Variation of experience can only produce educated guesswork at this point
As one might expect, trust leaders report very different experiences depending on how COVID-19 demand is actually affecting their trust. London has been the first region to experience the surge in demand. But the pressure is now nearly on an equal level in the West Midlands, with increasing activity in the North West, parts of the East of England and the South East. It’s very difficult at this point to understand the reasons for this different pattern of demand, though population density seems likely to be a key determinant, with the virus spreading out from urban centres.
It’s also striking that there appears to be significant variation in what’s actually happening. To give an example, one trust chief executive was trying to understand why their intensive care unit had managed so far, admittedly on a small sized cohort of patients, to successfully discharge all their patients who had been on mechanical ventilators with no deaths. The neighbouring trust, 20 miles down the road, with a much larger cohort, had a mortality rate of around 40% of their mechanically ventilated patients.
All this is a preamble to saying that the experience of how COVID-19is impacting on trusts, that is shared here, can only be educated guesswork based on individual trust leader feedback.
How does the reality compared to the expected modelling?
One way to look at how COVID-19 is impacting on trusts is to look at the reality of what appears to be happening against the modelling, referred to above, of what was expected to happen.
Most of the public dialogue around COVID-19 hospital patients has been framed as a single, large, undifferentiated group of patients. But to understand what’s going on, it’s probably better to think about different groups of patients and look at what is happening to these groups. There are a number of different ways of doing this grouping but the one that has resonated most is a three-part grouping, remembering that all of these patients are seriously ill and need hospitalisation.
One group are those who need basic breathing support to assist with their recovery. A second group are those who need full mechanical ventilation in critical care. The third group is made up predominantly of the frail elderly with multiple, serious, long-term conditions. For this group, the impact of COVID-19 is so severe that they are starting to suffer or are suffering from multiple organ failure. Ventilation support makes little to no difference to their long-term prognosis. For this group, the requirement is high-quality palliative care.
What we’re hearing from hospital chief executives who are dealing with large numbers of COVID-19patients at this point is the following, in relation to these three groups.
First, that the overall number of hospitalised COVID-19 patients is about as expected. Second, the number of patients requiring high-end mechanical ventilation capacity is actually lower than originally estimated. This is good news given the potential pressure on ventilation capacity. However many trusts report that a large number of these patients, who are not necessarily frail and elderly, and who may not have long term conditions, can quite quickly develop multiple organ failure, often requiring significant renal support. Third, the overall mortality rate is also lower than originally estimated. This is also, of course, good news. Fourth, those who recover need a longer length of stay in hospital than originally estimated, as do those who need palliative care. Fifth, the clinical picture in a lot of patients is unlike that described in other countries. For example, trusts tell us they are increasingly concerned that, in this country, there seems to be a greater rate of prevalence of covd19 in its most serious, life threatening, form among black and ethnic minority patients, with several trusts now conducting more detailed analysis to try to understand whether and why this might be the case.
Most of the public dialogue around COVID-19 hospital patients has been framed as a single, large, undifferentiated group of patients. But to understand what’s going on, it’s probably better to think about different groups of patients and look at what is happening to these groups.
The emerging hypothesis, therefore, is that there are likely to be three capacity constraints. The first is the well known one of ventilated critical care beds. The second one is general and acute (G&A) beds for those who can recover without mechanical ventilation, or after having had it, and those needing palliative care. The third is dialysis machine capacity to provide renal support.
A typical "my last few weeks" story from a London hospital trust chief executive, focusing on the match between demand and capacity therefore runs something like this - lots of extra capacity created, a period of quiet, then a sudden influx of patients. Some initial nervousness that the hospital’s critical care capacity is going to be quickly and fully used up, a lot of activity at pace to make sure this initial surge is appropriately cared for, given that the number of patients requiring critical care and ventilation support is unprecedented.
But then the increase in demand for critical-care capacity does not increase in the exponential way originally predicted. Critical-care capacity gets expanded chunk-by-chunk. At this point (i.e. right now) still some more critical care capacity to deploy as it’s not filled as fast as first thought, compared to the initial surge, and the modelling. The rapid initial activity surge turns into a very hard and pressured, but more regular and stable, pattern of activity. But looking mid to long term, a realisation that greater extra G&A bed capacity will be needed given the longer length of stay and lower mortality rate.
It’s important to remember that this pressure is not just hospital based. Community services providers are looking after the significant number of extra patients recently discharged from hospital, many with more complex needs than community service staff ordinarily experience. Mental health providers are providing new 24/7 emergency mental health services and intermediate care wards where those who are recovering can be cared for, freeing up vital hospital beds. And ambulance services are having to rise to completely new challenges like how to convey patients to and from the new Nightingale hospitals and fit these into their existing real time demand management systems.
It’s important to remember that this pressure is not just hospital based. Community services providers are looking after the significant number of extra patients recently discharged from hospital, many with more complex needs than community service staff ordinarily experience.
The importance of the NHS regional structure
Although the NHS has not, so far, had to trigger the full entirety of its regional surge capacity plans, the existence of these plans and the extra spare capacity has been hugely reassuring. It is also important to remember that modelling suggests the first peak of demand is still probably a number of days away.
As the NHS has moved from preparing for the extra COVID-19 related demand to dealing with it, NHS England and Improvement regional teams have become more important, ensuring that an accurate picture of each trust’s capacity can be shared with all leadership teams in their region and adjustments made accordingly. It helps, for example, that because of the way demand surges are managed in winter, hospitals and ambulance services are already used to working closely with each other to monitor hospital capacity in real time and divert patients accordingly.
London trust chief executives talk of the reassurance provided by the daily London regional gold command phone calls. These are led by a London regional director who, just a year ago, was one of the country’s leading hospital chief executives and therefore knows exactly what it is needed to lead a busy trust effectively. These calls enable every trust chief executive to highlight potential problems, seek mutual aid and escalate more complex problems for regional level support. Trust leaders describe them as a very far cry from the distressing stories they’ve heard of hospital leaders in Northern Italy who seemed to be trapped as isolated and overwhelmed individual islands without support from colleagues.
The power and importance of the NHS regional structure is well illustrated in the role it is playing in prioritising the support the NHS is receiving from the armed forces. Given the range of tasks the army can help with, and how many trusts could benefit from their support, it is vital that their resource and effort is targeted to best effect. All requests are therefore channelled through a single armed forces regional liaison officer sitting alongside each NHS regional team and prioritised accordingly. The result has been a much-needed immediate increase in capacity, right across the country, in key areas such as logistics planning, construction and transport.
As the NHS has moved from preparing for the extra COVID-19 related demand to dealing with it, NHS England and Improvement regional teams have become more important, ensuring that an accurate picture of each trust’s capacity can be shared with all leadership teams in their region and adjustments made accordingly.
The problem of current staff absence rates
One of the biggest problem trust leaders tell us they have faced in dealing with this initial spike of coronavirus related demand has been the level of staff absence. Trusts are trying to deal with the biggest increase in demand for critical care they have ever experienced, with large levels of staff absence – a particularly difficult challenge to surmount.
The absences are due to four different factors:
- 'normal' staff absences
- staff members who actually have coronavirus
- staff members who have to self isolate for 14 days because they have a suspected household member with COVID-19 or COVID-19-like symptoms
- members of vulnerable groups having to self isolate long term (two examples include four pregnant intensive care nurses from a single ICU in one trust and two 70-something year old ICU consultants in another trust). Helpfully, some of this is being offset by staff being willing to delay planned leave, thought this is only a short-term, temporary, solution.
The NHS started this crisis with nearly 100,000 vacancies (around 8.1% of the workforce) and a workforce that had already been working flat out over winter with no 'traditional' summer lull. Trust leaders are saying that current levels of absence, on top of this, are problematic. That’s why they have been so keen to ramp up staff testing (more below) as every member of staff returning to work is hugely valuable.
The ease of coping with these absences varies by type of trust and service. For example, a hospital might be able to flex its staff/patient ratios or rely on a different grade of staff to cover a gap on a general ward (e.g. a healthcare assistant temporarily covering a nurse). But if an ambulance trust has too many paramedics away from work, it has no choice but to take precious ambulances off the road. Community services depend significantly on 1:1 or 2:1 staff-to-patient care, so losing staff in these services can also have a particularly significant impact.
Trust leaders universally praise staff’s response to these problems and highlight several aspects of that response. The willingness of staff to move rapidly to new areas of work in which they have little or no experience, with less than perfect induction or training before being expected to pitch straight in to their new work. Their readiness to adopt new and demanding shift patterns at very short notice, stay beyond the end of shifts and work extra shifts. Their willingness to take on new roles – for example, with no visitors allowed, qualified staff members being asked to act as the daily contact point with next of kin for daily patient updates and arranging video calls with family members. The fact that staff are prepared to work in new, expanded teams with very different patient/staff ratios to normal and much less expert supervision than would normally be expected. These all, of course, considerably add to the difficulty of the work staff are having to do.
The NHS started this crisis with nearly 100,000 vacancies (around 8.1% of the workforce) and a workforce that had already been working flat out over winter with no 'traditional' summer lull.
What’s it like for frontline staff?
This narrative so far does little to capture the relentless reality of frontline staff’s current experience. There have been a lot of well written, thoughtful pieces of frontline testimony. Two that caught the eye, written by experienced clinicians, are here and here. If you prefer moving images, the BBC’s six-minute video report from a London critical care unit is equally compelling.
They all capture five features of the current experience of frontline clinical staff that are particularly echoed by trust leaders with selected paragraphs, from the two articles highlighted above to illustrate each point.
The dedication, commitment and professionalism of frontline clinical staff, and those who support them, to continue doing the best possible job they can, come what may: "Being in and out of hot, restrictive face-covering protective gear and on constant vigilance for infection control is tiring. But the way in which the whole of acute care has within weeks reorganised work-streams, ward areas and job roles, doubled up on rotas to provide more continuous cover, cut through usual rules, myths and rituals to ensure patients keep flowing through the hospital, increased capacity in intensive care and even stepped up to the challenge of creating field hospitals in exhibition centres has been a marvel – much of it fuelled by gallows humour and team spirit”.
The speed of difficult decision making that is required. “We are used to people dying in hospital, because it's often a place where people die. But normally we are reflective in our practice, we give time, and time is a great instrument for us in health care. But in the hospital today we are making rapid decisions about life and death - decisions about ventilation, about escalation care and when to make the decision about end of-life-care”.
The frustration and sense of inadequacy at being unable to provide the quality of care staff would like to provide or are used to providing. “We also risk what some researchers have termed “moral distress” at having to provide a standard of care, staffing or expert supervision that is less than we would want or be trained for because of unparalleled demand and staff absences. This includes not being able to see patients’ families face-to-face on wards, coping with staffing gaps and rushed care, sending people home sooner than we normally might and with an imperfect home situation as it beats being exposed to infection in hospital”.
The impact that the current relentless intensity and pressure is having on staff. “She [a ward sister] has also noticed the emotional strain that staff are under - people crying in a corner, or admitting that they cry when they get home and have to hide it from their children. She has raised the idea of designating a room as a "wobble room" where hospital staff can go for a moment if they are feeling emotionally wobbly. I think there is a mass insomnia among the staff, because our normal routine has suddenly been totally disrupted. I've taken to waking up through the night thinking about it myself”.
The sense of personal jeopardy that staff can feel. “In 31 years as an NHS doctor I have never been scared of immediate personal risk from my job. But fear is now a constant companion for many of us, fear of becoming infected - perhaps fatally - with recent first-hand experience of how sick people can become and how many clinicians in other countries have been hospitalised by infection, fear of infecting our patients, families or colleagues”.
The dedication, commitment and professionalism of frontline clinical staff, and those who support them, to continue doing the best possible job they can, come what may.
Trust leaders know that their most important task is to support their staff as best they can in these very difficult circumstances. The response is changing over time, as needs change. In the early days it was free car parking, working with supermarkets to enable easy access to shopping and providing accommodation for those who wanted to stay close to their place of work especially if they were having to separate from household members with COVID-19 or possible COVID-19 symptoms.
Now it’s a combination of short-term needs – providing hot food on site and trying to ensure that everyone gets an adequate rest every so often – with starting to think about the mid- to long-term support that will be required. Trust leaders are clear that there will be considerable need for psychological and mental health support.
There is a big concern here. It seems increasingly likely that the NHS will successfully navigate this first initial peak. But it feels like the NHS may be moving, in a phrase of the moment, to a ‘flat sombrero’ where demand on the NHS is spread over a much long period of time than initially expected. But this will still require NHS staff to work at a very high level of intensity and pressure. If that is the case, the NHS is going to have to think very carefully and deeply about how it can support its staff over that period.
The NHS has good experience of supporting relatively contained groups of frontline staff through major, short duration, crises like the Manchester Arena bomb and Grenfell Tower. Even though these incidents are geographically concentrated and most patients had returned home within weeks, the level of support for the staff involved has been complex and long lasting.
Trust leaders know that their most important task is to support their staff as best they can in these very difficult circumstances. The response is changing over time, as needs change.
Supporting the number of staff affected by this crisis, over a much longer period, feels to be of an exponentially greater magnitude. Will this, in the mid- to long-term, prove to be the NHS’ biggest challenge?
What has moved trust leaders and frontline staff is the help provided from those outside the NHS to support staff. Free hot food, hotel rooms, shopping, transport, clothes, flowers -the list of items provided, and the number of people providing them, is endless. As is the appreciation back from those in the NHS in receipt of such striking generosity.
What’s been important?
If, as seems increasingly likely, NHS capacity will be sufficient to navigate the current peak, what will have been the key success factors? An initial guess would centre on four things:
- the extensive planning and preparation the NHS has done since January 30
- the amount of extra capacity the NHS has created in that time
- the impact of social distancing in slowing and spreading the demand
- the outstanding response from frontline staff to the intense demands placed upon them.
But it’s not all been perfect. There have been well publicised challenges in a range of areas. Has the NHS been as effective as it should have been in addressing these?