‘No-one should be going through this alone’ is the message from Ottery St Mary’s network of community volunteers.
Philippa Davies www.sidmouthherald.co.uk
As the coronavirus crisis has escalated, so has the number of people joining the network, now numbering around 400.
The network, set up by the town council, the NHS, the Coleridge Medical Centre and Ottery Help, is working in groups, each focusing on a section of Ottery comprising around 100 homes.
They will distribute leaflets and email people to find out who are the most vulnerable people in their areas.
The community volunteers are initially concentrating on practical support such as shopping and collecting prescriptions, but are appealing for people with medical training to join them.
They are also aware that some elderly or vulnerable people might be nervous about opening their door to a stranger.
All volunteers will carry photo ID, and the list of volunteers has been registered with the police, so that people can phone to check their credentials.
If you need help contact firstname.lastname@example.org
Anyone interested in joining the network is asked to email email@example.com
“The south west looks most vulnerable in terms of ratios. It has the oldest population (so highest expected mortality) and lowest number of critical care beds per head of population. The modelling suggests it needs six times more than currently exists there (600 per cent).”
“On the upside, the south west currently has a relatively low infection rate. Public Health England (PHE) should be doing everything possible to keep it that way through aggressive testing and containment of new cases [If only! – Owl]. If the virus gets out of control in the south west it is likely to sweep through the region’s retirement towns and nursing homes, overwhelming local hospitals.”
Owl hopes that all those who went along with bed closures locally will reflect upon their actions – we are all in this together – no-one is immune, no-one can “buy their way out”.
Those living in rural areas, the south west and midlands are most vulnerable, while London is best equipped.
We know the NHS as a whole has too little capacity to cope with the coronavirus outbreak. That’s why all hospitals were on Tuesday ordered to send “medically fit” patients home and cancel all non-urgent operations, moves which will impact tens of thousands.
“Covid-19 presents the NHS with arguably the greatest challenge it has faced since its creation”, said its boss Simon Stevens, in a letter to all trust and hospital chief executives.
Despite such announcements, it’s a mistake to think of the NHS as a single service. It is anything but. Health care in the UK is run independently in each of the four nations. Even in England, the service Mr Stevens’ presides over, the NHS, is not really one entity run and controlled from the centre. In reality it’s a federation of sometimes competing services.
The analysis below showing huge regional variation in the NHS’s ability to respond to the Covid-19 outbreak is partly explained by this and partly by the nature of the virus itself.
The modelling has been done by Edge Health, a leading provider of data analysis to many of the country’s 206 hospital trusts. It was the same company that calculated a 7.5 times shortage in critical care beds last week, prompting the health secretary to charge industry with urgently making more ventilators.
Mr Stevens’ action aims to free up 30,000 of the current 100,000 overnight acute beds across England. But the latest modeling shows that even a doubling of that capacity may not be enough to meet the additional demand generated by Covid-19.
“Even if the entire NHS bed capacity were recreated in just six weeks we would still have patients in need of a bed by the middle of May”, the report says. “This pressure is most significant for patients that need critical care beds with ventilation support.”
This is the national picture for England but it hides “huge regional variation”, as the Health Service Journal (HSJ), bible of health service managers, said today (Thursday) based on the same data modelling study. London has 30 per cent more critical care capacity than the much more elderly south west of the country, for example.
(Updated Peak demand embed)
Arguably this existing bed base is adequate for ‘normal demand’ based on current demographics. But “the unique challenge from Covid-19 is that it appears to result in significantly higher mortality rates for older people who tend to be based in areas where there are fewer beds per head of population”, the report reveals.
Where are these areas – those that are going to come under greatest pressure as the epidemic sweeps the country?
The first and most obvious casualty is likely to be rural England. “The maps show that existing bed capacity, much of which has high occupancy, is located away from rural communities where the age profile is older,” the modelling study shows.
The number of critical care beds in different regions and – crucially – their current availability is also going to be decisive. “In England critical care beds were reported as being 83 per cent occupied in December – this starkly contrasts to Italy which had reported occupancy levels pre-Covid-19 of 33 per cent, although this may in part be due to different reporting methodologies,” says the study.
Regionally, it looks like London is best positioned to weather the epidemic, although it too will come under immense pressure.
The capital currently has the highest number of Covid-19 infections per head of population but it also has the youngest population (so lowest expected mortality) and the highest number of critical care beds per head of population.
Even then it is projected to need more than double the number of beds with ventilators than it currently has (129 per cent more). But this is much better than the rest of the country.
The south west looks most vulnerable in terms of ratios. It has the oldest population (so highest expected mortality) and lowest number of critical care beds per head of population. The modelling suggests it needs six times more than currently exists there (600 per cent).
On the upside, the south west currently has a relatively low infection rate. Public Health England (PHE) should be doing everything possible to keep it that way through aggressive testing and containment of new cases. If the virus gets out of control in the south west it is likely to sweep through the region’s retirement towns and nursing homes, overwhelming local hospitals.
In terms of ratios (percentage increase in beds required), the south east and east of England are on a par, requiring a bit more than a four-fold increase in ventilators. However, in terms of demand by sheer volume, the Midlands is projected to need a massive 2,900 additional ventilators – and the medical staff to go with them.
George Batchelor, a co-founder of Edge Health and the report’s principal author, said that having identified the major regional gaps, the NHS needs to think “creatively” to fill them. In particular it should resist the urge simply to try and increase hospital capacity, he said.
“Moving people in and out is going to be important – large flows going through a small stock of beds can quickly cause havoc. The NHS needs to agree its criteria for how it stratifies and moves patients through the different levels of care rapidly, so it makes the best use of limited resources,” he said.
Severely ill patients are very likely to require piped oxygen at high flow rates but they do not necessarily need to be in an existing hospital environment.
“That could actually make things worse because you can only vacate a critical bed if you have somewhere to move the recovering patient to. If other beds are full you get a blockage. It’s a bit like a bath overflowing as the plug is blocked and the tap stuck on,” said Mr Batchelor.
Instead we should “think radically” about how to handle severely ill patients, and learn from the experience of others. “Italy has tents, China built temporary hospitals,” he noted.
In France the army has started helicoptering patients between regions.
“It may also be worth considering how to use regional differential to our advantage – could some London capacity be used to support other regions?”
Finally there is the sensitive issue of triage to be considered if gaps in capacity cannot be filled. The standard process for this involves two or more senior doctors deciding on who gets help and who does not based on a pre-agreed set of criteria.
“Establish a process for triage of patients competing for limited resources, including admission, early discharge, and life support. These decisions should not be made solely by one person. The criteria used to make these decisions should be created in advance and formally sanctioned by the medical staff and hospital administration,” says an advisory note to US hospitals from the John Hopkins Center for Health Security.
In the UK we follow a similar process, often referred to as the Three Wise Men. The aim of the protocol – which should only come into play once national, as opposed to local – resources run out, is to ensure that those patients most likely to survive get treatment.
But to do this well you need good data on survival prospects. How, for example, do age and different underlying conditions interplay in determining survival prospects?
In northern Italian hospitals, which were overwhelmed by Covid-19, the criteria used appeared, from the outside at least, horribly crude, and based largely on age because no better data was available. We urgently need a more sophisticated system here today.
“No one should be making these difficult decisions by themselves”, said a spokesman for the Intensive Care Society. “We will be engaging with NHS England in the hope that guidance will be sent to clinicians across the country.”
Even with the divided and uneven NHS we have, this is something that can and should be done centrally.
Open office working …. well, no door handles but a long way for a sneeze to travel – and that narrow, tall, council chamber has people sitting cheek to cheek …..!
Editor of the Lancet asks the question.
On 24 January, Chinese doctors and scientists reported the first description of a new disease caused by a novel coronavirus. They described how a strange series of cases of pneumonia had presented in December in Wuhan, a city of 11 million people and the capital of Hubei province. At that time, 800 cases of the new disease had been confirmed. The virus had already been exported to Thailand, Japan and South Korea.
Richard Horton is a doctor and edits the Lancet www.theguardian.com
Most of the 41 people described in this first report, published in the Lancet, presented with non-specific symptoms of fever and cough. More than half had difficulties in breathing. But most worryingly of all, a third of these patients had such a severe illness that they had to be admitted to an intensive care unit. Most developed a critical complication of their viral pneumonia – acute respiratory distress syndrome. Half died.
The Chinese scientists pulled no punches. “The number of deaths is rising quickly,” they wrote. The provision of personal protective equipment for health workers was strongly recommended. Testing for the virus should be done immediately a diagnosis was suspected. They concluded that the mortality rate was high. And they urged careful surveillance of this new virus in view of its “pandemic potential”.
That was in January. Why did it take the UK government eight weeks to recognise the seriousness of what we now call Covid-19?
In 2003, Chinese officials were heavily criticised for keeping the dangers of a new viral disease, severe acute respiratory syndrome (Sars), secret. By 2020, a new generation of Chinese scientists had learned their lesson. Under immense pressure, as the epidemic exploded around them, they took time to write up their findings in a foreign language and seek publication in a medical journal thousands of miles away. Their rapid and rigorous work was an urgent warning to the world. We owe those scientists enormous thanks.
But medical and scientific advisers to the UK government ignored their warnings. For unknown reasons they waited. And watched.
The scientists advising ministers seemed to believe that this new virus could be treated much like influenza. Graham Medley, one of the government’s expert scientific advisers, was disarmingly explicit. In an interview on Newsnight last week, he explained the UK’s approach: to allow a controlled epidemic of large numbers of people, which would generate “herd immunity”. Our scientists recommended “a situation where the majority of the population are immune to the infection. And the only way of developing that, in the absence of a vaccine, is for the majority of the population to become infected.”
Medley suggested that, “ideally”, we might need “a nice big epidemic” among the less vulnerable. “What we are going to have to try and do,” he said, was to “manage this acquisition of herd immunity and minimise the exposure of people who are vulnerable.” Sir Patrick Vallance, the government’s chief scientific adviser, suggested that the target was to infect 60% of the UK’s population.
After weeks of inaction, the government announced a sudden U-turn on Monday, declaring that new modelling by scientists at Imperial College had convinced them to change their initial plans. Many journalists, led by the BBC, reported that “the science had changed” and so the government had responded accordingly. But this interpretation of events is wrong. The science has been the same since January. What changed is that government advisers at last understood what had really taken place in China.
Indeed, it didn’t need this week’s predictions by Imperial College scientists to estimate the impact of the government’s complacent approach. Any numerate school student could make the calculation. With a mortality of 1% among 60% of a population of some 66 million people, the UK could expect almost 400,000 deaths. The huge wave of critically ill patients that would result from this strategy would quickly overwhelm the NHS.
The UK’s best scientists have known since that first report from China that Covid-19 was a lethal illness. Yet they did too little, too late.
The virus quickly made its way to Europe. Italy was the first European country to suffer huge human losses. On 12 March, two Italian researchers, Andrea Remuzzi and Giuseppe Remuzzi, set out the lessons of their tragic experience. Italy’s health service simply could not cope. They did not have the capacity of intensive care beds to deal with the scale of infection and its consequences. They predicted that by mid-April their health system would be overwhelmed. The mortality of patients with severe infection was high. A fifth of health workers were becoming infected, and some were dying.
They described the situation in Italy as an unmanageable catastrophe. They wrote: “These considerations might also apply to other European countries that could have similar numbers of patients infected and similar needs regarding intensive care admissions.” And yet the UK continued with its strategy of encouraging the epidemic and the goal of herd immunity.
Something has gone badly wrong in the way the UK has handled Covid-19. I know Chris Whitty, the chief medical officer, and Patrick Vallance. I have the utmost respect for both. They have had the services of some of the most talented researchers in the world to draw on. But somehow there was a collective failure among politicians and perhaps even government experts to recognise the signals that Chinese and Italian scientists were sending. We had the opportunity and the time to learn from the experience of other countries. For reasons that are not entirely clear, the UK missed those signals. We missed those opportunities.
In due time, there must be a reckoning. I sat with the director general of the World Health Organization, Dr Tedros Adhanom Ghebreyesus, in Geneva in February. He was in despair. Tedros had been criticised for not calling a public health emergency of international concern sooner. But when he did and when he asked for the modest sum of $675m to help the WHO combat the growing global pandemic his pleas were ignored.
The UK is now taking the right actions to defeat this new epidemic. But we have lost valuable time. There will be deaths that were preventable. The system failed. I don’t know why. But, when we have suppressed this epidemic, when life returns to some semblance of normality, difficult questions will have to be asked and answered. Because we can’t afford to fail again. We may not have a second chance.
Scientists are struggling to understand why the death rate from the coronavirus is so much lower in Germany than other countries. Germany has seen just 27 deaths from the virus so far despite recording 10,082 infections — more than anywhere except China, Italy, Iran and Spain.
That represents a fatality rate of just 0.2 per cent, compared to 7.9 per cent in Italy — raising hopes Germany might be doing something right that other countries can follow.
By Justin Huggler Berlin 18 March 2020 www.telegraph.co.uk
The disparity has even led to allegations of a German cover-up by the Italian far-Right. But experts have cautioned that Germany may simply be at an earlier stage of the pandemic, and that death rates here may soon catch up.
But they also point to other factors that may be helping keep the German death rate down.
“Germany has had a very aggressive testing process,” Dr Mike Ryan, health emergencies director at the World Health Organisation (WHO) said. “So the number of tests maybe detecting more mild cases.
“From the beginning, we have very systematically called upon our doctors to test people,” Prof Lothar Wieler of Germany’s Robert Koch Institute said.
“We can provide testing to a high degree so that we can easily look into the beginnings of the epidemic.”
“Test, test, test” has become the WHO’s mantra in fighting the coronavirus, and experts say Germany’s vigorous testing programme may be doing more than just keeping the death rate down by documenting more cases.
“Italy has a much older population. And in many ways Italy is the poster child for living longer lives, but unfortunately in this case having an older population means the fatality rate may appear higher,” Dr Ryan said.
Official figures show that rates of infection among the most vulnerable age group, those aged 60 and above, are much lower in Germany than elsewhere.
That may just be a case of luck, but it may be that by identifying cases early, Germany has been able to track chains of infection and prevent the virus reaching the most vulnerable.
“There is a very big systemic difference between Germany and other countries,” Christian Drosten, the leading virologist at Berlin’s Charite teaching hospital, told Watson magazine.
“Our regulations for the introduction of new test procedures are very liberal. In other countries, there is a central authority that does all the testing for new diseases.”
By contrast, in Germany any doctor can perform a coronavirus test and public health insurance will pay. Germany is not the only country to record a lower death rate. In South Korea fatalities have also been much lower than the general trend.
“In South Korea it appears it was probably a combination of factors, rather than just one,” says Suerie Moon of the Graduate Insititute in Geneva. “Initial cases were among the young, and focused around one church which made it easier for the authorities to contain. But it appears testing also played a crucial role.”
Other differences in the German health system may also be significant. The country has far more intensive care (ICU) beds than anywhere else in Europe.
Intensive care beds can mean the difference between life and death for those who become seriously ill with the virus, and dire reports from northern Italy have told of doctors being forced to choose which patients get them.
Germany has 28,000 ICU beds. By contrast, the UK has just 4,000. And 25,000 of Germany’s already have the ventilators seriously ill patients need.
At the outbreak of the crisis, Germany had 29.2 intensive care beds per 100,000 people. Italy had 12.5. The UK had just 6.6.
In part, that is because of the different way healthcare is funded in Germany. Public health insurance is compulsory and collected at source alongside income tax — but it is passed directly to insurance funds and never enters government coffers, effectively firewalling health funding.
Germany may be better prepared for the virus than most of its neighbours, but it may yet need all the beds it has. Authorities here have warned people not to be complacent about the death rate.
“This is just the beginning for Germany,” said Prof Wieler of the Robert Koch Institute. “If you imagine an epidemic like a curve, then there are countries that are simply further along it.”