Charlie looks at Scotland's Exercise Iris, how it holds up against COVID-19 and what we can learn from it.
I heard on BBC News this morning that the Exercise Iris report has been published on the Scottish Government’s website, and since I had recently written a bulletin on Exercise Cygnus, England’s Pandemic preparedness exercise, I thought it would be interesting for bulletin readers to see what we could also learn from Scotland’s exercise.
The first point to make is that the Scottish exercise was a completely different scale to Exercise Cygnus. England’s exercise involved 34 different agencies and was conducted over three days, whilst Exercise Iris was conducted over one day and only involved health participants, rather than the wider resilience community. The exercise was not taken that seriously within Scottish health boards, as the report commented ‘whilst the event was well attended, not all boards were able to attend and attendance from some boards was limited’. The look, feel and content of the Scottish exercise report was that of a much lower level than Cygnus. However, even though the two exercises were of very different scales, it is still interesting to look at what issues were discussed and in hindsight of the COVID-19 response to date, were the issues identified during the exercise relevant in the response to COVID-19, or are the issues different and not even mentioned during in the Exercise Iris report?
In looking at the scenario for Exercise Iris, it was very close to what actually happened in COVID-19. The scenario involved a patient coming back from Dubai with MERS-CoV, who takes some time to present themselves to a hospital, so they had the opportunity to spread the virus to their family, those they have been in contact with while travelling, plus the NHS staff they have interacted with when they arrived at A&E. The exercise ends with 40 MERS-CoV confirmed cases, the initial patent died, and with 8 likely further deaths, they reported: ‘no more hospital capacity in your board area and neighbouring boards are at close to capacity due to the ongoing outbreak and the wider pressures of the flu season’. What is interesting about this scenario is that there was no pre-warning of possible cases spreading elsewhere in the world before arriving in the UK and no pre-warning by WHO of a novel virus, so the actual scenario during Exercise Iris was worse than what actually happened in Scotland during COVID-19.
One of the key issues with COVID-19 has been the lack of available PPE, both in Scotland and throughout the UK. In the exercise report there is the comment ‘it was recognised that the availability and use of Personal Protective Equipment (PPE) would be a key consideration in the early stages of the outbreak’. Other comments on PPE went on to say, ‘discussion would include fit testing, consistency, messaging, availability of equipment and procurement’. Although availability of PPE was discussed during the exercise, there was no specific action to look at solutions. I suspect that those attending saw this as a Scottish Government issue and were perhaps not aware of the amount of PPE available in government stockpiles or felt that this was not a problem for them.
It was agreed during the discussions that one priority was ‘contact tracing and implementing infection control measures’. In looking at contact tracing, the emphasis was on identifying staff members who might have been in contact with the infected patient and looking at the impact excluding these staff members might have on the ongoing delivery of NHS services. There is no mention in the report of contact tracing of members of the public that the patient had been in close proximity with. In both Scotland and England’s contact tracing systems, IT and assigned personnel is set up from scratch, so any existing system developed prior to the pandemic was not able to deal with COVID-19.
COVID-19 in Scotland has been responsible for more deaths in care homes than in hospitals, so the protection of vulnerable people is a major issue. There is only one mention of social care ‘Social Care colleagues should be included in board command and control structures’, so care homes and protecting the elderly and vulnerable is not a major issue that was discussed in the exercise.
Reading through the report, although there is not an attendee list, I personally get the impression that this it is a low-level exercise, attended by a number of middle ranking resilience personnel with very few or no senior managers or decision makers in the room. Not all organisations found the time to attend, which also suggests that it was not a meeting of senior decision makers. Reading the actions in the report, such as ‘HPS to include a register of Scotland’s specialist facilities in guidance’ and ‘liaison with NHS 24 included in comms planning’ seems to show a very simple level of planning for this type of event, as these identified actions are basic planning items. Both of these elements suggest that MERS-CoV planning was not taken that seriously.
However, those who attended went away ‘feeling positive about the arrangement following the event’. In conclusion, it is better to have an exercise than to not, and the more you exercise the better your response should be. In this exercise the people who I suspect should have turned up, delegated responsibility to more junior staff, as often happens in exercises. If one good thing does come out of the COVID-19 response, it may be that senior staff realise that exercises are important and that learning lessons from them can identify issues which can be solved before it becomes a real life incident.
A copy of the Exercise Iris report can be found on the Scottish Government's website here.