“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.