Covid-19: why is the UK government ignoring WHO’s advice?
BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1284 (Published 30 March 2020) Cite this as: BMJ 2020;368:m1284Read our latest coverage of the coronavirus outbreak
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Dear Editor
In a fast expanding epidemic, once the surge is controlled by universal mass physical distancing, control of contacts of new cases is the public health option of choice (2). This has worked in the past and has been shown to be successful with COVID-19 in China in combination with physical distancing and without the need for physical distancing in South Korea, Singapore and Hong Kong (3). There they manage to control their epidemics without recourse to population lockdown. This is due to planning for major epidemics with serious intent following their SARS experience. The planning allowed the rapid deployment of public health staff to trace contacts and virus test in sufficient numbers required to confirm new cases through the contact tracing approach. The results are impressive. The economies and schools continue nearly as before.
The UK situation
The lockdown will start to reduce new cases immediately and deaths three weeks later. There is talk and models depicting the effect of pulsed reduction of physical distancing (4). This will not control the epidemic but simply reduce the cases requiring hospital care. There is also talk about testing and smart phone applications. These technologies support but do not obviate or supplant the fundamental need for finding and quarantining cases and contacts. The epidemic is at different stages in different places in the UK. The need to maintain physical distancing and thereby curtail economic activity will be different in different parts of the country.
Decentralisation is crucial
Control of communicable disease was until the re-organisation in 2002 held at district level with a Director of Public Health looking after each local health authority. This allowed local knowledge of the community, the local politicians and leaders, the laboratory, the hospital and its consultants and the GPs. Control is not possible without this local expertise (1). There is a Director of Public Health in each local authority who together with support from a Consultant in Health Protection/Communicable Disease Control and the local Health Protection Team from Public Health England can take the management responsibilities for each local authority.
The control of COVID-19 should be managed by the local authority who should have the responsibility to start and modify physical distancing measures within their boundaries. The legal powers are already available through Schedule 21 (Powers relating to potentially infectious persons) of the Coronavirus Act 2020. Public Health England which has a strong central and regional structure can co-ordinate in England. Public health functions are already devolved in Scotland, Wales and Northern Ireland but may benefit from further decentralisation. China demonstrates the success of this hierarchical approach (5).
Case finding and contact tracing
Case finding and contact tracing remain the key control measure and should be re-started immediately in each local authority (2). The following tables show the staff required to handle new cases and control spread through contact tracing and quarantine (6). The numbers required now and two weeks later assuming decay in numbers started on 6th April (as will have occurred in some but not all areas) are shown in Table 3. Once established the generalised physical distancing measures can be relaxed and the local economy return to normal. These measures can be titrated if surging of cases occurs. The assumptions used to estimate the staff required are in Table 1 and the hours of staff required are in Table 2.
Local public health capacity
Each new case will require 102 hours of community health staff and volunteers time to trace 90 contacts and test 6.3 symptomatic contacts a third of whom will have COVID-19. The requirement for staff will vary with time as physical distancing is currently reducing contact numbers and should become less if phone applications as used in Singapore are used by individuals here. On average there will need to be 2.8 full time local staff and trained volunteers to cope with each new case.
A selection of health visitor (HV) and environmental health officer (EHO) staff can be relieved of current duties and deployed to lead local teams of volunteers to contact trace (13). Most local authorities have established volunteer registers (14) and recently retired HVs and EHOs can join the volunteers. The system of contact tracing should be up and running in 5 working days. It should be possible for most Directors of Public Health alongside the Public Health Physician secondee from Public Health England to assess if they have control of the spread of the virus in their district a week later.
Initially the number of cases can be best estimated from local deaths. As the system gets under way new cases will be notified in the standard way for which testing is helpful but not necessary. The number of cases will fall as physical distancing succeeds as in China. Probably 3000 volunteers will be needed by late April in the averaged sized local authority. Training will take one day as will setting up the administrative arrangements using local authority resources. Testing facilities can be negotiated with the local health laboratory. The local authority will take on the public information function.
Exiting physical distancing
Once under control locally the local authority can relax physical distancing measures to get schools reopened and the local economy back on its feet. Most local authorities outside the cities will be in sufficient control to do this by the end of April if and when cases are rapidly identified and their contacts rapidly traced. Cities will inevitably take longer to control but this is all the more of a reason to start case finding and contact tracing now. Tighter physical distancing measures and travel restrictions from hot areas may be required if the epidemic gets out of control again. The public can be made aware of this possibility by their local leaders.
In conclusion an early return to full economic activity is possible in many parts of the country if local authorities are given the devolved powers to control physical distancing, if the viral tests are made available for contact tracing and if local public health departments take back communicable disease control (15).
References
1. Pollock AM, Roderick P, Cheng KK, Pankhania B. Covid-19: why is the UK government ignoring WHO’s advice? BMJ [Internet]. 2020 Mar 30 [cited 2020 Apr 6];368. Available from: https://www.bmj.com/content/368/bmj.m1284
2. Contact tracing: Public health management of persons, including healthcare workers, having had contact with COVID-19 cases in the European Union – first update [Internet]. European Centre for Disease Prevention and Control. 2020 [cited 2020 Apr 5]. Available from: https://www.ecdc.europa.eu/en/publications-data/contact-tracing-public-h...
3. Ng Y, Li Z, Chua YX, Chaw WL, Zhao Z, Er B, et al. Evaluation of the Effectiveness of Surveillance and Containment Measures for the First 100 Patients with COVID-19 in Singapore — January 2–February 29, 2020. MMWR Morb Mortal Wkly Rep. 2020 Mar 20;69(11):307–11.
4. Report 11 - Evidence of initial success for China exiting COVID-19 social distancing policy after achieving containment [Internet]. Imperial College London. [cited 2020 Apr 6]. Available from: http://www.imperial.ac.uk/medicine/departments/school-public-health/infe...
5. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) [Internet]. [cited 2020 Apr 7]. Available from: https://www.who.int/publications-detail/report-of-the-who-china-joint-mi...(covid-19)
6. Resource estimation for contact tracing, quarantine and monitoring activities for COVID-19 cases in the EU/EEA [Internet]. European Centre for Disease Prevention and Control. 2020 [cited 2020 Apr 5]. Available from: https://www.ecdc.europa.eu/en/publications-data/resource-estimation-cont...
7. Estimates of the population for the UK, England and Wales, Scotland and Northern Ireland - Office for National Statistics [Internet]. [cited 2020 Apr 11]. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigrati...
8. Keeling MJ, Hollingsworth TD, Read JM. The Efficacy of Contact Tracing for the Containment of the 2019 Novel Coronavirus (COVID-19). medRxiv. 2020 Feb 17;2020.02.14.20023036.
9. Global Health Data Exchange | GHDx [Internet]. [cited 2020 Apr 8]. Available from: http://ghdx.healthdata.org/
10. Rapid risk assessment: Coronavirus disease 2019 (COVID-19) pandemic: increased transmission in the EU/EEA and the UK – eighth update [Internet]. European Centre for Disease Prevention and Control. 2020 [cited 2020 Apr 9]. Available from: https://www.ecdc.europa.eu/en/publications-data/rapid-risk-assessment-co...
11. Jombart T, Zandvoort K van, Russell T, Jarvis C, Gimma A, Abbott S, et al. Inferring the number of COVID-19 cases from recently reported deaths. medRxiv. 2020 Mar 13;2020.03.10.20033761.
12. Leung K, Wu JT, Liu D, Leung GM. First-wave COVID-19 transmissibility and severity in China outside Hubei after control measures, and second-wave scenario planning: a modelling impact assessment. The Lancet [Internet]. 2020 Apr 8 [cited 2020 Apr 9];0(0). Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30746-7/abstract
13. Public Health England. Best start to life and beyond; improving public health outcomes for children, young people and families [Internet]. 2018. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploa...
14. Community advice [Internet]. Coronavirus advice in Devon. [cited 2020 Apr 8]. Available from: https://www.devon.gov.uk/coronavirus-advice-in-devon/document/community/
15. Pollock AM. Covid-19: local implementation of tracing and testing programmes could enable some schools to reopen. BMJ [Internet]. 2020 Mar 24 [cited 2020 Apr 6];368. Available from: https://www.bmj.com/content/368/bmj.m1187
Table 1 – Assumptions used to calculate staff requirements for contact tracing
Each new case has 36 high risk traceable contacts (6)
Each new case has 54 low risk contacts (6)
Population UK – 66,435,550
Average Local Authority population 357180
URTI prevalence 42/1000 pop (7)
Reproductive number Ro 2.5 (10)
2 Car hours to test station or home and back
Case fatality rate 0.66% (11)
Decay per day from peak 5.5% (12)
Estimates of hours required (6)
Table 2 – Staff required to contract trace one new case
Interview new case 2 hours
Register case 0.25 hours
Create contact list 4 hours
Classify contacts 1 hour
Interview contacts 65 hours
Monitor high risk contacts 10.8 hours
Monitor low-risk contacts 1.6 hours
Test symptomatic contacts 6.3 hours
Car service all symptomatic contacts 12.6 hours
Total 101.6 hours = 2.8 WTE (36 hours/wk)
Table 3 – Illustrative example of staff required now and in two weeks after peak for UK and the average Local Authority in the UK
Location UK Average Local Authority
Population 66,435,550 357,180
Average weekly caseload 6th April 485,195 4,242
WTE required 6th April 1,369,516 11,975
Weekly caseload 2 weeks after peak 188,834 1,123
WTE required 2 weeks after peak 533,005 3,169
Competing interests: No competing interests
Dear Editor
I distinctly recall the bewilderment of colleagues when the old regime of Local Authority based public health doctors was swept away by the Lansley reforms. I hope there will be a rigorous review of PHE when this is all over. At present it is difficult to know how effective they have been, and hence if they are fit for future challenges.
Furthermore, there is a plethora of apparently separate quangos divvying up the nation's health-related activities. Should they be reviewed too?
Michael Sherratt
Competing interests: No competing interests
Pollock is clearly an enthusiastic supporter of the WHOs mantra of “trace, test and treat” and of “immediately instituting a massive programme of community contact tracing”. Unfortunately she presents no evidence that such a tracing program could ever be established in the UK. We are far less sanguine than Pollock that it can and do not even recomend establishing one. This contrary belief is not a bigoted opinion but one based on field data and personal experience (1).
In 2009 we were NHS consultants responsible for managing the Birmingham H1N1 “hotspot” and gained appreciable experience in contact tracing.
When the epidemic hit we prioritised workloads of staff and contracted with a large private provider. We had no financial constraints and the weather and community support excellent. Despite all this our peak capacity at contact tracing was just 15 a day which suggest a (very maximum) national daily tracing capacity of 2,000.
How large a testing service does WHO mantra require for the UK? Well, the Government mentions establishing a (credible but unclear) daily testing capacity of 100,000 (2) . With a 5% positive result this would generate 5,000 case needing primary contact tracing. In turn these would generate dozens requiring further tracing - say 50,000; a workload 25 times our existing capacity.
Clearly the government's enormously enhanced testing program will be ineffective if these positives are not linked to a tracing system enormously greater than at present. So large that we cannot even imagine such a massive societal intervention. Can Pollock advise on what tracing model should be attempted?
Pollock may be right in recommending that massive contact tracing is the panacea needed to control this pandemic, but this is a recommendation which cannot be implemented. A recommendation that will divert enormous investment away from programs with a good track record for saving lives - like acute care.
1 Reflections on the UK’s approach to the 2009 flu pandemic - Chambers JS, Barker K, Rouse A Health and Place 18 [2012] 737 -745 doi: 10.1016/j.healthplace.2011.06.005. Pmid: 22682089
2. Coronavirus: Matt Hancock sets aim of 100,000 tests a day by end of April - BBC News. https://www.bbc.com/news/uk-52140376
Rapid Response:
Re: Covid-19: why the UK government should ignore the call for contact tracing REDO
BMJ 2020; 368:m1284
https://www.bmj.com/content/368/bmj.m1284/rr-6
Dear Editor c0 tests a day by end of April - BBC News. https://www.bbc.com/news/uk-52140376
Competing interests: No competing interests
Dear Editor,
As a medical student, it is safe to say that no classroom teaching on public health will ever compare to the opportunity to experience a pandemic unfolding in real-time. However, it has remained difficult to truly understand the plan being put forward by the UK government, and the points raised by Pollock et al. resonate. Consistency in action between international communities is necessary, and this should be supported with clear communication on a national level. Unfortunately, however, the underlying rationale behind several key decisions has been made less than clear.
Interestingly, a quotation from a media briefing made by WHO Director-General, Tedros Adhanom Ghebreyesus, has recently circulated on social media. Dr Ghebreyesus stated that “People infected with COVID-19 can still infect others after they stop feeling sick, so [household isolation] should continue for at least two weeks after symptoms disappear” (1). This is clearly at-odds with UK Government recommendations, which advise that symptomatic individuals should isolate for 7 days from when symptoms begin.
For both the UK and WHO, I was unable to find references to appropriate evidence through official sources, and the exact rationale underlying this guidance still remains unclear. Looking at primary literature, research surrounding the duration of viral shedding beyond the symptomatic period provides mixed results (2,3,4). In these early stages, more confirmatory data is needed.
Putting this aside, a crucial point remains: conflicting advice inevitably sparks confusion and mistrust against both sides, endangering what ought to be a consistent and measured public health effort with the primary aim of keeping the public safe. If acting in accordance with principles of evidence-based medicine, the UK government’s rationale throughout this crisis should be made easily accessible, traceable and clearly backed up with reference to peer-reviewed, published data. This would go some way towards providing reassurance to the general public and healthcare professionals alike. In these unsettling times, greater transparency is crucial - or else a dangerous anti-scientific precedent will continue to be propagated forwards.
References:
(1) WHO. WHO Director-General's opening remarks at the media briefing on COVID-19 - 16 March 2020. Available from: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-re...
(2) Liu Y, Yan L, Wan L, Xiang T, Le A, Liu J et al. Viral dynamics in mild and severe cases of COVID-19. The Lancet Infectious Diseases. 2020
(3) Wölfel, R., Corman, V.M., Guggemos, W. et al. Virological assessment of hospitalized patients with COVID-2019. Nature. 2020
(4) Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet. 2020
Competing interests: No competing interests
Dear Editor,
There exists a large pool of people who could be recruited to a programme of case finding, tracing,
observation and testing. The many young people trapped at home with time on their hands, including students unable to return to their university and school leavers obliged to abandon their gap year plans, for a start. The prospect of getting out of the house and filling their days with something worthwhile could be very attractive, and the experience could prove life-changing.
Competing interests: No competing interests
Dear Editor,
The simple answer to this question appears to be that the UK government believes it is "following the science". Unfortunately even though Dr Ryan of the WHO stated on the 11th March, "This is a new disease; its a coronavirus; its not an influenza" (1), it appears to believe that it is dealing with an influenza, and rolled out, and continues to roll out an influenza pandemic plan.
Maybe the more interesting question is not only why has the clear advice from the WHO been ignored but why has an editorial such as this, in one of the most prestigious journals in the world, not had more impact. It doesn't appear to have been picked up by any of the main stream news organisations even when in normal times criticising the government in a BMJ editorial would have been a surefire way of creating some copy in the tabloids.
One of the partners in my wife's practice, Dr Jamie Parker, aka "the singing doctor", has had more air time. Maybe we should ask him if he has another song in him? I will suggest the lyrics that we can all join in with: "test, test, test".
(1) https://www.who.int/docs/default-source/coronaviruse/transcripts/who-aud...
Competing interests: No competing interests
Dear Editor
I have just read Allyson Pollock's paper asking why the UK Government is ignoring WHO advice.
May I suggest that failure to seek out cases and contacts means that there is no knowledge of where cases are occurring so responses cannot be targeted where needed. There is also no active learning about patterns of risk and patterns of mitigation. We do need to know more about the household or work contacts who are not getting ill, they have a lot to teach us.
Seeking out cases or making case reporting simple can be made straight forward but it may mean PHE needs to recruit more staff and / or volunteers and give them basic training and some oversight.
Competing interests: No competing interests
Dear Editor
Train and deploy a community level public health workforce to combat Covid-19
We strongly support Allyson Pollock’s views in this editorial. We do not understand why the Government is not following WHO guidelines regarding basic infection control practice. https://www.who.int/publications-detail/critical-preparedness-readiness-...
The public are in danger of being seen as helpless disaster victims but they can become a significant resource of community-based responders. It is a shame that numbers of public health staff have been reduced so much over the past decade, but it is possible to train lay volunteers very quickly to perform a limited number of essential public health duties. With short training, the new workforce can be skilled up to identify cases of Covid-19, trace close contacts, give simple instructions regarding management, and advise on isolation and quarantine. The basics of where and when to seek more help from 111 or primary care and how to record case on a mapping app, can also be taught. Every effort must be made to acquire and deploy more testing equipment. Until it becomes available the new community level workforce will be trained to identify cases by their symptoms and signs. It must be people under 50 who undertake this volunteer role.
In our communities there is enormous good will. Mutual aid groups have sprung up throughout the UK. Thousands of volunteers are being recruited to ensure that vulnerable people have food as well as some social contact. Clearly these activities are very important, alongside the highest priority which is reducing the number of cases.
So far the outbreak has been managed in a top down way from London. Focus is on hospital-based activities and technological solutions. More ventilators, good antibody tests, vaccine development, etc., are all vitally important, but there must also be a community led, bottom-up approach in line with WHO guidelines. We support the mass lock-down strategy but there are still some parts of the country with surprisingly few cases. Particularly in these places a mass program to identify cases, contact trace and quarantine will contribute to flattening the epidemic curve locally and nationally. We may also need this bottom up approach in any second wave of infection that occurs.
Competing interests: No competing interests
Dear Editor
Pollock et al’s article is very timely. A failure to listen to and heed expert medical and scientific advice by governments is not unsurprising.
In fact, a glance back into history suggests it is fully to be expected.
This phenomenon of playing the odds and side-lining risks one would rather not hear about has been the case for decades. There have for a great many years been numerous forceful expert warnings that the world was facing a pandemic, and that pandemic infectious diseases of either natural or man-made origin – not banking crashes, religious conflict, or climate activism - were high among the number one risks facing mankind.(1)
These warnings – based on sound science – about the need to prepare have been repeatedly and consistently been expressed, articulately and intelligently.(1-10) Over 20 years ago, Green, writing about pandemic influenza, said “We have time to plan now but may not later”(11), while as recently as September 2019, highly respected US medical journalist Laurie Garrett wrote…. “The world knows an apocalyptic pandemic is coming, but nobody is interested in doing anything about it”.(8)
Unfortunately, there has for a long time been a much greater willingness for many governments to listen to and follow the messages contained within the well-crafted lobbying funded by businessmen, bankers and hedge fund managers than any unvarnished counsel and advice proffered by doctors, other healthcare workers and scientists. Presumably there are always people who will only listen to, and believe, what they want to hear, whatever the truth.
Governments have been very prepared to invest massively in, for example, the “military-industrial complex” warned of by President Dwight D. Eisenhower (12) rather than being willing to prioritise and invest in the maintenance and protection of the health of their wider populations. According to the “Ending Pandemics” group (Skoll Global Threats Fund), in 2020 nearly 70% of the world’s countries were unprepared to respond to public health threats.(13)
Does such an approach represent the best quality of leadership we can aspire to?
In Greek mythology, Cassandra’s gift of accurate prophecy was accompanied by a curse guaranteeing disbelieving dismissal. Going forward we, as a species, really do need to learn to heed Cassandra and do better.
References
1. Future of Life Institute. https://futureoflife.org/background/existential-risk/?cn-reloaded=1
2. World Health Organization, Revision and Updating of the International Health Regulations, WHA48.7, Forty-eighth World Health Assembly (1995). https://apps.who.int/iris/bitstream/handle/10665/178403/WHA48_R7_eng.pdf...
3. Heymann D. Health: Preparing for Pandemics. Chatham House, 1 June 2009, Number 3. https://www.chathamhouse.org/publications/twt/archive/view/168325
4. Green ST, Cladi L, Morris P, et al,. Undergraduate teaching on biological weapons and bioterrorism at medical schools in the UK and the Republic of Ireland: results of a cross-sectional study. BMJ Open 2013;3:e002744. https://bmjopen.bmj.com/content/3/6/e002744
5. McCloskey B, Dar O, Zumla A, Heymann DL. Emerging infectious diseases and pandemic potential: status quo and reducing risk of global spread. Lancet Infectious Diseases 2014:14;P1001-1010. https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(14)70846-1/fulltext?_eventId=login
6. Smith MJ and Silva DS. Ethics for pandemics beyond influenza: Ebola, drug-resistant tuberculosis, and anticipating future ethical challenges in pandemic preparedness and response. Monash Bioeth Rev. 2015; 33: 130–147. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7100556/
7. Madhav N, Oppenheim B, Gallivan M et al. Pandemics: Risks, Impacts, and Mitigation. Editors Jamison DT et al. Source Disease Control Priorities: Improving Health and Reducing Poverty. 3rd edition. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2017 Nov. Chapter 17 https://www.ncbi.nlm.nih.gov/pubmed/30212163
8. Monaco L, Gupta V. The next pandemic will be arriving shortly. FP. 28 September, 2018. https://foreignpolicy.com/2018/09/28/the-next-pandemic-will-be-arriving-...
9. Wilton Park. Powerful actor, high impact bio-threats – initial report. Wednesday 7 – Friday 9 November 2018 - WP1625. https://www.wiltonpark.org.uk/wp-content/uploads/WP1625-Summary-report.pdf
10. Garrett L. The world knows an apocalyptic pandemic Is coming - but nobody is interested in doing anything about it. FP. 20 September, 2019. https://foreignpolicy.com/2019/09/20/the-world-knows-an-apocalyptic-pand...
11. Green ST. Zanamivir, influenza, and meningococcal disease. BMJ 2000; 320(7231): 378. .https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1127153/
12. Avalon Project. Military-Industrial Complex Speech, Dwight D. Eisenhower, 1961. Yale Law School – Lilian Goldman Law Library. https://avalon.law.yale.edu/20th_century/eisenhower001.asp
13. “Ending Pandemics” group (Skoll Global Threats Fund) 2020 https://endingpandemics.org/
Competing interests: No competing interests
National COVID-19 surveillance – A system-wide informatics deployment in primary care to enable surveillance and transformation of a sentinel system to support clinical trials
Dear Editor
Following the Editorial, BMJ 4th April, page 11 - "Controlling the spread of Covid-19; Testing and tracing must resume urgently in the UK”, we would like to describe a system-wide informatics deployment in primary care to enable surveillance and transformation of a sentinel system to support clinical trials.
UK general practice is highly computerised, with GPs using computerised medical record systems (CMR) in-consultation since the 1990s. The Royal College of General Practitioners RCGP Research and Surveillance Centre RSC and Public Health England (PHE) have collaborated for over 50 years to deliver an English national surveillance system, with over 20 years based on CMR data. However, there were no clinical codes to record COVID-19 and activated country codes for where people had visited.
We collaborated with CMR system suppliers to make the national surveillance system fit for purpose by creating new codes to record both COVID-19 details and countries visited.
We completed this implementation within two weeks, with the required codes across all brands of CMR system. The CMR Supplier ‘local’ codes created will map 1 to 1 with the official emergency release of Sytematized Nomenclature of Medicine Clinical Terms (SNOMED CT) COVID-19 codes. CMR suppliers will then convert their local COVID-19 codes to official SNOMED-CT ones.
An ontological approach was used to classify cases into confirmed cases, cases under investigation and those with negative tests excluded from having COVID-19 infection. We have created an online network observatory and individual practice feedback via a dashboard, updated weekly. We now provide information similar to RCGP RSC reporting of influenza, and have increased to twice-weekly reporting.
The successful establishment of a national primary care Covid-19 surveillance ( https://clininf.eu/index.php/cov-19/ ) attests to the strong relationships and collaboration between RCGP, PHE, CMR system suppliers and the primary care informatics community. Following the introduction of these coding changes, sentinel network family practices are actively recording data.
Progress and collaboration have not stopped there. The Oxford Primary Care clinical trials unit (CTU) has set up a platform trial to test emerging therapies for COVID-19 and The RCGP RSC has transformed itself into a trials platform to support the CTU. It has become clear that there are insufficient practices in the current RCGP RSC to support several trial arms. Again the CMR system suppliers have stepped in and have delivered, and continue to deliver solutions whereby practices can rapidly agree to providing data for surveillance or participate in the PRINCIPLE trial (Platform Randomised trial of INterventions in against COVID19 in older people). Over 150 EMIS CMR user practices signed up within days of being given the opportunity.
These rapid and successful collaborations have enabled national deployment of the means to monitor the COVID-19 outbreak over a nation-wide network and to scale the implementation of a first arm of this platform trial.
Yours sincerely,
Simon de Lusignan 1, Gayatri Amirthalingam 2, Shaun O’Hanlon 3, John Parry 4, Michael Feher 1 , Richard Hobbs 1
1. Nuffield Department of Primary Care Health Sciences. University of Oxford
2. Immunisation and Countermeasures Division, National Infection Service, UK
3. EMIS Group, Leeds, UK
4. TPP (SystmOne), Leeds, UK
Competing interests: Professor Richard Hobbs occasionally consults or lectures, usually linked to an international medical society event, for global biotech companies which include Amgen, Bayer, BI, BMS, Novartis, Novo Nordisk, and Pfizer in the past 5 years on his specialty expertise in cardiovascular disease and digital studies. Dr John H Parry is a full time employee of TPP (Leeds) Ltd who supply the SystmOne product, one of the two electronic medical record systems included in the article.