Fears of bed shortage in regional hospitals
NHS hospitals outside London are at greater risk than those in the capital of being overwhelmed, according to analysis. Rural areas will be hit hardest by a national shortfall of beds as the outbreak sweeps across the country, modelling seen by The Daily Telegraph suggests.
Senior doctors warned that elderly and frail people might be denied critical care if hospitals run out of room. Health chiefs are discussing plans to “move the goalposts” so priority is given to younger patients with better survival chances, it is understood. Last night, senior NHS sources defended the approach, adding that it would help the health service to “flex” during a potential crisis. According to the analysis produced by Edge Health, which advises NHS trusts across England, London is better prepared than other regions to cope with coronavirus although the capital, too, will face substantial pressures. Its analysis is published in today’s Health Service Journal, bible of health service managers.
The largest shortfall in hospital beds is in the Midlands, where 2,900 extra beds and ventilators will be needed during the epidemic’s expected peak in the coming weeks. In the South West, the region with the oldest population and highest expected mortality rate, hospitals are equipped with the lowest number of critical care beds per head of population, although infection rates are currently low.
“Our ‘balanced scenario’ (mitigated growth and isolation of vulnerable) estimates a requirement for an additional 155,000 beds and 18,000 beds with ventilators,” says the report. “The maps show that existing bed capacity, much of which has high occupancy, is located away from rural communities where
We know the NHS has too little capacity to cope with the coronavirus outbreak. That’s why all hospitals were ordered to send “medically fit” patients home and cancel all non-urgent operations.
“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 this, 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 our four nations. Even in England, the service over which Mr Stevens presides is not an entity run and controlled from the centre.
In reality, it’s a federation of sometimes competing services.
The analysis below showing huge regional variations 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 provider of 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 order industry to make more ventilators urgently.
Mr Stevens’s action aims to free up 30,000 of the current 100,000 overnight acute beds across England. But the latest modelling 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, the bible of health service managers, said today, 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.
Arguably, this bed base is adequate for normal demand. 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.
So where are these areas? 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 away from rural communities where the age profile is older,” the modelling study shows.
The number of critical care beds in different regions and their availability will also be decisive. “In England, critical care beds were reported as being 83 per cent occupied in December. This contrasts with Italy, which had reported occupancy levels pre-covid-19 of 33 per cent, although this may be due to different reporting methodologies,” says the study.
Regionally, it looks like London is best positioned to weather the epidemic, although it will come under immense pressure.
The capital has the highest number of infections per head of population but also the youngest population 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 is most vulnerable in terms of ratios. It has the oldest population (so highest expected mortality) and the lowest number of critical care beds per head. The modelling suggests it needs six times more than currently exists there.
On the upside, it currently has a relatively low infection rate. Public Health England should do everything possible to keep it that way. If the virus gets out of control, it is likely to sweep through 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 fourfold increase in ventilators.
But in terms of demand by volume, the Midlands will need a massive 2,900 extra 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, and resist the urge simply to try to increase hospital capacity. “Moving people in and out is going to be important – large flows going through a small stock of beds can cause havoc. The NHS needs to agree 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 a 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.”
Instead, he noted, we should think radically about how to handle severely ill patients and learn from others. “Italy has tents, China built temporary hospitals.” In France, the army is helicoptering patients around.
“It may also be worth considering how to use regional differential to our advantage – could some London capacity support other regions?”
Finally, there is the sensitive issue of triage if gaps in capacity cannot be filled. The standard process involves two or more senior doctors deciding on who gets help and who does not based on a pre-agreed set of criteria.
“The criteria should be created in advance and sanctioned by medical staff and hospital administration,” says an advisory note to US hospitals from the John Hopkins Centre for Health Security. In the UK, we follow a similar process. The aim, 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.
To do this well, you need good data. For example, how do age and underlying conditions determine survival prospects? In northern Italian hospitals, overwhelmed by Covid-19, the criteria appeared 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. Even with a divided and uneven NHS, this is something that can and should be done centrally.