On the frontline of the coronavirus crisis, A&E consultant Ian Higginson is confronting a challenge he never expected: splitting his department to ensure virus patients are segregated from those who have sought treatment for other health emergencies.
He must do so against the backdrop of an ageing estate often ill-fitted to the demands of even regular 21st century medicine — let alone a raging and unpredictable pandemic.
Many hospitals and emergency departments “were designed before we became aware of things like Mers, Sars and now Covid-19. Staff and managers are having to do their best with what is, at times, very outdated infrastructure, to make it as safe as possible for staff and patients,” said Dr Higginson, who is vice-president of the Royal College of Emergency Medicine.
The National Health Service’s distinctive funding model, in which the vast majority of services are provided free to Britons of all income levels but at the price of tight controls on its budget, has led to a cash-limited system that may now be less resilient than those in some comparable nations.
Policy, as well as tight funding, has moulded the service. For decades, it has cut hospital beds at a faster rate than most other nations, part of a well-intentioned but fitfully-executed plan to shift resources into the community.
The service’s plans for coping with the coronavirus have brought the consequences of this policy firmly into focus this week, with the prospect of an alarming mismatch between the resources needed to tackle the outbreak and what the service can currently command.
The NHS currently has 3,700 adult critical care beds and 8,175 ventilators, with a plan to obtain about 4,000 more to treat people who suffer respiratory complications from the virus. Matt Hancock, health secretary, has made clear, however, that at least 20,000 ventilators will be needed and the government has issued a call to arms for manufacturers.
This week all main hospitals across the NHS have run an exercise to plot what is likely to happen at different points in the pandemic.
Keith Willett, a trauma surgeon who is leading NHS England’s response to the virus, told MPs this week: “Some of them will have their plans in place and can test out their plans; others will realise that . . . they need to think much more creatively and innovatively about how they move towards the sort of bed numbers, mechanical ventilations and sites that they can provide over that period of time.”
Dr Higginson said the news from Italy, where the virus has killed more people than in China, “was the first really stark warning shot we had of what this might look like in a European country and the effect on the health system”. Medics and managers understood for the first time there would be “a high number of patients requiring respiratory support whether by ventilation or other means”, he said, adding: “That is quite a short time to buy lots of ventilators that aren’t easy machines to make.”
In the most striking sign yet of how the epidemic will strain the service, Northwick Park Hospital in Harrow, North London, on Thursday evening declared a “critical incident” after running out of critical care beds. The incident, in which it contacted neighbouring hospitals to see if they could take patients, lasted until late afternoon on Friday.
Single payer systems like the NHS tend to shine in national health emergencies because they can mandate action across an entire country — like an edict this week to cancel all non-emergency surgery in England for three months to free up space. Nigel Edwards, chief executive of the Nuffield Trust think-tank, said the UK approach had impressed staff at World Health Organisation Europe who were using it as the basis for advice to some eastern European health systems.
But the UK also has the disadvantages of a taxpayer-funded system, notably the tight budget controls exercised by the Treasury.
Mr Edwards said: “The system works on a knife edge in terms of the balance between capacity and demand. You see it every winter and it doesn’t take much of a surge to put the system into quite severe difficulties from which it has increasingly found it hard to recover.”
In deciding to shift care from hospitals into the community, the government has also failed to provide the necessary investment in out-of-hospital care. The NHS lost 44 per cent of its general and acute beds between 1987-8 and 2018-19, according to data analysed by the King’s Fund, and now has 2.1 acute beds per 1,000 people. Although the Netherlands, one of the strongest international health systems, has 2.9 beds per 1,000, it spends about 1 per cent of gross domestic product more on social care than the UK.
“It was, and still is, a pretty good aim to reduce the number of people in hospital. The question is has it been sufficiently resourced [in the UK] and I think the answer to that is probably no,” Mr Edwards said.
The coronavirus may have a permanent — and more positive — legacy in the UK by changing the way patients receive healthcare and staff go about their day to day work.
Harpreet Sood, a GP in central London with many patients from disadvantaged backgrounds, has seen a huge change in the way he and his colleagues treat patients.
Where previously they provided telephone consultations for just a few patients a day, with the vast majority of appointments conducted face to face, in the weeks since the virus struck “we have flipped the model a bit” to ensure patients did not have to sit in a crowded waiting room and that the medics themselves were protected from infection.
Dr Sood said that on Thursday he had done “all telephone [consultations], one video and no face-to-face which could be a potential game-changer”. Feedback from patients suggested they preferred the new approach, which had not required extra kit, since both the GPs and their patients mostly used regular iPhones.
He had also found that collaborative working between different parts of the system — GP and hospital services for example — had become much easier now that discussions could be conducted through conference calls without the need to find a time for a physical meeting.
Elsewhere, staff at one London teaching hospital have been told normal IT governance rules can be relaxed so they can communicate however they like, including through WhatsApp groups. One staff member, who did not wish to be named, said: “We think it can transform the way we work and that the best changes will become permanent features. We’re all rather fired up by it!”
