Moosa Qureshi: My battle with the government over transparency and covid-19 pandemic preparednessBMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n2992 (Published 09 December 2021) Cite this as: BMJ 2021;375:n2992
“I’m just very stubborn,” smiles consultant doctor and transparency campaigner Moosa Qureshi. His mood reflects a successful campaign to force the publication of key government documents on NHS pandemic preparedness. The newly unearthed reports expose government failure to act on the many infectious disease modelling exercises it staged in the five years running up to the covid-19 pandemic.
The scale and nature of that planning is only just coming to light, largely thanks to the efforts of Qureshi, who fits campaigning work around a career as a full time NHS consultant haematologist. He has been backed by lawyers Leigh Day (working for a heavily discounted fee), individual supporters who crowdfunded more than £80 000, and journalists. This week [9 December] The BMJ has awarded him its annual “Speaking Truth to Power” award in recognition.
To Qureshi, who studied European law before entering medicine, it is “absolutely crazy” that these reports were being kept secret. His first target was Exercise Cygnus, the codename for a large scale exercise in 2016 to test how the UK’s health system would respond to an influenza pandemic. He says that, at the beginning of the covid-19 pandemic, “nobody seemed to know what happened during Exercise Cygnus and what the outcome was. It went against everything I’d been taught during medical training about the importance of openness and shared learning.”
The final report, written in 2017 but not published until Qureshi’s campaign last year, forewarned of the crisis in care homes if a pandemic hit the UK as well as a warning that services were not prepared for the “extreme demands” of a “severe pandemic.”6 The exercise had taken place over three days and involved more than 950 people, from cabinet ministers to members of the emergency services.
Qureshi’s freedom of information campaign and legal action led to the publication of 11 secret reports and briefing papers into pandemic exercises conducted since 2015, modelled on highly infectious diseases such as Lassa, Ebola, and avian influenza.1 Crucially, they include Exercise Alice in 2016, which simulated a coronavirus pandemic and accurately predicted the importance of isolating patients, contact tracing, provision of personal protective equipment (PPE), trained staff, and adequate beds. These documents show that the Department of Health and Social Care, NHS England, and Public Health England were aware of the risks to lives posed by a major coronavirus pandemic.
At the time of his initial freedom of information request in April 2020, Qureshi had read about the existence of Exercise Cygnus, but none of the names of the other exercises were known, nor how many had taken place, or what type of pandemic was being simulated.
“We had no idea what we were looking for. We knew there was a report from the Cygnus exercise and we also suspected there was much more, but we didn’t know how much. I knew the limitations of the Freedom of Information Act. There’s also some evidence that the cabinet office might have set up a clearing house unit, which freedom of information requests go through, and they can obstruct public transparency.”
Qureshi, supported by his lawyers, set off on a fishing expedition for information. His initial request for the Cygnus report and all of the Department of Health and Social Care’s “pandemic preparedness documents” were rebuffed as too onerous, so he devised a more specific request. With journalist Tommy Greene, Qureshi also launched a judicial review, arguing that the government had a duty to disclose the reports under the Civil Contingencies Act. The strategy that Qureshi and his team pursued was to follow the freedom of information process all the way up to the information commissioner and at the same time pursue action through the courts.
Qureshi initially had little faith in the Information Commissioner’s Office (ICO). “I had more faith in British judges than the ICO; I thought the ICO was a token organisation. But the information commissioner Elizabeth Denham ordered the government to respond to our request for the Cygnus Report, which was really surprising. The ICO is a very effective regulator—under resourced but not afraid to take on important powers.”
Shortly after, in October 2020, then health secretary Matt Hancock suddenly announced in parliament that he was publishing the Cygnus report, without acknowledging the legal campaign. “We went back and said, ‘We don’t think you’ve disclosed everything we requested at judicial review.’” Of particular interest was a recommendation in the Cygnus report that NHS England should prepare two documents, one on population triage, the other on social care.
The triage document was thought to focus on how clinical teams should proceed if the NHS was overwhelmed. Should they prioritise the worse-off patients most in need of treatment or those with the greatest chance of survival? In January 2021, just a week before the Department of Health and Social Care responded to Qureshi’s request for the release of the triage document, the Nuffield Council on Bioethics put out a call for national guidance on how such decisions should be approached.2
In the early months of the pandemic, when demand for intensive care beds and mechanical ventilation threatened to outstrip supply, clinicians were facing the dilemma of whether to prioritise younger patients over older patients, while also considering whether this was discriminatory. Although the BMA had issued guidance, the lack of official direction left doctors in fear of litigation or professional sanctions, said the Nuffield Council.
For Qureshi, the lack of national triage guidance was a key failing. “There are cases of doctors who potentially face legal liability for things that have happened during covid,” he says. “And I see that as a failure of NHS England to publish a triage document. For example, there are patients who were issued inappropriate do not attempt cardiopulmonary resuscitation orders purely because they had a learning disability. It is mentioned in the Commons’ inquiry into the government’s covid-19 response”3 The Care Quality Commission’s review of resuscitation notices4 during the pandemic pointed to “confusing guidance, pathways, and protocols” that may have led to inappropriate clinical decisions.
Without proof the NHS triage document existed, Qureshi accepted legal advice and dropped the action. “I had a meeting with my lawyers where the outlook for our campaign seemed very negative. I went away and thought about things and felt quite dejected.”
Qureshi’s innate stubbornness soon kicked in, though, and he renewed his efforts with a series of information requests to eight local resilience forums. These forums are made up of the public services involved in civil emergencies and, as participants of Exercise Cygnus, would have been sent all the briefing reports. Unlike the Department of Health and Social Care, Qureshi figured they “would be a little bit less under the control of politicians.”
“I thought Essex Fire Service would be a soft touch, that some big firemen would just hand the documents over to me. It didn’t happen that way in the end!” Instead, Qureshi detected the hand of central government in Essex’s replies: “They were putting forward arguments and obstacles that were unexpected for a regional fire service.” It taught him a lesson about “how things at a very local level were being controlled by central government.”
“It’s a very slow process but surprisingly, if the regulator actually does their job, it can be effective.” Alongside this process, Qureshi also built up relationships with journalists on the Telegraph and the Guardian. The persistence paid off and the information commissioner eventually ordered the Department of Health and Social Care to hand over the documents. The triage documents and an associated report on social care planning led to a series of front page news stories in the Telegraph.
The report on triage said that age and “life years saved” would be important in allocating care, said Qureshi. “It had lots of case scenarios and basically gave a valuation to everyone’s life. For instance, the top value is given to a pregnant mum because she’s going to have a baby and then the baby has 80 years of life ahead of it.” An annex provided guidance and specific clinical examples for health professionals on the ground in a pandemic—although this was never discussed with staff dealing directly with patients.
Qureshi still felt there were glaring omissions. “The Cygnus report says nothing about PPE, or about intensive care capacity. You don’t have to be a civil emergency expert to realise these things are important in a pandemic. So, where were these data? I thought there must be other reports.”
Qureshi’s next round of freedom of information requests were crafted to ask for information on all pandemic exercises over the past five years. It took months of activity, but Public Health England “suddenly gave me this table (see below), which had 11 different reports from the past five years. It gave me the exact dates, the name of the report, and the name of the infectious disease that the report modelled.”
Public Health England gave up most of the reports one by one, holding out the longest on Exercise Alice, which modelled MERS, until it unexpectedly yielded in October 2021. Unlike the national scale of Cygnus, Alice was a small exercise of around 40 officials from Public Health England, the Department of Health and Social Care, and NHS England. Everyone’s name is redacted in the report apart from Sally Davies, the then chief medical officer. The exercise came to a consensus position that the government needed to ensure there was enough PPE, NHS bed capacity, and trained personnel to deal with a major pandemic. Public Health England, the report said, should develop contact tracing capability as this would be important in a coronavirus situation.
“It essentially predicted the challenges of covid-19 because it said we are not going to have a vaccine or antivirals,” Qureshi says. “In that situation, the only thing you can do, at least at the beginning, is make sure you’ve got enough PPE and roll out contact tracing so you can isolate people effectively who have the disease, or you are just going to get overwhelmed by it—because your pandemic influenza strategy isn’t immediately possible with a coronavirus.”
Just after the Exercise Alice report came out, the Common’s covid-19 response report was published. Jeremy Hunt, chair of the Health and Social Care Select Committee, was invited on to BBC Radio 4’s Today programme—Hunt had been health secretary for England at the time that Exercise Alice took place.5
“The interviewer asked why Exercise Alice didn’t lead to pandemic planning, and Jeremy Hunt responded that no ministers were briefed about it. If we believe him, Jeremy Hunt seems to be saying that this coronavirus exercise was set up completely independently of any minister, even though Sally Davies—the chief medical officer—plays a central role and the Department of Health and Social Care, Public Health England, and NHS England all participated. They all gave a consensus that we didn’t have enough PPE or NHS beds and then somehow Jeremy Hunt and all the ministers didn’t know that consensus position. It’s incredible.”
Qureshi also believes that Hunt should have recused himself from the select committee inquiry into covid-19. “The person chairing an inquiry into why the UK wasn’t prepared for a pandemic was the same person who was responsible from 2012 to 2018 for ensuring that we were prepared for a pandemic. Hunt’s main explanation for our lack of preparedness was that everyone in the Western world, including the UK, was focused on pandemic influenza, and so we weren’t prepared for a coronavirus. But that’s just not true.”
The whole experience of trying to find answers about the NHS’s level of preparedness ahead of the covid-19 pandemic has left Qureshi with very little confidence in the UK’s ability to plan for the next pandemic. “There seems to be a great deal of anger in the emergency preparedness community,” he says. “My impression is that the planning and the emergency advice was actually very good. They did their job properly in Cygnus and Alice. The problem is the government basically just didn’t implement their recommendations.”
“And my only explanation is either the politicians really didn’t care or deep down they didn’t really believe the warnings of the scientific and emergency community. For politicians, the budget deficit seemed more tangible.”
“You know, the very serious concern is that if they don’t face up to what went wrong with preparedness, they won’t be prepared next time. Furthermore, if they don’t open up their mistakes to external scrutiny, then even their own learning from covid-19 will be flawed because of internalised groupthink.”
“There has to be a real honest and independent account of what went wrong with preparedness. And a plan for going forward, particularly with the NHS and with social care, for future pandemics—because we’ve seen a series of novel pathogens in recent years, and future pandemics will happen, it’s just a matter of time.”
The power of direct action
Moosa Qureshi discovered the power of direct action and crowdfunding through his involvement in several NHS cases of injustice.
While doing his PhD in Cambridge he stumbled across social media messages from Chris Day, the whistleblowing junior doctor, and went on to cut his campaigning teeth supporting Day through social media management and crowdfunding. He later successfully stood for BMA Council.
“It really was a case of 50 000 junior doctors losing their legislative rights to speak out when they saw patient safety issues at risk.” It introduced him to the “strange dynamics” of the NHS. “You saw issues that, if they were handled in an honest and transparent way from the start, could be sorted quite easily. But Chris Day’s case somehow spiralled into a hugely expensive legal battle, which went right the way up to the health secretary and called into question the medical establishment’s commitment to patient care.”
He was next swept up in campaigning for justice for Hadiza Bawa-Garba, the junior doctor convicted of gross negligence manslaughter in 2014 after the death of a child in her care. “I’ve seen a lot of racism as someone of colour. And, for me, Hadiza’s race was central to what happened to her. I just thought, this is completely insane. How could a doctor be allowed to take the rap for the multiple systemic failings of an NHS organisation?”
He joined forces with a group of doctors, including Day, to crowdfund for Bawa-Garba’s legal case, a campaign which ignited public attention and went on to raise £360 000.
“Sometimes small organisations, or even individuals, are able to achieve a lot more than large organisations because they’re just more dynamic and able to make decisions much more rapidly. Now if you've got something that is of public interest and you get enough people to support it, you can achieve quite a lot.”
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