Trust chief executives are proud of what has been delivered over the last ten weeks to prepare for coronavirus. Few outside the NHS realise how much has been achieved in such a short time.
A good starting point is to remember how large and complex NHS trusts are. The largest have annual budgets of over £1.5bn and employ nearly 20,000 staff. Running them requires a stretching combination of providing consistently outstanding care to patients and enabling a large, specialist and highly-skilled workforce to perform at its best, within a tight fixed budget. This needs a complex support infrastructure, equivalent in size to a small town for the largest trusts, including estates, power, oxygen, catering, laundry, patient transport and cleaning.
For community and mental health trusts, the complexity also comes in running consistently high-quality services across hundreds of small sites and, for ambulance trusts, in being responsible for emergency response across a large region of more than five million people.
And some of this is life or death. If trusts fail to clean an infected area correctly, get a procedure wrong or suffer a critical ambulance equipment failure, lives are at risk. Fundamentally reconfiguring trusts at the drop of a hat is therefore a huge undertaking. But that’s what’s been done. There are different elements to this.
One, which has been widely featured in the media, is the creation of a brand new 4,000 bed hospital in the Excel Centre in London and the other new Nightingale hospitals being created across the country. They are our own UK equivalent of the stories from China of building new hospitals in a fortnight. But in terms of extra bed numbers for coronavirus patients, they’re only a small part of the story.
For community and mental health trusts, the complexity also comes in running consistently high-quality services across hundreds of small sites and, for ambulance trusts, in being responsible for emergency response across a large region of more than five million people.
Another way to look at this startling transformation is to focus on the 33,000 extra beds that have been created. That’s the equivalent of building 53 more, average-sized, district general hospitals across the country. Or, if you like, a mini sized new hospital inside each existing hospital - in less than a month.
This scale of change is unprecedented in the NHS’ 72-year history. It may be a bit Heath Robinson in places but it’s like turning a five seat car into a 15 seat minibus overnight.
How has this been achieved? It’s been a combination of five different things all happening at once, at unprecedented pace, any one of which would have provided a significant challenge on their own. It’s the combination of all five that should, and this can be said with increasing confidence, mean that the NHS line will hold for this initial peak.
The five things are:
- discharging medically fit patients
- diverting/postponing planned care
- creating extra critical care capacity
- emergency training staff to support COVID-19 patients
- incorporating private sector capacity into the NHS.
A brief narrative on each follows.
Another way to look at this startling transformation is to focus on the 33,000 extra beds that have been created. That’s the equivalent of building 53 more, average-sized, district general hospitals across the country. Or, if you like, a mini sized new hospital inside each existing hospital - in less than a month.
Discharging medically fit patients
NHS hospitals usually have somewhere between 20% and 30% of their patients, many of them frail elderly patients, ready to go home. But they can’t go home because they are waiting for social care packages or a nursing/care home place. It’s one of the areas where the 1948 division between health and social care, following the creation of the NHS, has had a significant negative impact. The NHS has completely rewritten its discharge procedures in a week to enable a much more rapid discharge process. Thanks to the work of NHS community and mental health trusts, local government and social care, hospitals have discharged record numbers of patients in record time. One chief executive said that his trust had cut the number of medically-fit patients ready for discharge from 250 to 20 in a fortnight. That’s 230 extra beds to treat coronavirus patients.
Diverting planned care
The NHS has been diverting planned care – the treatments or follow ups that hospitals had planned but which can be delayed or delivered in a different way. There’s been a particular focus on identifying care which is critical – vital cancer operations being a good example – to ensure they continue to time and quality. With other planned care, routine outpatient appointments have been transferred to the phone, put online using a new platform that has been developed at breakneck speed or, where appropriate, delayed. It’s been a huge trust administrative effort to make this redirection work as patients need to know how their new online, phone or delayed appointment will actually happen.
Expanding critical care capacity
Trusts have been expanding their critical-care capacity. The experience from other countries shows there is a vital cohort of very ill COVID-19 patients who can survive if they get the right critical care, especially ventilation support. The NHS has therefore been seeking to rapidly expand this capacity. Again, it helps to be behind other countries like China and Italy, as the NHS has a better idea of what capacity, and how much of it, will be needed. Creating this extra capacity requires a lot of internal reconfiguring – think turning your bedroom into a kitchen overnight.
This has involved thousands of stories of frontline staff doing amazing things. For example, a proud tweet from a hospital paediatric intensive care unit (PICU) team who had literally 'picked up' their entire unit, very ill children and all, and moved it overnight to a completely different part of their hospital with no loss of bed space. Another trust fitted an entire building with new oxygen piping and ducting within a week to ensure every bed in the building could now use a ventilator.
Thanks to the work of NHS community and mental health trusts, local government and social care, hospitals have discharged record numbers of patients in record time. One chief executive said that his trust had cut the number of medically-fit patients ready for discharge from 250 to 20 in a fortnight. That’s 230 extra beds to treat coronavirus patients.
Emergency training staff and expanding the workforce
Trusts have rapidly expanded the number of staff who can look after critically-ill coronavirus patients. They’ve ensured a much greater range of staff know how to support COVID-19 patients with breathing difficulties. They’ve trained staff to help patients with basic non-invasive breathing machines that help patients breathe. They’ve worked with anaesthetists and theatre recovery staff to grow the number of specialists who can operate complex, high-end, mechanical ventilators that do the breathing for the patients. They’ve also supported staff who are moving into new roles to bolster the support that can be provided to critically-ill adult coronavirus patients. At the same time, trusts have also been training and incorporating the 36,000 nurses and doctors who have volunteered to return to the NHS after recent retirement.
Private sector capacity
The NHS has also struck its a comprehensive deal with the independent hospital sector to use their capacity to both treat coronavirus patients and help the NHS deliver other urgent operations and cancer treatments. At a point where every extra bed, member of staff and ventilator could be vital, this means the NHS will have an extra 8,000 hospital beds, 1,200 more ventilators and 18,700 clinical staff available.
This narrative so far, and nearly all of the media coverage, has been focused on preparations in the 150 or so hospital trusts. But there have been similar extraordinary achievements in the ambulance, community and mental health services which have been equally important.
Important in their own right, as these trusts have their own patients to care for and the ‘ordinary business’ of the NHS goes on, however important coronavirus may be. But there’s also been important preparation in these trusts to support acute hospitals to look after their ill COVID-19 patients. To give some examples:
Ambulance services
The ambulance sector has had to scale up their service provision across the board as they need to convey large numbers of COVID-19 and suspected COVID-19 patients to hospital. One ambulance trust has increased the size of their ambulance fleet by nearly 30%, adding more than 60 brand new ambulances in five days, compared to their normal, two-a-week rate of onboarding new ambulances. They’ve also re-fitted 50 non-emergency response vehicles in a similar timescale, so these can also now be used for frontline emergency response. 111 and 999 services have been dramatically expanded at very short notice, with NHS 111 call volumes jumping by 105% in March 2020 compared to 12 months ago and a new online coronavirus 111 service launched in March. Ambulance services have been expanding their workforce, for example incorporating members of the fire service into their teams. They’ve also been doing the behind the scenes work that’s easy to miss, like establishing rapid turnaround facilities to ensure ambulances are deep cleaned after carrying a covid19 or suspected covid19 patient.
111 and 999 services have been dramatically expanded at very short notice, with NHS 111 call volumes jumping by 105% in March 2020 compared to 12 months ago and a new online coronavirus 111 service launched in March.
Community service providers
Community service providers have faced the challenge of suddenly having to care for and support a significantly higher number of patients, given the volume of patients hospitals have needed to discharge at pace. The transformation of community services, in response, has been just as impressive and dramatic as that in hospitals. There’s been a rapid move to telephone and video consultations, where appropriate, particularly for vulnerable groups. There’s been a quick exercise to identify which services can be de-prioritised for the moment and where the staff can be re-deployed, with appropriate training, to more urgent tasks. To give a sense of the volumes here, one chief executive tweeted recently of how teams covering Barnsley (population 250,000) had, in the previous seven days, done 4,000 home visits and 10,500 video/telephone consultations, redeployed, inducted and trained 150 staff into temporary new roles and absorbed 25 hospital staff in support of a newly launched rapid discharge scheme that had been created from scratch in less than five days.
Mental health providers
Mental health trusts have had to ensure their inpatient services are equipped to deal with coronavirus patients. That’s been a particular challenge for those trusts with patients who are held in secure accommodation, where the flexibility to reconfigure physical space may be heavily constrained. Trusts have been working hard to create 24 hours a day, seven days a week, mental health emergency services to support those in mental health crisis. They have been creating empty wards to allow acute hospitals to transfer non-COVID patients. Staff have also been retrained to help provide physical care. One of the more distressing groups of COVID-19patients to treat are frail, elderly patients with dementia who are suffering from multiple organ failure and need high-quality physical and mental health care as they reach the end of their life. Mental health trust staff who have previously focused on supporting the mental health needs of this group of patients have been rapidly trained in how to support their physical health needs and provide end of life palliative care.
Primary care, social care and voluntary sector
Trusts are part of a wider health and care sector. Although NHS Providers does not represent these sectors, trust leaders have also commented on the huge effort these sectors have also made to prepare for coronavirus. They point, for example. to the speed with which GP consultations have moved online and the way that groups of GPs surgeries have cohorted themselves into dealing with COVID-19 and non-COVID-19 patients. They are also grateful for the way in which care and nursing homes, hospices and other voluntary sector organisations have been able to assist in enabling rapid discharge from hospital, recognising that this has placed a significant extra burden on these services. As for NHS community services, there remains a need to ensure frontline staff in community settings are supported to cope with the increased acuity of people now being cared for within their homes, or other community settings, who may have remained longer in hospital in normal times.
Underlying themes
There are some important underlying themes to highlight.
The sheer scale of transformation and how it’s touched every bit of the trust sector, the speed at which this has been done, the way the entire NHS workforce in trusts – estates, procurement, administrative staff, therapists, paramedics, doctors, nurses, healthcare assistants, midwives, allied health professionals, managers and leaders – have pulled together. The support from beyond the NHS – from suppliers to partners across the health and care system, the way that leaders at all levels of the NHS - national, regional and individual trust - have worked, hand in glove, as a single team.
The sheer scale of transformation and how it’s touched every bit of the trust sector, the speed at which this has been done, the way the entire NHS workforce in trusts – estates, procurement, administrative staff, therapists, paramedics, doctors, nurses, healthcare assistants, midwives, allied health professionals, managers and leaders – have pulled together.
There’s a quiet, but enormous, pride in what has been achieved, most of it below the radar. And irritation with those, like the Editor of The Lancet, who have described the NHS’ preparations as "chaos and panic". Or Charles Moore who has argued that the NHS is a “lumbering” bureaucracy that has responded ineffectively because of its “lack of adaptability and readiness”. In both instances, the precise opposite is the case.
Demand and capacity modelling
There’s one other important piece of preparation work to highlight.
Key to effective running of a trust is to create the best possible prediction of future demand and then try to ensure the trust has the capacity to meet that demand, particularly if that level going to be out of the ordinary. Trusts have been working hard over the last two months, supported by national modelling, analysis and intelligence, to estimate what the likely pattern of extra coronavirus related demand would be. The modelling has predicted overall demand, ventilation requirement, morality rate and length of stay (key to estimating required bed capacity). Trusts have therefore had a pretty clear idea of what they were likely to be facing and have been doing all they can to scale up their capacity to meet this demand.
This modelling is a great example of the advantages of our state funded, nationally co-ordinated, National Health Service and one of the reasons why the UK was judged, before the outbreak began, to be one of the top three nations in the world in preparedness for dealing with a pandemic. Modelling, analysis and insight into pandemic spread is a public health function. No individual hospital or hospital group has the capacity or expertise to do this well. It has to be done 'centrally', at both national and regional levels, as the speed of regional spread is likely to differ. Any health system then needs to turn this insight into a series of regional, and individual local system, demand predictions to enable each trust to make detailed plans of how much extra capacity they will need so they can then create that capacity.
Regional health systems also need to develop a surge capacity plan of what would happen if demand exceeds capacity in any given trust and how mutual aid will work (e.g. which of hospitals B, C, D and E would take hospital A’s patients if it ran out of capacity). The key is to avoid what appears to have happened in some countries - individual hospitals left to sink or swim, then getting completely overwhelmed, struggling to provide even the most basic care.
England’s public health organisation, Public Health England, is well plugged into the rest of the NHS. There is a well developed and resourced national and regional NHS infrastructure (NHS England and Improvement) that supports local trusts and their wider local NHS systems. The NHS is used to critical incident planning, rehearsing these plans, and, as part of the plans, trusts providing mutual aid to each other. These have been significant advantages to the UK in preparing for the arrival of the pandemic and all flow from having a National Health Service rather than the fragmented health systems we see in other countries.
But how have these preparations held up as the first peak of demand has hit? And what lessons should the NHS learn from this first peak?