London - The coronavirus pandemic is
forcing senior doctors in Britain's National Health Service to
contemplate the unthinkable: how to ration access to critical
care beds and ventilators should resources fall short.
The country's public health system, the NHS, is ill-equipped
to cope with an outbreak that is unprecedented in modern times.
Hospitals are now striving to at least quadruple the number of
intensive care beds to meet an expected surge in serious virus
cases, senior physicians told Reuters, but expressed dismay that
preparations had not begun weeks earlier.
With serious shortages of ventilators, protective equipment
and trained workers, the physicians said senior staff at
hospitals were beginning to confront an excruciating debate on
intensive care rationing, though Britain may be a long way from
potentially having to make such decisions.
Rahuldeb Sarkar, a consultant physician in respiratory
medicine and critical care in the English county of Kent, said
local NHS trusts across the country were reviewing
decision-making procedures drawn up, but never needed, during
the 2009 H1N1 flu pandemic. They cover how to choose who, in the
event of a shortage, would be put on a ventilator and for how
long.
Decisions would always be based on an individual basis if it
got to that point, taking into account the chance of survival,
he said. But nevertheless, there would be difficult choices.
"It will be tough, and that's why it's important that you
know, that two or more consultants will make the decisions."
Sarkar said the choices extended not only to who was given
access to a ventilator but how long to continue if there was no
sign of recovery.
"In normal days, that patient would be given some more days
to see which way it goes," he added. But if the worst
predictions about the spread of the virus proved correct, he
suspected "it will happen quicker than before".
Britain is by no means the only country that faces having
its health system overwhelmed by Covid-19, but the data on
critical care beds - a crucial bulwark against the disease - is
concerning for UK authorities.
Italy, where the coronavirus has driven hospitals to the
point of collapse in some areas and thousands have died, had
about 12.5 critical care beds per 100,000 of its population
before the outbreak.
That is above the European average of 11.5, while the figure
in Germany is 29.2, according to a
has 6.6.
'MANY TIMES MORE' VENTILATORS
Estimates of the potential death toll in Britain range from
a government estimate of around 20,000 to an upper end of over
250,000 predicted by researchers at Imperial College. As of
March 19, 64,621 people had been tested, with 3,269 positive.
The NHS is preparing for the biggest challenge it has faced
since it was founded after the ravages of World War Two,
promising cradle-to-grave healthcare for all.
It was stretched long before Covid-19, struggling to adapt
to the vast increase in healthcare demand in recent years. Some
doctors complain that it is underfunded and poorly managed.
About a tenth of more than one million staff roles in the health
service are vacant while almost nine out of 10 beds are
occupied.
Prime Minister Boris Johnson was asked at a media conference
on Friday, after Reuters reported the concerns of physicians,
whether Britain could get to a stage where NHS workers had to
choose who to save because there weren't enough ventilators. He
urged people to follow public safety measures.
"The objective of this whole campaign is to ensure we
flatten the curve, as we have been saying repeatedly over the
last couple of weeks, but also that we lift up the line of NHS
resilience and capabilities," he said.
"That means there is a massive effort going on right now to
make sure we do have enough ventilators and ICUs to cope."
So how many life-saving ventilators are needed?
Health Secretary Matt Hancock said on Sunday that hospitals
had around 5,000 but that they needed "many times more than
that".
A van carries a message in support of the NHS outside Downing Street in London. Picture: Reuters
The physicians interviewed by Reuters said, if ventilators
were secured, the aim was to increase intensive care beds from
around 4200 to over 16,000, partly by using beds in other parts
of hospitals.
Rob Harwood, a consultant anaesthetist in Norfolk who has
worked in the health service for almost four decades, said
access to critical care could ultimately have to be determined
by patient scoring systems for survivability. Systems developed
for SARS, another coronavirus that broke out in 2003, could for
example be refined, he added.
"Once you have exhausted your capacity and exhausted your
ability to expand your capacity you probably have to make other
decisions about admission into intensive care."
But he emphasised that, for now, admission criteria would
stay unaltered: "We are a country mile from that at the moment."
'BECOME CANNON FODDER'
While shortages of critical care equipment may be most
alarming, the coronavirus has exposed how generally ill-equipped
the health system is for a pandemic.
The British Medical Association said doctors have been
asked to go to hardware stores and building sites to source
protective masks.
Some doctors are worried about Public Health England's
(PHE) new advice last week which reduces the level of the
protective equipment they need to wear.
Previously, staff on ward visits were told to wear full
protective equipment, comprising high quality FFP3 face masks,
visors, surgical gowns and two pairs of gloves. But the new
advice recommends only a lower-quality standard paper surgical
face mask, short gloves and a plastic apron.
PHE referred queries about doctors' worries to the health
department, which did not respond to requests for comment on the
matter.
A senior NHS epidemiologist, who was not permitted to be
named, told Reuters this advice was based on a sensible
assessment of the biohazard risk of the virus. "It's not Ebola,"
the doctor said, pointing out the risk to medical staff without
underlying medical conditions was low.
Matt Mayer, head of the local medical committee covering an
area in south of England, said GPs had been sent face masks in
boxes that said "best before 2016" and that have been relabelled
with new stickers reading "2021".
"If you are going to lead people into a hazardous situation
then you need to give them the confidence that they have the kit
to do a decent job and they are not just going to become cannon
fodder," said Harwood the anaesthetist.
The department of health said that they had tested certain
products to see if it is possible to extend their use.
"The products that pass these stringent tests are subject to
relabelling with a new shelf-life as appropriate and can
continue to be used," a spokesman said.
RAPID GUIDELINES
Dr Alison Pittard, dean of the Faculty of Intensive Medicine
and a consultant in Leeds, northern England, said there had been
chronic underinvestment in critical care in Britain. But she
said the country was not yet at the stage where it had to make
calls about rationing patient resources.
She said, if rationing became necessary, medical ethics
should still prevail and guidelines needed to be issued on a
national level so that no patient was worse off based on where
they lived. The NHS might also need the advice of military
leaders, she said, on how to effectively triage.
"If we got to a difficult position where we had to exhaust
every bit of resource in the country then, yes, we may have to
change the way we approach the decision-making."
Stephen Powis, the National Medical Director of NHS England,
said there were plans to issue new guidance to give doctors
advice on how to make difficult decisions if there was a surge
in coronavirus cases, like in Italy.
The National Institute for Health and Care Excellence (NICE)
said on Friday it would shortly announce a "series of rapid
guidelines" on the management of people with suspected and
confirmed Covid-19, including in critical care.
The guidelines are not, however, expected to be prescriptive
but to suggest leaving key decisions to individual doctors.
Pittard said patients with pre-existing conditions who
already had life-threatening health difficulties should be
having conversations with their family about how they wished to
spend their last days, in the event of them being infected.
"If I get coronavirus now I've got a very high chance of
dying of it," she said, putting herself into the shoes of such a
patient. "So do I want to die in hospital and when my relatives
can't come in to visit me because it's too risky, or would I
like to die at home?
"And if I do want to go into hospital, do I then want to go
to intensive care where my chances of surviving are minimal?"