PPE: How a global shortage and bureaucratic screw ups combined to leave Britain short

It was mid-March when they started to notice that some of their orders for supplies were going unfilled. Hospital employees I spoke to at one major English hospital, on the condition of anonymity, described the growing worry and uncertainty on whether they could access all the necessary items of PPE. As coronavirus spread across the country their hospital was rapidly becoming a major treatment centre with their catchment area one of the worst affected in the country. And PPE was hard to come by.

Just as the virus began to take root in the wider general public, some supplies started to go missing, apparently pilfered. Alcoholic hand gel usually at the end of every patients’ bed disappeared en masse. Boxes of masks and even of gowns disappeared as well. The staff heard similar stories from other hospitals. While not very large the disappearances were sharply resented as PPE began to run short.

Donations from the public helped keep things afloat. While some of the material donated, such as protective masks given by a generous soul, was definitely medical grade – there was no such certainty when it came to other items, such as visors handmade by local volunteers.

By the end of the March ordering and distribution of PPE, previously managed like other medical supplies on a departmental basis, was under tight central control within the hospital. This was not only to prevent further disappearances, but even more importantly to ration what PPE was available.

Now, over a month down the line since those problems first started appearing in hospitals across the country, requests for PPE are often still not met in full.

Staff performing procedures deemed lower risk are not given the equipment which offers the most protection, something that became official policy after government guidelines downgraded the quality of PPE required for certain procedures. While officially the government said this was as the risk posed by the virus had been revised down, reporting by BBC Panorama this week suggested this revision was in fact a reaction to the growing shortages.

Donated equipment continues to fill some of the gaps, but it was only in the past week that the staff who spoke to me were ordered to test the donated supplies to ensure they met medical standards.

Even though the precise shortfall is difficult to quantify in an emergency, there are sufficient reports of shortages identified by doctors, nurses and care owners around the country to suggest there is a serious problem.

How have things come to this?

Part of the answer is undeniably that there is a global shortage of PPE as manufacturing struggles to keep up with the soaring demand for it driven by coronavirus. Yet it also seems undeniable that the inadequacy of many government systems here, in particular NHS procurement, have exacerbated this crisis.

Global Shortage

On 23 January the Chinese government, long reluctant to admit there was a problem, took the sudden and drastic step of locking down Wuhan, a city of 11 million. Over the following days the lockdown was extended to all other cities in the province of Hubei, and eventually covered almost the whole of China.

The cause, of course, was coronavirus. The lockdown was accompanied by a vast mobilisation of medical capacity. For many this was epitomised by the dramatic building of a hospital capable of treating 1,000 patients in just 10 days. No less dramatic were China’s efforts to secure the vast supplies of PPE it required both to protect medical professionals and keep up with the demand for masks from the general populace.

China already produced roughly half the world’s facemasks, as well as about half the world’s supply of a vital component in their production, non-woven polypropylene fabric. By early February it was preventing the export of both. Still, it needed more. Across the world PPE manufacturers found themselves doing something they had never anticipated – shipping their products to China, the global centre of PPE production, and on a vast scale. The one exception was Taiwan, the world’s second largest producer of facemasks, which, ever watchful of China and with an epidemiologist as their Vice-President, had banned their export on 24 January

In the UK the government started to take note of coronavirus and the potential threat it posed to the country, and its medical supplies. On 11 February Steve Oldfield, the Chief Commercial Officer at the Department of Health, wrote to NHS suppliers about the potential risks of coronavirus.

While he claimed that “the NHS and wider health system are extremely well prepared for these types of outbreaks” the letter also stated the government had put together a task-force to examine and mitigate the risks concerning the UK’s “supply requirements in the case of an expanded outbreak in the UK” and “the potential pressures on global supply chains due to the impact of coronavirus and control measures that the Chinese authorities have put in place or may put in place.”

To this end the government requested that the suppliers conduct a full risk assessment of the impact of the situation on their supply chains, including:

“• the implications of coronavirus for business activities;

• how the current restrictions within China may affect production and transport of finished products, Active Pharmaceutical Ingredients (APIs), excipients and components directly sourced from China,

• whether any of their non-Chinese suppliers rely, in turn, on components sourced from China.”

They were to then inform the government of the results of their risk assessment. In the meantime, it simply asked that suppliers continue filling NHS orders “in the normal way”, keep hold of any stockpiles they still had left from Brexit No Deal preparations, and “consider demand management plans in the event of excessive or unusual ordering patterns”.

Even in early February the letter looked outdated. Lockdowns had been in place in China for over three weeks, and the Chinese government was already moving aggressively to secure as much of the global supply of PPE as possible. It and Taiwan had already ceased exporting the vital equipment. The potential of virus to spread globally, presumably entailing further supply chain disruption, was being flagged in Cobra meetings.

Indeed, as the virus spread other countries from Germany to Turkey to the US imposed their own export bans, desperate to build up stocks before the crisis engulfed them. While most export bans were eventually lifted, including China’s and Taiwan’s by mid-March, experts have warned that the disruption helped fuel shortages elsewhere.

Export bans were far from the only bottlenecks affecting global PPE supply and distribution. Perhaps the most important issue still facing PPE manufacturers is the shortage of non-woven polypropylene fabric. The plastic polypropylene is mainly used for packaging, but can also be made into a non-woven textile whose filaments are less than one micron thick. Highly impermeable to liquids, light, resistant to cracking, and easy to mold polypropylene non-woven fabric is the most commonly used sort of plastic in the manufacture of medical PPE.

In order for this plastic fabric to be suitable for PPE production it must be meltblown, a specialist process involving high speed blowing gas. As mentioned above China was the world’s largest producer of this vital commodity, and was quick to limit its export. While these restrictions have been relaxed production has struggled to keep up with the vast boom in demand for meltblown plastic.

Increasing meltblown production is not easy. The machines needed are very expensive, $4.23 million apiece, as well as difficult to produce and install because of the extreme precision with which they must operate. Assembling production lines is estimated to take half a year, if not more. Enthusiastic claims by some Chinese companies that they can do it 16 days looks implausible. On top of this is of course the risk that workers in these factories will fall sick.

Nor is meltblown plastic the only issue. Masks for example also require components like elastic straps and metal clips, all of which may be produced in different locations across the world and all of which have to be brought together to produce PPE.

This usually near seamless process, enabled by just-in-time delivery, has become much more difficult as coronavirus lockdowns and quarantines have limited freight capacity.

Sea-Intelligence has estimated there could be a 25% fall in shipping in the first half of 2020. Air freight has been hit even harder. Usually 50% of all air cargo is carried by passenger airplanes, almost all of which have now been grounded by the pandemic. Stepping up cargo service is difficult due to shortages of properly configured aircraft, a lack of pilots, and international restrictions. Even if PPE is produced and acquired abroad the problem of freight once again recurs.

Shortages of key materials, freight difficulties, and problems expanding production all make for major bottlenecks. It is no coincidence that one of the few companies which has successfully managed to step-up production of coveted N95 masks on a large scale in 3M. That it has been able to do so is in large part due to the fact that most of its factories are located in the markets they cater for, produce key components in-house, and were designed with surge capacity in mind after the company saw the spike in demand that followed the SARS epidemic in 2002-2003. Unfortunately, this seems to be far from standard practise.

National procurement

Undeniably the NHS PPE shortage cannot be laid wholly at the government’s door. The shortage is a global phenomenon and across the world medical professionals have protested their lack of supplies – varying from Americans’ healthcare workers #GetMePPE appeal that trended on Twitter to German doctors posing naked to highlight their lack of protection.

Nevertheless, it is also increasingly apparent that the dangerous situation NHS workers have found themselves in has been made worse by government failures. Part of the problem was a lack of stockpiling. That Panorama investigation – criticised because Labour activists were interviewed, but nonetheless revealing – demonstrated that successive governments had failed to stock up on PPE deemed vital in case of pandemic, for example purchasing no protective gowns which are now in desperately short supply.

One former Tory minister I spoke to suggested things may in fact have been even worse without No Deal Brexit preparations. Considerable supplies were built up in anticipation of potential disruption, he said. While they were being wound down before coronavirus hit medical stockpiles, public and private, do seem to have helped plug some gaps. The preparations also included identifying potential supply chain vulnerabilities, which the former minister argued may have helped avert or mitigate disruptions to supplies of some vital medical equipment. Still, neither has been enough to avert the ongoing PPE shortage.

Indeed, the failure of long-term planning and the difficulty the government is facing procuring emergency supplies of PPE both seem to be, at least in part, expression of the dysfunction that allegedly characterises NHS procurement.

According to Colin Cram, Chief Executive of Marc1 Ltd and former civil servant specialising in procurement, the system has long been “stumbling from one crisis to another just throwing money at problems”, and now bad procurement practises “have resulted in an unknown number of deaths”.

This is in fact not the first time the NHS has faced a supply crisis. In 2012 there was an acute shortage of dialysis tubes, with disaster only averted narrowly thanks through the use of “squirrel stocks” – small emergency supply stockpiles kept by hospitals. The cause was an earthquake in Italy which took out a factory producing said equipment, and which the only two approved NHS suppliers both purchased from.

Nor was this the only incident of this sort. The former minister noted that NHS Trusts face supply crises “fairly frequently” with trusts running low on stocks they struggle to procure themselves, and having to call on the central supply chain to bail them out.

Cram argues that potential supply chain vulnerabilities have long been overlooked, and that the 2012 situation has been allowed to repeat on a grander scale with regards to PPE, at least in part due to the poor organisation of NHS generally procurement which, he claims, lacks “accountability and transparency”.

As things stand England has no single centralised system of procurement. There is NHS Supply Chain, previously privately managed by DHL and now by Supply Chain Coordination Limited, a limited-liability corporation under control of the Secretary of State of Health and Social Care. However, this body does not actually negotiate directly with suppliers, instead contracting out the actual procurement to various companies. The government also does not, and long has not, required NHS Trusts to use these centrally negotiated procurement contracts. Instead, NHS trusts often also negotiate some deals off their own bat.

The result is a mess. The piling of “consortia-on-consortia” seems to drive up costs and makes it nigh-impossible to hold any one person accountable for the system’s failings. The NHS’s potential power as a vast consumer of medical goods is not made effective use of in negotiating supply contracts as the government cannot guarantee all NHS Trusts will actually then make use of them.

It also means the system is uniquely poorly adapted for the sort of crisis we now face. In the face of global PPE shortages a single central body may be needed to consolidate and ration supplies in a way that prioritises those most in need. The government has recognised this and has attempted to set up such a system.

But the previous outsourcing of these tasks means that there is no in-house experience of procuring and distributing PPE, no pre-existing relationships with suppliers who civil servants now need to coordinate with, and a limited ability to leverage the NHS’ power as huge potentially extremely valuable client.

Had these sorts of structures been in place beforehand they might even have allowed civil servants to notice the surge in PPE orders from China, and take action to mitigate potential problems and secure supplies earlier on.

Meanwhile, NHS Trusts and GPs surgeries desperate for equipment are, understandably, also purchasing what they can themselves – competing against each other in a way that undermines the centrally controlled provision of supplies.

The lack of a clear central procurement body also perhaps explains the strange unresponsiveness that suppliers volunteering to help produce PPE for the NHS have been complaining of. Indeed, suppliers have apparently found the Scottish and Welsh governments, which operate centralised NHS procurement bodies for their devolved health systems, more responsive to their offers.

That NHS England should have a similar body has long been called for, not just by Colin Cram. Back in 2013 a government report noted the inadequacy of NHS procurement, and the potential advantages if the NHS could be made to “act as a single customer” and work more closely with suppliers.

Perhaps the coronavirus crisis will finally incentivise the government to resolve the issue that its predecessors have long ducked. Certainly, as things stand something has gone badly wrong and if the government wishes to hedge against future crises through better stockpiling, or even by encouraging suppliers to manufacture vital goods locally, a powerful central body will be necessary. Until such measures are taken the NHS will remain hostage to the next crisis which disrupts it supply lines.