PPE Supply During the Covid-19 Pandemic [1]

INTRODUCTION

Personal protective equipment (PPE) protects the wearer against health or safety risks at work. In health and social care, PPE ranges from basic items, such as aprons, gowns, face masks and disposable gloves, to specialised items, such as face shields, respirator masks and body bags. Before the Covid-19 pandemic, relatively few workers needed to wear PPE and it was relatively straightforward to acquire. UK NHS Trusts bought much of their PPE from NHS Supply Chain, a centralised procurement facility, whereas other NHS providers and social care providers used private-sector suppliers.

COVID-19 had an extraordinary impact on global demand for PPE. At the same time, the global supply of PPE declined as a result of a fall in exports from China, the country that manufactures the most PPE. Other countries also imposed temporary restrictions on exports of PPE. The result was an extremely overheated global market with desperate customers competing against each other, pushing up prices, and buying huge volumes of PPE often from suppliers that were new to the PPE market. The situation was made more difficult as the specifications and certifications PPE must meet are complex and were updated throughout the pandemic as understanding of the virus improved.

The actions taken by the UK Government in relation to the PPE supply disruption conform to the recovery model shown below.

RESPOND

Government attempted to use its stockpiles to meet demand for PPE but there were difficulties distributing PPE from the stockpile, including physical access to stock and a lack of information on how much PPE each trust needed. It was decided that the NHS Supply Chain’s infrastructure and operations would not be able to cope with the pandemic demand. Procurement of PPE from existing suppliers was increased, but this was not enough.

A Parallel Supply Chain was set up to manage the rapidly deteriorating situation. This aimed to urgently source and distribute PPE to trusts and other healthcare providers by obtaining products through existing suppliers, new suppliers and new UK manufacturing. The Parallel Supply Chain had around 450 staff to find and buy PPE.

A full estimate of PPE requirements was undertaken, which predicted that massive amounts would be needed. A far greater volume of some items would be required than was held in the stockpile. For example, nine times more aprons would be needed than were available.

14.6 billion items of PPE worth £7 billion were ordered through the Parallel Supply Chain. Because of the time lag between ordering the PPE and it being available to use, the Parallel Supply Chain could barely satisfy local organisations’ requirements.

Initially the Parallel Supply Chain had limited information on the PPE held by local organisations and it undertook a daily engagement process with stakeholders to inform its distribution of PPE. No national body held information on how much PPE local organisations held in stock. The Parallel Supply Chain therefore distributed PPE to trusts and local resilience forums on a ‘push’ basis, and initially all trusts received the same amounts.

The Parallel Supply Chain’s procurement processes were designed to enable rapid procurement, but this meant that some PPE was procured that did not meet requirements, wasting hundreds of millions of pounds. The chaotic nature of the PPE market during the pandemic increased the risks involved in purchasing PPE, including that suppliers might not provide products of the standard required.

The Parallel Supply Chain had a process to check suppliers’ equipment against government’s PPE specifications so that equipment that failed to meet requirements could be placed into quarantine and not issued to local organisations. However, in some cases the Parallel Supply Chain bought equipment that did not meet the specifications.

The spend on PPE became enormous, owing to both higher prices and increased volumes. These increases ranged from a 166% increase for respirator masks to a 1310% increase for body bags. Government had to pay such high prices because it was in the position of needing to buy huge volumes of PPE very quickly.

RECOVER

Over time the Parallel Supply Chain created and refined a process to better inform its distributions. This was based on estimates of the PPE required by local organisations, reflecting guidance for PPE usage and the number of patients. It adjusted these estimates to reflect information from NHS regions, local resilience forums and the National Supply Disruption Response team.

The Parallel Supply Chain and NHS Supply Chain procured 32 billion items of PPE between February and July 2020. Over the same period they distributed 2.6 billion items to front-line organisations. As a result, as at the end of September, the department reported that it was on course to have stockpiled four months’ supply of PPE by November 2020.

Lessons learned:

NHS Supply Chain was set up to prioritise financial savings. It was set targets to increase its share of NHS procurement and achieve financial savings for the NHS, which were surpassed. However, the performance management regime did not include any targets related to the resilience of supplies and the operating model was not designed to respond to a pandemic.

Furthermore, responsibility for managing PPE supply and stockpiles was spread across multiple public bodies and private-sector contractors. The stockpiles were intended for an influenza pandemic and they were inadequate for coronavirus.

Business-as-usual activities within government need to strike the appropriate balance between operational and financial efficiency versus the longer-term need for resilience and capability for dealing with shocks. For PPE, this includes consideration of the cost implications of, and incentives needed for, developing and maintaining a domestic manufacturing base and increasing diversity in international supply.

Emergency plans for dealing with a pandemic must provide for appropriate stockpiles of high-quality PPE together with comprehensive and resilient arrangements for the rapid procurement and distribution of PPE, based on reliable information. Organisations responsible for maintaining and testing their plans must actively monitor for new threats that might overwhelm their plans.

Effective governance, lines of accountability and resourcing responsibilities are important for an effective rapid response in an emergency situation. Developing these arrangements, and ensuring that they remain up to date, should be part of the emergency plan for activation when required.

Clear, timely, two-way information and communication are vital for both providing services at the front-line and for managing the response at the national level. This includes information on national and local PPE stocks and requirements, and feedback loops. Deficiencies in information can lead to a breakdown of trust, failure to take effective action, and poor value for money.

RESILIENCE

Taking into account the lessons learned, Government published a new PPE strategy in September 2020. The strategy aims to increase supply resilience by means of a bigger stockpile, a much larger UK manufacturing base, a better distribution network, and an improved understanding of user needs. There are, however, challenges to overcome, including how to sustain a large UK manufacturing base for PPE that might not be competitive in cost terms.

A comparison of the pre-Covid-19 situation, the emergency response and the proposed strategy to stabilise and build resilience is shown in the following table.[2]

The new consolidated, agile and resilient supply approach is shown below.[3]

[1] Adapted from: https://www.nao.org.uk/report/supplying-the-nhs-and-adult-social-care-sector-with-personal-protective-equipment-ppe/

[2] https://www.gov.uk/government/publications/personal-protective-equipment-ppe-strategy-stabilise-and-build-resilience/personal-protective-equipment-ppe-strategy-stabilise-and-build-resilience

[3] https://www.england.nhs.uk/coronavirus/primary-care/infection-control/ppe/