Trust leaders knew in advance that, with this scale of challenge arriving at such short notice, pinch points and problems would emerge. So it’s proved. PPE, testing capacity, ventilator capacity and oxygen system delivery capacity have all, in their different ways, presented NHS leaders with difficult challenges.
Before considering each of these areas individually, it’s important to understand how trust leaders have approached them in general. For understandable reasons the media discourse, particularly on PPE and testing capacity, has been to highlight the scale, nature and reasons for the problems and then seek to identify those responsible. Trust leaders share the sense of frustration around these issues - they highlighted PPE and staff testing as early concerns. But their task is to work with national leaders to solve these problems. For them, the debate on what could have been done better or differently is for later, not now.
The current list of gaps, problems and failures is, also, incomplete. More problems will emerge as trusts’ experience of dealing with COVID-19 patients plays out, with oxygen system supply capacity (see below) being a good example. With something so unprecedented arriving so rapidly, trusts will only be able to identify some problems when they’ve actually encountered them.
Those operating with the benefit of hindsight will argue that each of the pinch points could have been identified from the experience of other countries. But that ignores the fact that the healthcare challenges presented by this pandemic are so numerous, extreme, and varied that it has been impossible to identify, in advance, which of the many potential pressure points should have been top of the list of priorities in the preparation phase. It also ignores the fact that the NHS only had ten weeks, at most, to prepare. Section one sets out how those weeks were used. But, inevitably, the NHS has not been able to prepare for everything that has subsequently proved to be important.
For understandable reasons the media discourse, particularly on PPE and testing capacity, has been to highlight the scale, nature and reasons for the problems and then seek to identify those responsible.
Many of the challenges trusts have faced have also been due to complex technical and operational details that aren’t particularly interesting to those seeking to point a simplistic finger of blame. Supply chain logistics, the availability of testing kits, swabs and reagents and the capacity of hospital vacuum insulated evaporator (VIE) oxygen systems are key to understanding why some important things haven’t happened in exactly the way the NHS would have wanted.
PPE – distribution to trusts
The trust leadership perspective on PPE is simple. Nothing could be more important than ensuring their staff have the personal protection equipment they need, particularly given staff concerns about their own personal safety. Trust directors also have a legal obligation to ensure their staff have the right equipment. They are deeply concerned when the right equipment isn’t available when needed. There have been two main problems – distribution and frontline staff confidence in the PPE guidance. A narrative on each follows.
In looking at the PPE distribution problems, it’s important to distinguish between two different parts of England’s health and care system as they have different requirements that bring different logistical challenges. The trust sector, that NHS Providers represents, consists of a relatively small number of organisations (217) with a requirement for high volumes of equipment. The primary care (GPs), social care (nursing and care homes) and voluntary organisation (e.g. hospices) sector is much broader. It’s over 50,000 organisations and they need smaller amounts of equipment than trusts. Demand for the higher level of protection equipment is also much greater amongst trusts.
Looking at trusts first, then the wider health and care sector.
A bit of background to start with. Over the last decade NHS procurement (buying supplies and equipment) and supply chain management (transporting and delivering those supplies and equipment) has been rationalised and centralised. It’s what every large-sized organisation – be they a supermarket chain, a local authority or the military – has done. Demand for protective equipment in a pandemic is a well-known risk, so the UK has also always held a significant back up, reserve, stock of equipment ready for distribution.
The trust leadership perspective on PPE is simple. Nothing could be more important than ensuring their staff have the personal protection equipment they need, particularly given staff concerns about their own personal safety.
The supply chain the NHS created over the last few years has served the NHS well, based on just in time delivery of a wide range of goods and supplies against a stable, predictable, pattern of demand. The challenge of coronavirus is that when the pandemic hit, demand from trusts for PPE escalated exponentially with demand for some items increasing 5,000% overnight. Every trust wanted huge amounts of PPE at very short notice. There was sufficient stock in the national reserve but delivering so much of it, so quickly, so widely, presented a massive logistical challenge.
The response from national NHS leaders that NHS Providers observed was rapid recognition of the problem, quick mobilisation of help from the army and the UK logistics industry, and effective co-ordination with the existing supply chain and national strategic reserve. One of the most experienced hospital trust chief executives was asked to act as the link between the national NHS team working to solve the problem and local trust leaders.
The first step taken by national leaders was to do an emergency flip from the usual trust ‘pull’ ordering system to proactive ‘push’ deliveries – just getting stock from the national reserve out to trusts as quickly as possible, knowing they would need significant numbers of all PPE items. For trusts, after an understandable time lag, this approach has largely, but not completely, solved the immediate problem. Community, mental health and ambulance trust leaders also felt that it took too long for national leaders to recognise their needs and that a 'prioritise hospitals alone' mentality took time to shift.
This emergency approach has recently given way to an entirely new, trust specific, PPE-dedicated distribution chain to meet the much higher-distribution volumes required. This has been created from scratch within a fortnight.
The response from national NHS leaders that NHS Providers observed was rapid recognition of the problem, quick mobilisation of help from the army and the UK logistics industry, and effective co-ordination with the existing supply chain and national strategic reserve.
There have been unhelpful, but understandable, complications. For example, it was impossible in this 'push delivery' approach to carefully allocate the ‘usual’ or a consistent single brand of FFP3 mask to each trust. Given that each brand of mask needs to be fit tested for each wearer and a fit test can take as long as 60 minutes, that has required a lot of time consuming mask fit testing at the frontline.
There have also been shortages of certain items for trusts. For example, for a period of time, there was a shortage of mask fit testing liquid. This has been eased by the Army’s Porton Down chemists assisting with production.
The national PPE strategic stock reserve did not carry large amounts of visors and the highest protection level clinical gowns. So a burgeoning 3D visor printing industry has sprung up overnight and trusts have shared approaches on the best way to ensure maximum reuse of existing visors.
The shortage of clinical gowns over the past week has been more difficult to address as, to protect staff, the gowns have to meet a high technical specification. The constraints around securing gowns are a good example of the problems national NHS leaders are currently grappling with.
China is the only immediate high-volume source of clinical gowns. Specialised fluid-repellent treatment is needed, very high-volume manufacturing capacity is required and other smaller-source manufacturing countries are placing export bans on gowns. There is massive global competition for gowns, all concentrated on China. National NHS leaders started buying stocks many weeks ago but the delivery has been erratic despite daily freight flights. The Chinese have apparently been delaying consignments to conduct local testing before releasing stocks. There have been instances of stock being mislabelled with gowns seemingly arriving only to find, on opening, that the boxes contained masks. Once actual stocks have arrived, they have to meet stringent safety tests with no guarantee that these will be passed. National leaders, working closely with the Foreign Office and the Department for International Trade, have worked hard to overcome these constraints. But the reality is that, for some trusts, stocks of gowns have started to run critically low over the last week.
The shortage of clinical gowns over the past week has been more difficult to address as, to protect staff, the gowns have to meet a high technical specification. The constraints around securing gowns are a good example of the problems national NHS leaders are currently grappling with.
National and NHS trust leaders have been working extremely hard to address these shortages. The remaining national reserve stock of gowns was carefully allocated to those most in need via a series of emergency deliveries over successive days. For some, this was literally just in time. Public Health England has now approved the use of coveralls in place of gowns and a consignment of 200,000 has now been released for use. Trusts have also been helping neighbouring providers to ensure gown stock is shared wherever possible with this mutual aid a key benefit of being in a National Health Service.
But these have been last-minute actions to prevent gown stock from running out, and the stock position for a number of trusts still remains precarious at time of writing. Trust leaders believe it is vital to include them early in helping to find solutions to problems like these. For example, if there is going to be a shortage of a particular item, then far better to know about it well in advance. There is always a risk to sharing potentially difficult information more widely, especially if it reaches the public domain and can be weaponised to attack. But fully enlisting the skill, commitment and ingenuity of trusts to solve PPE challenges is key.
Personal protection equipment (PPE) – distribution to wider health and care sector
The problems of the wider health and social care sector have been more difficult to solve. Lots of these organisations were not customers of NHS Supply Chain and ordered their PPE from individual commercial suppliers who have no stock due to global shortages. So national leaders tell us they’ve adopted a similar ‘emergency response first, sustainable longer-term solution follows’ approach for these organisations. The emergency response has been two fold. Push drops to larger providers like GP surgeries with pre-packed mini packs of aprons, gloves, surgical masks from the national strategic reserve. And an emergency telephone ordering line directly connected to the national strategic reserve, though this has been swamped with enquiries. We understand that a longer-term, sustainable, e-commerce "register, order online, get delivery" system will be launched shortly.
There have been major and widespread problems with PPE availability, particularly in the wider health and care sector beyond trusts, that any post coronavirus public inquiry will need to examine. Questions that will need answering will include whether the UK reserve was carrying the right levels of the right stock items, whether responsibility for PPE was clear, and whether the risks around emergency distribution once a pandemic arrived were fully assessed and mitigated.
The public debate about PPE distribution has also seemed to get stuck in an unhelpful, seemingly irreconcilable rut. On the one hand, the government has been quoting ever-growing figures of how many millions of pieces of PPE being delivered to the frontline. On the other, frontline staff and their representatives have been pointing, with increasing frustration, to multiple instances of PPE not being available when required. The reality is that both have always been right. There is a huge NHS effort to supply PPE to the frontline, but gaps remain. There is a strong argument that it would have helped if those gaps had been publicly acknowledged and the reasons for them more clearly set out. It would also have helped if the work the NHS is doing to fill the gaps, overcoming major constraints along the way, was better understood.
The public debate about PPE distribution has also seemed to get stuck in an unhelpful, seemingly irreconcilable rut. On the one hand, the government has been quoting ever-growing figures of how many millions of pieces of PPE being delivered to the frontline. On the other, frontline staff and their representatives have been pointing, with increasing frustration, to multiple instances of PPE not being available when required. The reality is that both have always been right.
PPE guidance
The second PPE issue has been the national PPE guidance – the rules on what type of PPE to wear when. Frontline staff confidence in this guidance has been dented for a number of reasons. They didn’t think the guidance was adapting quickly enough to increasingly widespread prevalence of COVID-19 and they therefore felt they were being asked to wear either no or inadequate protection when dealing with suspected COVID-19 patients. The guidance was changed a month ago, in early March, with what staff felt was inadequate explanation. The previous guidance felt very technical and didn’t cover a range of important healthcare settings. And there was insufficient clarity on how the guidance related to World Health Organisation (WHO) guidelines with a strong sense that it was somehow inferior.
On 2 April, new guidance was published. These addressed frontline staff concerns in three helpful ways. The guidance was updated to reflect the latest understanding of COVID-19. The underlying assumption now is that, given its widespread prevalence, frontline staff should act as though every patient has coronavirus and that basic level protection equipment (apron, gloves, surgical mask and eye protection if danger of splashing) should accordingly be worn. The guidance was also clear, with appropriate supporting scientific evidence, on exactly when the higher level of protection (full gown, gloves, FFP3 mask and visors/alternatives) needed to be worn. Staff could therefore be confident in the basic level of protection for all other care.
The new guidance was presented in a clear and helpful way that covered the full range of healthcare settings where PPE is needed. It also contained a clear statement that the guidance was endorsed by the WHO and indeed, in some areas, was more stringent (e.g. use of FFP3 masks as opposed to the lower standard FFP2). In particular, WHO endorsed the long-held UK position on staff being bare below the elbow as acceptable.
Trusts report that, following the guidance change announced on 2 April, frontline staff now have confidence in the new guidance. Though there is frustration in how long it took change the guidance and that confidence could have been maintained through earlier, clearer communications. In the end, however, PPE will only subside as an issue when everyone who requires it can get the equipment they need, when they need it.
Trusts report that, following the guidance change announced on 2 April, frontline staff now have confidence in the new guidance.
Sustainability of PPE supply
There is a third PPE issue which has had very little discussion - the sustainability of supply. Is the NHS using its PPE at a rate that can be sustained in the long term? Particularly since every nation in the world is currently seeking to purchase stocks of PPE and supply is constrained.
Assessing total PPE risk over the lifetime of a pandemic’s duration, the greatest risk probably occurs if a healthcare system runs out of stock of key items, particularly the highest level of protection equipment, at a certain point. The risk is often a short- to medium-term one, as there may be a gap between the stock in a national pandemic reserve being used up before the arrival of stock that’s been ordered once the pandemic spread has started.
It’s striking that the PPE debate in other countries has focused more on the importance of strict stock control to ensure sustainability of supply. In the UK because of the focus on the initial distribution problems and clinical confidence in the guidance, this debate has barely got going. Without knowing current and likely future stock levels, it’s difficult to know how big the risk is, and therefore how important this debate should be.
National leaders argue that there is, and will be, sufficient stock. But trust leaders would like as much transparency around estimated stock levels as possible. If there is a risk that certain stock items will run short, as has happened with gowns, it’s important that everyone knows that and does all they can to preserve stocks. If that risk doesn’t exist, then every good reason to be public and clear about the reasons for that confidence.
Assessing total PPE risk over the lifetime of a pandemic’s duration, the greatest risk probably occurs if a healthcare system runs out of stock of key items, particularly the highest level of protection equipment, at a certain point.
Testing
There have been similar frustrations around testing capacity from a trust leader perspective. Trusts leaders flagged very early on that they wanted to test significant numbers of staff. When the social distancing rules were announced on 16 March, those in a household who had someone with suspected or possible COVID-19 symptoms had to self isolate for 14 days. These rules meant a significant number of staff then had to leave work, despite strong anecdotal evidence that the relevant household member didn’t actually have COVID-19.
Trust leaders suspected, and were subsequently proved right, that significant numbers of these staff (and the linked suspected household member) would test negative, allowing a return to work, as staff were keen to do. Trust leaders also wanted to test staff who were still working, but thought they might have COVID-19, to enable them to remain at work but also because staff understandably wanted to protect their own families.
However, testing capacity has been limited, with national leaders initially arguing that this limited capacity could only be used to test patients. Reasons for this focus on patient testing included the importance of identifying which patients actually had COVID-19, to separate them from non COVID-19 patients, and to ensure they had the right quality of timely care. Second, to maintain patient flow in a hospital – when test results were taking up to five days to return in some places early in the pandemic, hospitals were having to keep patients on wards until the test results come back. The longer the delay on patient testing, the more congested the hospital became. And third, the patient testing data was key to identifying the national and regional spread of the virus which, in turn, was driving key decisions such as whether to speed and tighten up social distancing measures and where to allocate extra ventilator capacity.
Trusts were therefore formally instructed to use all capacity for patient testing until 29 March when they were allowed to use 15% of that capacity to test staff. This 15% cap was lifted on 1 April. Since then, after a time lag, staff testing capacity has grown and trust leaders tell us that they are now broadly able to get staff tested when required.
The post coronavirus public inquiry will need to identify why UK testing capacity was so constrained and why it took so long to grow that capacity, given the importance of staff testing and mass public testing for long term control of the virus. Indeed, it remains unclear at this point, whether the stated target of 100,000 tests by the end of April will be reached.
Trusts leaders flagged very early on that they wanted to test significant numbers of staff. When the social distancing rules were announced on 16 March, those in a household who had someone with suspected or possible COVID-19 symptoms had to self isolate for 14 days.
For trust leaders there were four issues. First, unlike some other nations, the UK did not have a single national testing regime with clear responsibility for policy, capacity levels and pandemic mobilisation in a single set of hands. It was only with the announcement of a clear testing plan and the appointment of a national testing co-ordinator on April 2 that, for NHS leaders, there was clarity on who was ultimately responsible for what.
Second, actual testing capacity is split across a number of different organisations. These included NHS trusts and their pathology laboratories, Public Health England laboratories, the newly commissioned private sector Lighthouse Laboratories, and the wider group of smaller private laboratories now coming on stream. Prior to the beginning of April, there was no clarity on how all these different sources of testing capacity fitted together, what the purpose of each would be, and how quickly their capacity was meant to be growing. The involvement of the private sector added complexity as it brought the involvement of the government’s Office of Life Sciences, the Cabinet Office and the Department for Business, Energy and Industrial Strategy (BEIS) on to an already crowded pitch. Trust leaders argue that it remains unclear to them exactly what contribution each of these sets of laboratories is meant to be making to delivery of the 100,000 target, for what purpose, when.
Third, trust leaders actually running pathology laboratories reported significant shortages of the swabs, plastic testing kits and chemical reagents needed to complete the tests. These shortages were exacerbated by the fact that there are a number of different testing equipment manufacturers with the consumable swabs, reagents and plastic kits often tied to the particular testing platform. NHS trust laboratories have the machine capacity, by themselves, to process around 100,000 tests a day. But shortages of swabs, reagents and plastic kits meant that in late March/early April they were only able to complete less than 10% of that number of tests. The tied consumables also meant that, frustratingly, in the early days when the virus was concentrated in London and a few other hotspots, some NHS testing capacity was going unused. These constraints are now easing but still remain in some places.
Prior to the beginning of April, there was no clarity on how all these different sources of testing capacity fitted together, what the purpose of each would be, and how quickly their capacity was meant to be growing.
Fourth, trust leaders felt that there was a gap between top level government statements about testing and the underlying reality and detail. Statements were, for example, made at various points early in the pandemic about how much testing capacity was available, how quickly it would grow and when antibody (‘have you had it’) tests would arrive. For leaders working on the ground, trying to manage staff expectations and pressure from staff representative groups, these impressions of 'all being well', and the lack of detail on when they would actually be able to start and grow staff testing, made a difficult situation worse.
Again, community, mental health and ambulance leaders felt that they were significantly disadvantaged in this process. They had often not been full members of the regional pathology networks that manage most NHS trust laboratories and when those laboratories started increasing staff testing capacity, tests were concentrated on acute hospital staff. It is striking that London Ambulance Service, who were hit particularly hard by their levels of staff absence, were one of the first trust to enter the staff testing regime as their need was considered greatest given the constraints they were facing.
Ventilators
Experience from other countries who were earlier in the cycle of dealing with coronavirus highlighted the importance of ventilator capacity, as oxygen support to assist breathing is the only proven treatment option for those most affected by the virus.
The NHS, as part of its preparations, conducted a complete inventory of available ventilation capacity and was able to identify around 8,000 ventilators, including private sector and armed forces capacity. Spare ventilators were allocated to a national reserve with a seven-day-a-week national team making decisions on how to allocate this reserve. This preparation work has made a significant difference. Trust leaders report that, as they have expanded their critical care capacity and needed more ventilators, their requests for equipment from this national reserve have, up to now, consistently been met.
Alongside this, there has been a government-led process to secure new ventilators from a range of commercial partners and from other countries. The public debate around this process hasn’t always been particularly helpful. For example, the early focus on the need to reach a set figure of 30,000 ventilators before the virus was simplistic as it ignored a number of factors.
The NHS, as part of its preparations, conducted a complete inventory of available ventilation capacity and was able to identify around 8,000 ventilators, including private sector and armed forces capacity. Spare ventilators were allocated to a national reserve with a seven-day-a-week national team making decisions on how to allocate this reserve.
It ignored time – the fact that supply will grow over time. It ignored delivery and manufacturing timescale – ordering something is not the same as it being in use on the ground. For example, some trusts expecting ventilators from abroad have had export blocked by the host country government. Manufacturing a ventilator from scratch, getting regulatory approval (even if expedited), testing it and getting it into service are all bound to take some time and it’s very difficult to predict in advance how long this will take.
Aiming for a single figure, at a single point in time, also ignores demand pattern. While ventilators are mobile, adequacy of supply will depend on actual demand. If every region is experiencing a peak of demand at the same time, it will be difficult to have adequate supply. If demand is spread across different regions at different times and ventilators can be moved to match that pattern, it will be much easier to meet required demand.
As a result of the focus on the single 30,000 figure, the public debate on ventilators seemed to veer between "we’re miles short of 30,000, let’s panic" and "we’ve just ordered 10,000 new ventilators from x, it’ll be fine". Neither was particularly helpful.
There is another reason why it is difficult to answer the question of "have there been and will there be enough ventilators", as clinical thresholds for use of life-saving equipment will, inevitably, partially be influenced by the availability of that equipment. If there is a ventilator available and it might offer a very small chance of recovery, a clinician might decide to use that ventilator on the small probability that it could make a difference to the eventual patient outcome. If there are insufficient ventilators, that option is not available. In the current environment, there is clearly not enough capacity to give everyone who could have the slightest possible chance of benefitting, access to a ventilator. But does that mean "there aren’t enough ventilators"? Many would argue this is the wrong conclusion to draw.
In the minds of trust leaders, they can never have enough ventilators to deal with the impact of this virus, recognising that having sufficient staff with the right skills to operate a complex piece of machinery is a limiting factor. But what we can say is that, overall, at this point, trust leaders argue that ventilator capacity does not seem to be the constraint they initially feared it might be.
While ventilators are mobile, adequacy of supply will depend on actual demand. If every region is experiencing a peak of demand at the same time, it will be difficult to have adequate supply.
There have been hiccups. As with testing, the division of responsibility has not always been clear with the Cabinet Office, BEIS and Department of Health and Social Care all involved in the procurement of new capacity, alongside NHS England trying to ensure that the NHS had the right equipment it needed at the right time. Some of the early new ventilators have not had the levels of functionality that trusts hoped they would have. Some have required serious amounts of “bodging”, in the words of one trust chief executive, to make them compatible with NHS systems.
There has also been frustration from external suppliers, as in testing and PPE manufacture and supply, that offers of help have not been properly or speedily taken up. As outlined above, NHS leaders are incredibly grateful for the support that has been offered and this is making a real difference in a range of different ways. Clearly, any post coronavirus public inquiry will need to examine how the NHS has handled the offers that haven’t been taken up in the way those making the offer would have liked. But it is important to understand the constraints from the NHS side of the fence.
The sheer number and range of offers of support has been difficult to cope with. The capacity needed to log and process these offers is significant and is potentially employed on securing the items required from existing suppliers. Is it, for example, worth redirecting a procurement expert from contacting existing known, at scale, global suppliers of PPE to analysing a relatively small offer of support from a UK fashion producer that may be able to help, but it’s not really clear whether they can or can’t from the initial offer? Identifying which offers are valid and realistic, and which aren’t, is not always easy. And, as in any situation where demand massively outstrips supply, there will always be unscrupulous people seeking to make a profit at others’ expense so careful analysis of offers of support is vital.
Those offering help may not always be aware that there are exacting and complex technical specifications that must be met if the support offered is to be used safely – ventilators and PPE equipment being good examples. And once it arrives, the support offered must actually work to the required standards – there have been well publicised examples of testing kits and PPE items failing to work as required.
There has also been frustration from external suppliers, as in testing and PPE manufacture and supply, that offers of help have not been properly or speedily taken up. As outlined above, NHS leaders are incredibly grateful for the support that has been offered and this is making a real difference in a range of different ways.
Some of this can be addressed. For example, the NHS has now published a detailed technical specification of the ventilation capacity it requires. And NHS leaders will do all they can to process all offers of help as quickly as possible but this is another clear, current, pinch point.
Oxygen system delivery capacity
There has been much focus on ventilators. But ventilators can’t work without adequate oxygen supply. Hospital oxygen is usually supplied via a central vacuum insulated evaporator (VIE) system. This involves a large tank storing oxygen at very low temperatures with the oxygen then distributed from the tank across a hospital site using piping and ducting to connect to operating theatres, beds in wards and, importantly for coronavirus, ventilator machines.
The amount of ventilator support needed to treat COVID-19 patients means that hospitals need to use unprecedented amounts of oxygen. The NHS, in fact, prepared well for most of the oxygen supply issues it was likely to face, identifying which extra beds could be used for oxygen support and ensuring appropriate supply of oxygen and logistics support to transport it.
However, once hospitals started connecting ventilators to their VIEs in numbers they had never done before, it rapidly became clear that the key pinch point was not oxygen supply, ventilator capacity, or piping and ducting but VIE capacity. In particular, if hospitals try to draw more oxygen from their tanks than the maximum flow for which they were designed this can compromising supply to patients and/or cause permanent damage to the system. Indeed, two safety warning notices have been issued following VIE incidents of this type in late March and early April.
Hospitals have reacted accordingly. They have established new, more regular and precise, oxygen-flow monitoring processes. They have been working at pace with a range of specialist suppliers to expand their VIE system capacity as rapidly as possible. Where trusts have encountered capacity problems, they have triggered the well practiced mutual aid processes outlined above, to transfer patients to near neighbours.
The amount of ventilator support needed to treat COVID-19 patients means that hospitals need to use unprecedented amounts of oxygen. The NHS, in fact, prepared well for most of the oxygen supply issues it was likely to face, identifying which extra beds could be used for oxygen support and ensuring appropriate supply of oxygen and logistics support to transport it.
The problem of oxygen system supply capacity is perhaps the best illustration of the process trust leaders are now continually cycling round. Do all you can to prepare well. Encounter a problem you hadn’t expected and prepared for. Assess its importance and prioritise accordingly. Mobilise rapidly. Call on specialist outside support, as needed, which is always very willing to help. Create a ‘make do and mend’ temporary solution while longer-term, sustainable solutions are developed. Deploy longer -term solution. Move on to next problem.
Other NHS care
What else is on trust leaders’ worry list? The two main things are the impact of coronavirus on other care – the ‘normal business’ the NHS undertakes day in, day out – and the current quality of care being provided in some settings.
There have been previous times when the NHS has had to focus on a particular, immediate, pressing, capacity threatening, problem – for example winter flu. The evidence from these episodes shows that it’s vital to keep a close eye on the overall level of patient harm. In the face of an overwhelming, widespread, pandemic like coronavirus, it would be easy for the NHS to over-prioritise combatting coronavirus at the expense of the treatment of other critical conditions like cancer.
This is a difficult juggling act. Compared to many other equivalent first world health systems, the NHS has much less spare capacity, regularly running at 90-95% bed capacity when other systems, like Germany’s, run at 80%. This means that if the NHS is to create capacity to treat pandemic victims, it has to discharge medically fit patients and divert planned care. As outlined in section one, that has enabled the NHS to create an extra 33,000 extra beds to treat coronavirus patients.
The two main things are the impact of coronavirus on other care – the ‘normal business’ the NHS undertakes day in, day out – and the current quality of care being provided in some settings.
But trust leaders are deeply aware that there could be risk of harm involved in every patient discharged early and each episode of planned care diverted. Trusts have tried to carefully identify and mitigate the risk each time but in such a fast moving environment, that will have been impossible to get right in each individual case.
This issue will, of course, be even more pronounced if it turns out that the NHS has created more critical care capacity than it ended up needing. It will, however, be important to remember that at the point when the expansion of critical-care capacity began, the NHS was looking at an unprepared Northern Italian health system in meltdown with a massive capacity shortage. The strategy, quite rightly, was to avoid repetition of this position. That is what has been done.
There is another related issue here, impacted by the behaviour of patients and other healthcare professionals. There can be a tendency for people to worry that trusts are so overloaded that they don’t want to 'bother' a trust, that their problem must be less severe than those of the other patients the trust is dealing with or that the trust might be a dangerous place to come to.
While chief executives are, in one sense, pleased to see the volumes of patients attending A&E departments decline dramatically, they are also worried. One trust chief executive pointed to a 60% drop in A&E attendance volumes which worried him more than a 30% drop as he felt sure this meant that there would be some patients who should be attending A&E who currently weren’t. He commented, with a wry note, that for the first time in 20 years he had been publicly urging people who need to attend A&E to do so, rather than trying to dissuade them because of winter overload! This is a message that national NHS leaders have strongly echoed.
The same chief executive was concerned to see GP referrals for two-week target turnaround cancer diagnostics drop from 500 a week to 105. If coronavirus is with us for a long time, continuation of trends like these will be a real concern. And for trust leaders a particular worry because, unlike planned care, they can’t control when or whether these patients actually ask for treatment.
There is another related issue here, impacted by the behaviour of patients and other healthcare professionals. There can be a tendency for people to worry that trusts are so overloaded that they don’t want to 'bother' a trust, that their problem must be less severe than those of the other patients the trust is dealing with or that the trust might be a dangerous place to come to.
Quality of care
Trust leaders are also deeply aware that, by necessity, the quality of care being provided to some patients will sometimes be short of the standard of care their trusts would ordinarily provide and would ideally like to provide. It’s 'by necessity' because of the unprecedented levels of extra demand trusts are experiencing and the level of staff absences they are currently having to cope with.
Trust leaders are clear that, as ever, frontline staff are providing the best possible care they can in the circumstances. But, as the frontline testimony above highlighted, gaps are inevitably opening up with care for both coronavirus and non coronavirus patients.
The contrast, for example, between a ‘normal’ quality of critical care and current levels of critical care can, inevitably, be quite stark. ‘Normal’ critical care usually involves an experienced team, with the full mix of skills and experience, practiced at working with each other, with a staff-patient ratio of 1:1. The team will operate in a dedicated, purpose built, area with access to all the equipment required and time to consider important decisions like when to move to palliative care.
But, for a hospital currently working at full pelt with a large influx of COVID-19 patients, it will now usually be a makeshift larger team, with a number of people with little experience of critical care, with obvious skills and experience gaps, working on staff-patient ratios of up to 1:4. Many staff will be working in areas not dedicated or purpose built for critical care, like operating theatres or surgical recovery areas, and there may be shortages of equipment. The team will have little time to make an endless stream of important decisions.
Trust leaders rightly argue that the ‘current’ standard of critical care being provided is exemplary for the circumstances. They highlight the resourcefulness of staff in finding ways to improve that care wherever they can, for example providing electronic ways for relatives to comfort and say goodbye to patients at the end of their life. But, given the circumstances, this is very different to the 'normal' standard of critical care
So while trusts have prepared well and are dealing effectively with the current explosion of coronavirus related demand, these achievements have to be balanced with the fact that clear problems have emerged and there are obvious risks of patient harm.
But what lessons can be learnt for both the immediate future of how the NHS deals with coronavirus and the long term future of the service more generally?