:24,310 --> 01:01:32,200
But so on the one sense there was things were easier because of because of the protection that vaccination afforded.

571
01:01:33,310 --> 01:01:37,300
But the workforce is really really tired. Yeah. And and there are still,

572
01:01:37,390 --> 01:01:43,810
you know huge service pressures so you did I think you said you were going to come back to testing because obviously the situation

573
01:01:43,810 --> 01:01:51,040
with testing changed at some point and testing of the health care workers was something that was obviously going to be an important.

574
01:01:51,400 --> 01:02:01,600
Yes, absolutely. And so we and so testing, testing of healthcare workers sort of happened in, well, two context, really.

575
01:02:01,600 --> 01:02:10,810
So we provided regular testing for healthcare workers before routine lateral flow testing was was available to everybody to sort of take care.

576
01:02:10,820 --> 01:02:18,370
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.

577
01:02:18,400 --> 01:02:26,020
Yes. Derek Crook and colleagues in the university with Katie Jefferies input and the and many, many others.

578
01:02:26,770 --> 01:02:37,480
And on the back of that, there were some important publications around, you know, sort of helping us understand relative risks in different areas.

579
01:02:37,750 --> 01:02:43,180
It's difficult to interpret, you know, completely because of lots of potential confounders.

580
01:02:43,510 --> 01:02:48,940
But actually, I think one of the key messages that came out to me and for others was that in the areas,

581
01:02:49,060 --> 01:02:52,300
you know, one of the areas that we'd worried most about was intensive care.

582
01:02:53,110 --> 01:02:58,590
But actually the risk of infection in that setting was lowest in term in terms of that.

583
01:02:58,810 --> 01:03:02,620
And again, you know, if one ignores to mitigate some of the potential confounders,

584
01:03:02,950 --> 01:03:09,790
that it does actually make sense because often the people that were getting really sick and requiring intensive

585
01:03:09,790 --> 01:03:16,209
care were in that second phase of the illness where the most infectious vari McVeighs had already happened.

586
01:03:16,210 --> 01:03:19,150
And then there was the second immunologically driven phase,

587
01:03:19,150 --> 01:03:31,809
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

588
01:03:31,810 --> 01:03:37,540
precautions were greater in terms of the PPE that was worn and many of them are ventilated so in a closed circuit.

589
01:03:37,540 --> 01:03:42,969
So the process of ventilation is a potentially high risk aerosol generating procedure.

590
01:03:42,970 --> 01:03:46,960
But once you're on a closed circuit, actually the risk should be very small.

591
01:03:47,770 --> 01:03:54,429
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.

592
01:03:54,430 --> 01:03:57,370
I think, again, I think you can't say it often enough,

593
01:03:57,370 --> 01:04:07,300
but huge respect to colleagues of all colours who who work in these environments and every country and.

594
01:04:08,950 --> 01:04:15,100
So so yes, testing, testing for staff was was was really important.

595
01:04:15,850 --> 01:04:21,910
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.

596
01:04:22,590 --> 01:04:28,080
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.

597
01:04:30,020 --> 01:04:36,460
I think sort of where we are now is we're left with that tired workforce.

598
01:04:36,880 --> 01:04:45,430
And clearly, you know, that's obviously in the news with industrial action and, and and I think very obvious to everybody.

599
01:04:46,140 --> 01:04:50,410
And at the same time, these huge service pressures say we've got very long waiting lists.

600
01:04:50,410 --> 01:04:54,760
There's huge pressure on social care, which is causing the pressure, you know, pressure on hospitals.

601
01:04:55,240 --> 01:05:00,370
And we've we've seen, you know, anecdotally and I think, you know,

602
01:05:00,370 --> 01:05:04,659
borne out some of the data delayed presentations of a number of things with because

603
01:05:04,660 --> 01:05:08,800
we did have reduced health care presentations during COVID for a lot of reasons.

604
01:05:09,190 --> 01:05:15,430
You know, some of those were fear of healthcare as a as a potential risk of infection.

605
01:05:15,460 --> 01:05:18,640
Some of it was a desire not to overburden healthcare.

606
01:05:18,880 --> 01:05:24,880
Some of it was difficulties or different models of access to health care.

607
01:05:25,270 --> 01:05:31,510
And although patients were always encouraged, people were always encouraged to present if they if they were unwell.

608
01:05:32,080 --> 01:05:33,850
And the mental health burden is huge.

609
01:05:33,850 --> 01:05:42,850
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.

610
01:05:42,850 --> 01:05:48,339
But it's being felt in the acute hospital setting and it's very definitely felt in the emergency department and,

611
01:05:48,340 --> 01:05:53,800
and adds its own toll to the staff who work in those areas and the ward areas.

612
01:05:54,340 --> 01:06:01,510
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.

613
01:06:01,510 --> 01:06:09,880
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.

614
01:06:11,470 --> 01:06:17,470
We know that during COVID the standard things that we do in terms of preventative medicine were less good.

615
01:06:17,470 --> 01:06:20,860
So people were not monitored for their blood pressure.

616
01:06:21,070 --> 01:06:25,060
People were not being as routinely diagnosed of high blood pressure.

617
01:06:25,390 --> 01:06:30,940
There's, as predicted, you know, high rates of cardiovascular disease and stroke and things as a result.

618
01:06:30,940 --> 01:06:36,340
So the pressure on the acute services is has remained very high and in some cases higher.

619
01:06:36,700 --> 01:06:41,500
But of course, there's all that elective backlog as well. So so that's the situation we're in now.

620
01:06:42,160 --> 01:06:53,110
And I wanted to make sure we did cover how your own role developed as a result of because I mean,

621
01:06:53,110 --> 01:06:59,170
it sounds to me as if a lot of what you were doing to all this was management planning.

622
01:07:00,940 --> 01:07:05,590
Allocation of resources, human and otherwise, thinking of better ways of doing things.

623
01:07:06,550 --> 01:07:16,360
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?

624
01:07:16,870 --> 01:07:22,540
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.

625
01:07:22,540 --> 01:07:28,930
You add that I love my clinical work and the but a couple of things.

626
01:07:29,950 --> 01:07:34,780
It sort of inspired me to do it both inside and outside work actually.

627
01:07:35,140 --> 01:07:45,730
So I appreciate that I was involved as chair of governance for a local school and as a as a very unique school.

628
01:07:47,110 --> 01:07:51,219
We had a number of challenges to deal with.

629
01:07:51,220 --> 01:07:56,140
It's a European school which which had to change its model post Brexit.

630
01:07:56,600 --> 01:08:05,860
And so I, I found myself working with some fantastic people to to sort of overcome some of those challenges and which,

631
01:08:05,860 --> 01:08:08,499
you know, we've negotiated, I think, very well.

632
01:08:08,500 --> 01:08:20,829
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,

633
01:08:20,830 --> 01:08:32,860
enjoying the challenge of problem solving in that sense and and the strategic challenge and and and the enjoyment of making things happen.

634
01:08:33,910 --> 01:08:38,530
I think so. So that was that was, I think, a very important formative experience.

635
01:08:39,010 --> 01:08:51,610
And then within COVID, as you say, I quite quickly got co-opted into some of the groups that were involved in this.

636
01:08:51,730 --> 01:08:58,090
And and as the clinical lead for the department had to take on a leadership role, as I'd say,

637
01:08:58,090 --> 01:09:05,169
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.

638
01:09:05,170 --> 01:09:09,880
It was enabling the team to together, but the need to do the skill.

639
01:09:10,090 --> 01:09:16,030
And I hope so. I think and I and I and I again, I found that a very rewarding experience.

640
01:09:16,030 --> 01:09:22,090
And, and there are huge challenges that face the health service.

641
01:09:22,720 --> 01:09:27,790
And I guess I go back to where I started in medicine. I came as in some ways from a.

642
01:09:28,750 --> 01:09:35,079
The public health perspective in terms of thinking about how do we improve health, health care?

643
01:09:35,080 --> 01:09:43,030
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,

644
01:09:43,030 --> 01:09:48,820
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?

645
01:09:48,880 --> 01:09:51,220
Can I have I got a role in trying to do that?

646
01:09:51,940 --> 01:09:58,810
And it's in that context that I applied for and was appointed to my current role and which has been rewarding to me.

647
01:09:59,260 --> 01:10:07,870
So it's been a it's been a journey and in many ways an unexpected one, but not one I've regretted.

648
01:10:09,070 --> 01:10:13,840
And what are the the main route I took to make another pitch about this as well?

649
01:10:13,840 --> 01:10:18,159
But quality improvement seems like a very sort of generic term.

650
01:10:18,160 --> 01:10:22,630
But what are this? The the areas to focus on, the most important areas to focus on.

651
01:10:23,980 --> 01:10:27,070
So as you say, quality improvement is potentially huge. And it is.

652
01:10:27,070 --> 01:10:30,100
And I, I think it also means different things to different people.

653
01:10:30,760 --> 01:10:41,800
Um, classic quality improvement or QE is, is all about trying to improve systems in a sort of grassroots up way.

654
01:10:42,070 --> 01:10:45,309
And actually echoing what I was saying a moment ago,

655
01:10:45,310 --> 01:10:53,740
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.

656
01:10:55,340 --> 01:10:57,260
Look for, see and implement improvements.

657
01:10:57,830 --> 01:11:06,830
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,

658
01:11:06,830 --> 01:11:12,300
but improving your job with benefits both for the service but also ideally for the staff as well.

659
01:11:12,320 --> 01:11:18,440
You work in that service. So so that's that's what that's I guess that's the nub of, of quality improvement.

660
01:11:18,440 --> 01:11:25,370
And what we are trying to do in there is foster a culture that allows that in terms

661
01:11:25,370 --> 01:11:29,269
of giving people the skills because there are some tools that allow one to do that.

662
01:11:29,270 --> 01:11:37,520
And and it certainly if everybody has a similar understanding of the tools and the approach,

663
01:11:37,520 --> 01:11:44,450
it makes it easier for people to collaborate on those things, but also hopefully shortcuts some of the potential pitfalls.

664
01:11:46,370 --> 01:11:52,159
But of course, you know, there are broader things out that, you know, service wide improvements that need to be made.

665
01:11:52,160 --> 01:11:59,030
And some of those are national challenges like the times we've got with agents and emergency care.

666
01:11:59,070 --> 01:12:06,740
You know, our organisation is under huge pressure, as is every acute trust in the country and many of the challenges will be similar.

667
01:12:06,740 --> 01:12:13,940
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.

668
01:12:13,940 --> 01:12:18,290
But some of the solutions are probably common to many of those many organisations.

669
01:12:19,670 --> 01:12:25,870
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,

670
01:12:25,880 --> 01:12:32,210
which would automatically create more capacity in the hospital to allow patients to flow through the department to create more space,

671
01:12:32,510 --> 01:12:36,410
which commissions the space to be able to see those patients and manage those more quickly.

672
01:12:36,590 --> 01:12:44,900
So there's, you know, there are some lots of interdependencies, some of which sit outside the immediate hospital sphere.

673
01:12:45,500 --> 01:12:49,070
And so then if that answers your questions, it does. It does.

674
01:12:49,280 --> 01:12:56,060
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.

675
01:12:56,110 --> 01:13:02,930
And I think the first thing to say is clearly what happened with vaccination was phenomenal.

676
01:13:03,350 --> 01:13:08,450
And, you know, it's wonderful that Oxford played such an important role in that.

677
01:13:08,450 --> 01:13:14,960
And I think we're very lucky to be embedded within the academic capital that we are.

678
01:13:15,650 --> 01:13:22,280
But it is easy to forget that the NHS dealt with two peaks and some really unprecedented challenges before vaccination came online.

679
01:13:23,020 --> 01:13:27,169
And we were really fortunate, not just with our academic background,

680
01:13:27,170 --> 01:13:31,280
but because of the leadership we had very early and seriously and allowed us to do it.

681
01:13:32,170 --> 01:13:41,750
And, and that teamwork which which, you know, was such a, an empowering and inspiring thing for me,

682
01:13:43,460 --> 01:13:48,560
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.

683
01:13:48,560 --> 01:13:54,410
But I think testing is a really good example. We took an approach which was not universal.

684
01:13:54,410 --> 01:13:58,190
If you look around other countries initially to centralise testing and,

685
01:13:58,700 --> 01:14:04,460
and we and because we centralised it, we also centralised the case definitions for testing.

686
01:14:06,350 --> 01:14:11,659
And around that we also have sort of centralised some, I think, dogma at the time.

687
01:14:11,660 --> 01:14:16,850
So there was a dogma early on that asymptomatic transmission didn't happen, for example.

688
01:14:17,540 --> 01:14:21,109
And then of course you're never going to discover if asymptomatic transmission happens,

689
01:14:21,110 --> 01:14:24,920
if you never test people who've been in contact with someone who's been asymptomatic.

690
01:14:24,950 --> 01:14:29,180
And I think, you know, anecdotally, for example, in Oxford,

691
01:14:29,600 --> 01:14:33,829
we had there was a it was there was an outbreak associated with one of the university choirs.

692
01:14:33,830 --> 01:14:36,890
And I remember the conversations at the time of could we could we test, you know,

693
01:14:37,310 --> 01:14:41,780
there was an explicit recognition about the about could there be asymptomatic transmission.

694
01:14:42,050 --> 01:14:47,450
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.

695
01:14:47,450 --> 01:14:48,790
So you didn't see testing didn't happen.

696
01:14:48,800 --> 01:14:56,990
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,

697
01:14:57,740 --> 01:15:01,550
and in fact it turned out that the test they were using centrally wasn't the best test,

698
01:15:02,630 --> 01:15:08,600
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?

699
01:15:09,170 --> 01:15:15,950
And had we not been so committed to centralising things early on, actually we probably learned about those things a lot earlier.

700
01:15:15,950 --> 01:15:23,170
And we may have you know, we may have spared some of the infection and mortality that happened as a result,

701
01:15:23,180 --> 01:15:26,930
you know, would have it would have informed our infection control precautions.

702
01:15:27,710 --> 01:15:34,400
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.

703
01:15:34,400 --> 01:15:40,969
But, you know, those the case definitions around travel also felt like I could vividly

704
01:15:40,970 --> 01:15:44,810
remember being need with with with people that you thought this could be COVID,

705
01:15:44,810 --> 01:15:50,630
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.

706
01:15:51,020 --> 01:15:55,550
I agree, but we can't because they've not know at the moment. Never really extended it to Taiwan.

707
01:15:55,580 --> 01:15:59,630
Yes. So so I think that was frustrating.

708
01:16:00,080 --> 01:16:05,510
And there are some other examples of that. I think, you know, centrally too, it was,

709
01:16:06,020 --> 01:16:11,069
and probably partly because it was focussed initially within the high consequence infectious disease network.

710
01:16:11,070 --> 01:16:14,930
And in fact we sort of became a surge centre in March,

711
01:16:14,930 --> 01:16:22,550
but only just before it was designated as a high consequence infectious disease and probably centrally nationally.

712
01:16:22,760 --> 01:16:29,660
It was slightly slow to realise what was actually happening on the ground and, and how quickly this and this then it exploded.

713
01:16:30,800 --> 01:16:34,100
But then by contrast, you've got recovery and, you know,

714
01:16:34,740 --> 01:16:39,920
I think it's no accident that it was 176 NHS hospitals that delivered the

715
01:16:39,920 --> 01:16:45,260
recovery trial and all the benefit that that has had for patients with COVID.

716
01:16:45,260 --> 01:16:52,180
And and I think for me, that's the single most important lesson to take away from this.

717
01:16:52,190 --> 01:16:56,000
I think we're incredibly fortunate to have our joined up National Health Service.

718
01:16:56,390 --> 01:16:59,390
It has many imperfections. There's lots of things that we could do better.

719
01:16:59,390 --> 01:17:00,920
It could be more joined up in some areas.

720
01:17:00,920 --> 01:17:11,900
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.

721
01:17:15,100 --> 01:17:18,250
Advancing the cause of research within the NHS.

722
01:17:18,370 --> 01:17:26,979
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

723
01:17:26,980 --> 01:17:32,320
do that rather than implementing things that perhaps don't yet have the have have a solid evidence base,

724
01:17:32,770 --> 01:17:39,159
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

725
01:17:39,160 --> 01:17:46,510
the heart of the UK Health Sciences Vision and so Life sciences vision and I think.

726
01:17:47,630 --> 01:17:56,560
It's really untapped potential. But we've got some hard work to do to meet that potential, because although we know that.

727
01:17:57,710 --> 01:18:02,060
Conditions want to be involved in research.

728
01:18:02,420 --> 01:18:08,090
And we know that being involved in research is associated with greater job satisfaction and so forth.

729
01:18:08,540 --> 01:18:12,020
We've got to create the time and resource to allow them to do that.

730
01:18:13,070 --> 01:18:18,320
And clearly the service pressures make that difficult. But I think it's part of our medium to long term plan.

731
01:18:20,060 --> 01:18:25,720
That's a crucial. Pillar.

732
01:18:26,030 --> 01:18:29,950
I think it would be really sad not to do. That's lovely.

733
01:18:29,950 --> 01:18:30,670
Thank you very much.