England currently has more than 30,000 patients in hospital with Covid-19. This is 62% more than at the first peak in April. Chris Whitty wrote in the Sunday Telegraph that the NHS faces the “most dangerous situation in living memory” and hospitals could be overwhelmed within two weeks. The London mayor, Sadiq Khan, declared a Covid emergency in the capital, warning that its NHS was already overwhelmed. Each new day of record admissions turns the screw on frontline staff. The problem is that while the NHS, government ministers and scientists are all sounding the alarm, there is also a reluctance to spell out exactly what this means.
This is an account of what it truly means for a hospital to be “overwhelmed”. It is gleaned from years of working with intensive care clinicians and hearing from doctors across the country. Much of this is happening already, but we have not yet seen the worst.
The danger is not of a sudden collapse, but an escalation of worsening care for patients and increasing pressure on staff. First, care that is not immediately essential is postponed: operations such as hip or knee replacements, scans or check-ups for chronic diseases such as diabetes or heart disease. This will mean that some people get sicker in the future because they missed out on care now. Others will have new cancers or heart disease missed for several months. This is already happening.
Then, as beds become scarce, capacity is expanded, particularly in intensive care units. This has meant finding and converting space – separated from non-Covid areas – for very sick patients, but also finding a way to staff them in an already stretched NHS. Intensive care is exactly that: intensive. There should be one specialised ICU nurse to every one or two patients. There are only a limited number of ICU-trained nurses, and acutely ill Covid patients are severely sick, even compared with other ICU patients.
As capacity is extended, ICU nurses are each allocated more patients to look after. This is already happening. With staffing stretched to as many as four patients to each ICU nurse, non-specialist nursing and clinical staff are drafted in to help. By this point, staff are exhausted from working as many shifts as possible with little time off. It is almost inevitable that care suffers. Small mistakes creep in and warning signs are missed. Most errors, perhaps all, will be caught and corrected. But it might then take longer for some patients to recover. It is incredibly distressing for clinical staff who cannot provide the level of care they wish to.
Then there’s the question of oxygen. Hospitalised Covid patients need help breathing. This can be a simple face mask that provides extra oxygen, a tight-fitting mask that uses pressure to force oxygen into lungs, or tubes doing the breathing for you in ICU. But the pipes in the hospital walls that deliver oxygen to each bed were not designed to be used by hundreds of patients at the same time. If this facility is breached, the whole system fails. This catastrophic scenario – where the oxygen stops being delivered to patients and many die – happened recently in Egypt.
It should never get to that stage – hospitals are constantly monitoring their oxygen supplies – but some hospitals in England are very oxygen-stressed, and this can affect decisions about care.
As for logistics, patients will keep arriving without enough beds to accommodate them, which is already happening in London and the south-east. Ambulances have had to queue for hours outside hospitals, waiting for a bed to become available. While they care for patients in the hospital queue, they are unable to pick up new patients so waiting times for ambulances get longer. A paramedic outside London told me that because of the queues, they are now attending to only half as many patients each shift as usual.
More and more ambulance and hospital staff are off sick from Covid and physical or mental burnout, putting further strain on the system. So far, other hospitals in England have been able to relieve some of the pressure by taking patients from London and the south-east, but as admissions rise across the country that option diminishes. Heart attack or stroke patients might die at home waiting for an ambulance, or inside the vehicle as they wait for a bed to become free.
The final stage, which London is now approaching, is where patient care is not just compromised but cannot be delivered. This won’t be dramatic and public – you won’t see patients refused entry to hospital or bodies on the street. It will take the form of doctors being forced to make impossible decisions about which patient can best benefit from a single spare ICU bed when many need one, or how long to wait for a very sick patient to improve before having the conversation with the family about withdrawing care.
This is called rationing. The NHS will speak about it as the ultimate warning, but it is very wary about saying exactly how those decisions would actually get made. The British Medical Association has published guidelines, but much is left up to individual hospitals and doctors. Senior doctors I know have been close to tears at the thought of making those decisions. Many are scared of being blamed afterwards.
The strain on the NHS will get worse over the next few weeks. If we are very lucky, we will avoid the worst scenarios outlined here. We can each contribute by reducing our contact with others as much as possible, wearing masks, opening windows, keeping distance.
But, in the aftermath of this wave, some people will have died who would have survived at a different time. We won’t know exactly who or how many. There will be thousands of traumatised doctors and nurses as well as grieving families. Any blame lies not with frontline staff, but with 10 years of NHS underfunding, with a government that has consistently delayed action against scientific advice, and with an aggressively infectious virus. In the future, the NHS must be protected by governments committing proper investment into it, as well as in pandemic preparedness and preventive public health, so that we never find ourselves in this situation again.
Christina Pagel is director of UCL’s Clinical Operational Research Unit, which applies advanced analytical methods to problems in healthcare