WILL THE NHS COPE?
Are there enough ventilators ++ what about oxygen ++ and does the health service have enough beds...
THE WORD crisis gets bandied around a great deal when it comes to the NHS. We are all used to hearing how issues such as bed-blocking, waiting times or flu outbreaks are stretching our beloved health service to breaking point.
But make no mistake, the coronavirus pandemic is the biggest single challenge the NHS has faced in its 70-year history.
On Sunday, Health Secretary Matt Hancock appeared on the BBC’s Andrew Marr Show pleading with British manufacturing firms — even those not normally involved in producing medical equipment — to start making thousands of extra ventilators that could be needed if intensive care units are completely over-run with desperately sick patients in the coming weeks and months.
He told viewers the NHS has around 5,000 ventilators — machines that help critically ill patients with their breathing — but needed ‘many more times that’.
The message to firms including car maker Rolls-Royce and heavy plant manufacturer JCB was clear — you make them and the Government will buy them.
But modern ventilators are hightech devices, packed with all kinds of electronic sensors, which are produced by a limited number of specialist firms. It’s unlikely a company that makes cars or tractors will be able to switch production over easily. Old-fashioned mechanical ventilators, with fewer cutting edge features, are simpler to produce, and it may be possible to fast-track production of them in the next few months.
Scotland has 190 intensive care beds with ventilators and Health Secretary Jeane Freeman has ordered 700 more.
NOW we are also told there is a potential shortage of oxygen if there is a wave of coronavirus patients. The Government has asked suppliers to quadruple production.
But even if Britain’s manufacturing fraternity does somehow manage to magic up extra lifesaving ventilators and oxygen overnight, there is still one big problem — we still do not have the staff to operate them.
Vague ministerial references to bringing retired doctors back into service and mobilising thousands of student nurses to help out ignore the fact that intensive care medicine is one of the most specialised fields of healthcare, requiring a huge amount of bespoke training and expertise — for doctors and nurses. For example, an intensive care nurse who has completed their normal nursing degree then needs another one to two years of specialist training to work with seriously ill patients.
It’s a job that requires a particular set of skills — constant monitoring of high-tech equipment, precise control of drug dosages, being able to supervise haemodialysis, where patients with failing kidneys are hooked up to a machine that cleans and filters their blood. And it’s also one of the most labour-intensive jobs in a hospital. At the very least, there is one specialist nurse per patient, and often more.
Staffing aside, many hospitals also face the logistical headache of where to put very sick patients.
In an average district general hospital, an intensive care unit might have eight to ten beds.
Most of the time, at least 80 per cent of those will already be occupied; in many cases, it will be 100 per cent. Some operations will be cancelled, which will free up beds. This will also free up space in operating theatres for makeshift intensive care beds.
These beds need an abundance of electric sockets to run all the equipment, as well as built-in piping to supply the oxygen to the ventilators.
You won’t find those in a corridor, or even on a general ward.
But these are extraordinary circumstances that require an extraordinary response. Hospitals needing makeshift intensive care capacity will need to look at areas that could be quickly adapted for use.
One such area is the recovery room, usually used for patients coming around from surgery.
These often have eight to ten bays available, with access to ventilators and oxygen. By cancelling routine planned surgery, recovery rooms could double as intensive care units.
Extra ventilators could also be drafted in from operating theatres if planned surgery is put off.
They’re not as complex as those used in intensive care; so we might need to use them for less severely ill patients and keep the more sophisticated ones back for very difficult cases with severe lung injury from the virus.
But how do we get around the staffing issue?
ONE possible solution is to draft in nurses with some knowledge that could be put to use in intensive care. These might include operating theatre staff, who share some of the skills used in critical care — such as constant observations of vital signs.
Nobody is suggesting they would be left in charge of critically ill patients on their own. But we could have a system where one highly experienced intensive care nurse supervises half-a-dozen or so less skilled staff. That way, all patients would still get the highest standard of care available.
It’s not a perfect solution, but we are working with an imperfect system.
When swine flu struck in 2009, the NHS emergency preparedness plan swung into action and we managed to cope.
But in the decade that has passed since, intensive care has been starved of proper resources. Demand for beds has risen by an average of 4 per cent every year, yet we have seen nothing like the same increases in staff, beds or funding.
It means we are in a much worse starting position than we were with swine flu to cope with a virus that is much more dangerous.
All of us now face a period of great uncertainty.
The only thing we can be sure of is that front-line NHS staff will do everything in their power to provide the best possible care.
And when this latest crisis is over, I will be demanding a highlevel review of how we fund and staff our precious and life-saving intensive care sector.
Next time — and there almost certainly will be a next time — we must be better prepared.
Doctor Pittard is a consultant in intensive care medicine at Leeds teaching Hospitals NHS trust and dean of the Faculty of Intensive care Medicine.