When Boris Johnson issued a stay-at-home order to Britons last month, he had one overriding aim: to protect the UK’s state-funded NHS from being overwhelmed by coronavirus cases.
Standing outside Downing Street on Monday, fresh from his own battle with the disease, Mr Johnson declared: “We are on the brink of achieving that first clear mission.”
The number of coronavirus deaths in Britain’s hospitals stands at 21,092, according to figures released by the Department of Health on Monday. But as the prime minister ponders whether to relax the UK’s lockdown restrictions, health leaders are increasingly confident that the service has passed the biggest test since its inception almost 72 years ago.
With the number of new cases “broadly flat”, according to the government’s chief medical officer, Chris Whitty, and hospital deaths from Covid-19 flattening off, the NHS still has hundreds of empty critical care beds and has not been forced to turn away patients it could have helped.
A vast operation to repurpose parts of hospitals, turning them into emergency intensive care wards, and deploying other medical and nursing staff, such as anaesthetists, to provide specialist care has paid off. So, too, has an operation to release more than 30,000 beds in NHS hospitals by halting non-emergency operations and discharging all those deemed medically fit.
Fears over intensive care capacity
Ian Higginson, a consultant in emergency medicine, recalled initial concerns that the UK would run out of beds as northern Italy and parts of Spain and China had done.
“We were worried the first phase would be a lot worse than it has proved to be . . . ICUs haven’t been overwhelmed, although some of them got pretty close to full and in parts of London they had to move patients [to other hospitals],” said Dr Higginson, vice-president of the Royal College of Emergency Medicine.
The numbers tell the story of NHS achievement. Confounding initial fears that critical care beds would be swamped, about 2,500 remain unfilled in England’s hospitals. This is partly the result of careful preparation, but also reflects the course the disease has taken, with fewer patients than expected requiring ventilation or a prolonged spell in an intensive care unit.
Carl Waldmann, an intensive care consultant and former head of the Faculty of Intensive Care Medicine, said: “Ventilators were important but what we didn’t realise was that a lot of these patients not only need ventilation but often needed other sorts of organ support.”
But at no point did Dr Waldmann’s hospital turn away patients because of a lack of resources, determining the best course of action on clinical grounds alone. As the outbreak began to take hold, “every couple of hours there were another two patients just come in that might need to come to ITU [intensive treatment unit], and it was quite worrying because suddenly you’d fill up. But luckily, we managed to escalate. We had an escalation plan,” Dr Waldmann recalled.
Signs of strain remain; ambulances are taking longer to arrive at emergency call-outs for example. Some hospitals have also been hit much harder than others, particularly in the capital.
But just one hospital, Northwick Park in London, has been forced to declare a “critical incident” because it had run out of intensive care capacity (a second hospital, Watford General, declared also an incident due to a technical issue affecting oxygen supplies).
Managing the aftermath
Health leaders’ attention is turning to how to manage the aftermath of the first wave. At its most direct, this will involve dealing with the physical and mental health of patients who have survived a spell in intensive care.
The consequences can include muscle weakness as well as neurological and psychological problems, Dr Waldmann said, querying whether the NHS would be able to cope with “the increased workload for rehabilitation”.
But the second key dimension is how to restore normality to a health service that has delayed treatment for millions and discharged thousands of patients into the community, some of whom still have significant health needs.
Two people familiar with thinking at senior levels of the NHS said serious consideration was being given to a limited lifting of the embargo on non-urgent operations.
On Monday Matt Hancock, health secretary, announced that from Tuesday, the NHS would “begin the restoration of other NHS services — starting with the most urgent, like cancer care and mental health support”.
Even before non-emergency surgery was halted, the backlog was causing concerns: at the end of February 4.4m people were waiting to start treatment; more than 80 per cent had been waiting up to 18 weeks with about 1,600 waiting more than a year.
Alongside these predictable consequences of the NHS’s aggressive approach to preserving beds for coronavirus patients, is an unwelcome and unanticipated development for health leaders: the dramatic reduction in people seeking help for non-Covid-19 conditions.
In A&E departments alone, attendances in March fell about 30 per cent and emergency admissions by 23 per cent.
Doing things differently
On top of tackling this backlog, the NHS must confront the prospect of a second wave of the virus — perhaps in the winter when the service struggles even in normal times to cope with seasonal pressures.
There are signs the NHS’s ways of working may have been permanently changed by the experience of coronavirus, with doctors highlighting the speed with which patients have been discharged into the community, without the usual bureaucracy and wrangling over funding.
Nowhere is the change more apparent than in A&E departments, long the pressure points in the English system, where people frequently wait for hours in crowded conditions.
“For the first time in a long time, our departments are much less overcrowded than they used to be. And that means that we can actually treat patients as we would like to,” Dr Higginson said.
He believes there is a moral and practical imperative to ensure the old conditions do not return, acknowledging that will inevitably raise hard questions about future funding.
The root causes of A&E overcrowding were “an under-resourced health system, an under-resourced social care sector and not enough doctors and nurses working in obsolete departments”, said Dr Higginson. “We know that a lot of that won’t have been magically fixed overnight.”
This article has been amended to add the number of coronavirus related deaths in UK hospitals.
Statistical research by Federica Cocco
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