In this analysis of over 12,000 HCWs across the UK, we found that reported access to appropriate PPE was particularly limited during the first UK lockdown and improved over the course of pandemic. Younger HCWs, Asian ethnic groups (compared to White groups), HCWs who worked in London (compared to multiple regions outside of London), those caring for COVID-19 patients as well as those who reported lack of trust in their employer were less likely to report access to appropriate PPE. HCWs in allied health professional roles were less likely to report access to PPE compared to those in medical roles during lockdown – but this effect reversed by the end of the study period.

Access to appropriate PPE is crucial to preventing HCW infection. When effective PPE is properly donned, removed and discarded, it protects both the HCW who wears it and those with whom the HCW comes into contact. Early in the pandemic, a study in China of 420 doctors and nurses who were deployed to Wuhan for 6 – 8 weeks to care for patients with COVID-19 demonstrated no HCW infection, by both PCR on nasopharyngeal swab and antibody on days 1, 7 and 14 after they had returned; all were fully trained and had access to PPE at all times.[3] Furthermore, a lack of access to PPE for HCWs caring for those with other high-consequence infectious diseases has been shown to be a significant source of physical and mental stress on HCWs as well as their close contacts.[14–16]

Our study provides the first large quantitative summary of reported PPE access amongst HCWs during the COVID-19 pandemic in the literature. We found that only 35% of HCWs in the UK reported having access to adequate PPE at all times during the period of the first lockdown, when at its worst, over 1,000 COVID-19 patients were admitted to hospital a day.[17] Clearly, this finding has implications for HCW infection and SARS-CoV-2 transmission. Our findings are in accordance with qualitative studies that investigated HCWs experiences with PPE during the first wave in the UK. In these studies, HCWs report a major PPE shortage, which in itself was a significant source of anxiety and distress, having a tangible impact on the workforce, resorting to reuse and improvisation of PPE to continue caring for patients when necessary.[18,19] Concern for inadequate PPE stocks may also explain why a higher proportion of allied health professionals and dentists reported lack of PPE access only during the first wave, where they may have been reserved for those looking after hospitalised COVID-19 patients.

We found that the groups which reported limited PPE access were also those that in other studies have been shown to be at highest risk of infection. Indeed, the number of COVID-19 patients seen was an independent negative predictor of PPE access. In a previous study, we found that junior members of staff were more likely to be seropositive for antibodies against SARS-CoV-2 in one UK hospital trust.[20] Junior members of staff are usually younger, and more likely to have more frequent patient contact and fewer administrative and managerial responsibilities, factors that may draw their more senior colleagues away from direct patient care. Furthermore, much of the outpatient work (often undertaken by more senior clinicians) was adapted to include more remote telephone or video consultations during the height of the pandemic, to reduce exposure and therefore the need for PPE. Similarly, HCWs who worked in London hospitals were more likely to have seen a higher number of COVID-19 cases compared to those working in other parts of the country.[21] The more often a HCW sees a patient with COVID-19, the more times one would have had to ‘don’ and ‘doff’ PPE, perpetuating their lack of access if resources during this time were limited. Taken together, these findings add weight to the possibility that lack of PPE access was directly associated with COVID-19 patient contact – which may in part explain the reportedly high number of HCW-associated infections in the UK. It should also be noted that although severe acute COVID-19 might be an unlikely result of SARS-CoV-2 infection amongst younger HCWs, this group may suffer debilitating, prolonged symptoms as a result of ‘long COVID’. Therefore, there may be severe implications both for the individual HCW and the healthcare workforce as a whole (due to absences from work necessitated by the illness).

Of concern, we observed that those from Asian ethnic groups, as well as those who report lack of trust in their employers were less likely to report adequate PPE access compared to White groups or those who reported trust in their employers respectively. Should lack of PPE access be directly related to risk of infection, it may partially explain why HCWs from ethnic minority groups are disproportionately affected by COVID-19.[22–25] Our findings suggest that disparities continue to exist within UK healthcare organisations, the reasons which may be complex.[24] Within the context of HCWs, this could be due to inequities in accessing the right equipment for the tasks required – which in turn can only lead to a further downward spiral of mistrust. It is important that healthcare organisations recognise that such disparities continue to exist and open dialogues with their staff, so that barriers to accessing adequate PPE can be identified and addressed. Furthermore, in light of these findings, it is even more vital that detailed occupational risk assessments that take account of ethnicity are undertaken for UK HCWs.[26]

Our study has limitations. As with any consented observational study, there is potential for self-selection bias. We may be reporting only HCWs’ perspectives regarding what is ‘adequate’ PPE rather than lack of access, since significant variation across a range of different clinical procedures exists for PPE between the UK, other countries and the World Health Organisation.[27] However, the large difference in the proportion of HCWs reporting access to PPE in the primary and secondary analyses provides evidence against this, given that UK PPE guidelines did not change in the intervening time. Our findings relating to trust in employer might indicate reporting bias (i.e. those that did not trust their employer to deal with a concern about unsafe clinical practice might be more likely to report a lack of PPE access in their workplace than those that did). Additionally, given the cross sectional nature of the analyses we cannot determine the direction of causality in this association. Finally, we are asking HCWs to recall their experiences of the last year and thus responses may be prone to recall bias. However, UK-REACH is one of the largest and most comprehensive HCW databases in the world to date, and if only a third of 12,000 HCWs report adequate PPE access, this is difficult for policymakers to ignore. Furthermore, risk factors for lack of PPE access were still present in the secondary analysis, which is less prone to recall bias.

In summary, we have demonstrated that significant proportions of HCWs in the UK reported a lack of access to appropriate PPE over the course of the COVID-19 pandemic and that PPE access was particularly limited during the first national lockdown compared to later in the pandemic. We have also determined key predictors of PPE access. Importantly we show that the demographic and occupational groups who were less likely to report access to PPE overlap with those facing a disproportionate risk of infection. Our study provides evidence of the extraordinary occupational hazard faced by UK frontline HCWs over the course of the pandemic, which has major implications for their physical and mental health, as well as that of their friends and families. Healthcare organisations should urgently implement strategies to understand and address loss of trust from their employees and combat institutional and structural discrimination.