An audit of Jersey's healthcare response to the pandemic has found that the specialist public health function was operating at "limited capacity" from the outset - with an absent Medical Officer of Health, and Dr Ivan Muscat juggling his role as one of two designated Deputy Medical Officers with his clinical responsibilities.
Government were also criticised for an absence of formal record keeping in the early stages.
Issues around staffing and capacity were rectified, according to the Comptroller and Auditor General, through a re-deployment of internal resources in March 2020, although there were times, she says, "when the 'key man' risk of having a single point of expertise was apparent."
A meeting of the Gold Group (the highest of the official command and control structure) on 26 March, for example, did not include an update on infection control, as Dr Muscat was not present at the meeting. The Medical Officer of Health returned to work at the end of April.
Whilst the audit trail improved from April, when STAC was established, even then, "the record of final advice given [was] not comprehensive, nor [were] there detailed records of the discussions around how this advice was created (including alternative options considered)".
Also missing from the documentation she received, she said, was an impact assessment of how advice given would affect vulnerable groups, "to ensure it does not widen health inequalities".
These groups could include people covered by protected characteristics such as age, race and disability as well as those experiencing poor physical or mental health or economic deprivation. From the documentation provided, it is not possible to see whether formal assessments had been undertaken on the effect of public health advice on vulnerable segments of the island's population.
The Comptroller and Auditor General also found the role of the government's Scientific and Technical Advisory Cell, in advising on key decisions had 'not been consistent'.
The report states that whilst STAC was heavily involved in advising on the re-opening of the island in May and June 2020, and the establishment of border controls, they were not asked to advise on the final set of restrictions imposed over the 2020 Christmas period, until Ministers sought advice "regarding possible exemptions to the Christmas guidance".
Despite shortcomings at the outset, she said "the hospital and community system did not experience significant gaps in staff deployment during the first wave" - the reasons for that being that "the number of Covid-19 patients never reached a level where staff became an issue". The suspension of non-urgent services also created staff availability.
Community care, meanwhile, was enhanced by the decision to employ the General Practitioners (GPs) to ensure the resilience and sustainability of GP services, as well as providing GP capacity where it was needed.
Overall, she found that the public health advice given had been "effective when assessed against a strategy of least overall harm". Despite 44 Covid-19 deaths in 2020, the overall mortality rate for 2020 was 14% lower than 2018, and 10% lower than 2019.
Amongst her recommendations is a "full reflective and evaluative lessons learned exercise" on the healthcare response across the whole health and care system. She also suggests a review of the proposed expansion of the public health function as part of the Jersey Care Model, "to address any future health protection emergencies".
Another recommendation is adopting a consistent code of practice for the establishment and operation of STACs in Jersey, encompassing principles and procedures to be followed as well as independence, communication and transparency.
Other points of note:
Non-urgent services suspended: During the second half of March, the majority of non-Covid elective and non-urgent care, the report states, was suspended. Yet, "decisions on which services were suspended and which face to face services could continue were not supported by consistent documentation against a clear set of risk based criteria".
During that same period, it states a decision was made to transfer a number of patients from Samares Ward at Overdale to the Sandybrook nursing home in St Peter.
The patients transferred were not screened for Covid-19 and staff at Sandybrook were not advised to wear Personal Protective Equipment (PPE), although PPE was available to all staff. Subsequently staff from Sandybrook had to self-isolate.
Non-urgent waiting lists affected: The significant reduction in "non-Covid-19 elective and non-urgent services provided", and the need to introduce "Covid-19 compliant clinical pathways" have resulted in waiting lists for other treatments growing. The number of patients awaiting out-patient appointments peaked in November last year, when over 10,000 people were waiting to be seen, compared to just above 8,000 in January 2019. As of 26 February this year, the number of patients awaiting outpatient appointments was 9,289. The report noted that significant lessons were learnt in the first wave when it came to impact on other services. Separate clinical pathways for Covid-19 and non-Covid patients, ensured non-Covid patients could continue to receive treatment in the second wave.
There is also a greater appreciation, both within HCS and STAC of the harms that can be caused by suspending services, including the impact on mental health.
Nightingale Hospital: The decision to build the Nightingale Hospital was based on a Public Health model which showed the 'reasonable worst case scenarios' for UK Crown Dependencies, and predicted a potential 248 bed gap. However, when the business case was made for the facility, estimating running costs of £4.3 million for a four-month period, including £3.3 million for staffing, the "operational plan had not been finalised and the risk of staff availability was not quantified".
Face mask training failures: Face mask training was criticised for "weaknesses in the administration and monitoring of compliance with the testing and training". Also, a list of doctors who had been through the training "was not maintained by the medical staffing department". Some doctors were noted to have failed the 'fit' testing.
Whilst a health and wellbeing committee was established to provide support for staff, there was criticism of the risk assessments in place for vulnerable staff. The methodology for risk assessments had not been formally signed off and it was unclear who had completed it, or who felt at risk.
Concerns were expressed in a number of interviews undertaken as part of my review as to the quality of the Occupational Health Service. The current service was described as being focussed on getting staff back to work, rather than a more proactive offer that supports staff health and wellbeing in a more rounded way.