As England embarks on a second national lockdown, we need to reflect on how our hospitals are “feeling” and what we can hope for over the next weeks and months.
Firstly, we must recognise that we are in a different place in acute secondary care compared to March and April this year. At that time there was a well-reported decrease, often quite dramatic, in the number of people presenting for acute care in the secondary sector. That is not the case now.
We are entering the autumn and winter period and areas of hospital care are already struggling. Recently a North West ambulance service declared a brief major incident and clarified that this was not due to covid-related calls. In terms of staffing we are in a poor place. The impact of the first wave of the pandemic is still being felt. Many staff were overstretched in directions not seen before, while witnessing their colleagues being seriously ill, and in too many cases, dying from covid-19.
We know that the burden of the second wave has, to date, not yet been felt in London, but rather in the North West of England. It appears to be spreading eastwards across Yorkshire and then to the Midlands. Regarding staff numbers, these areas have always been thought to be less “well-off” than the units in London, and are being increasingly strained by high levels of staff absence fed by illness and self-isolation. Most feel that these staff shortages are incompatible with the usual safe care of elective and emergency patients.
On top of this is the pressure on NHS Trusts striving to meet targets imposed on them to achieve levels of elective care that are frankly impossible to achieve with a worn-out workforce and limited beds and diagnostics.
As I write, targets with accompanying financial penalties are still in place. The burden of trying to achieve these elective targets put emergency care at risk. The pressures were laid bare with the unprecedented, in my working life, communications from senior figures in Liverpool about the conditions they are working under and the pressures being heaped on to them, as well as the news that the NHS has been put on high alert as intensive care beds fill up.
The question on many people’s minds is whether lockdown 2.0 will help. The most important thing to recognise in terms of hospital use is that admission to hospital will fall only seven to 10 days after infection rates decline and referrals to ICU will change a few days after that. Mortality figures probably would not change with the time of the lockdown. The other vital question is how the NHS will cope with the demand. The most obvious thing to me would be to relax elective targets. However painful this is in the long run, we need all our staff working together to meet this demand head on without unnecessary diversions.
Likewise, we need recognition that junior doctors and other staff on non-medical wards will again be needed to work outside their immediate job descriptions to help their medical colleagues, without detriment to their training and career progression. Bed-wise the major pinch points will be critical care and advanced respiratory support. To this end I am not certain how reopening Nightingale units will help, as all highly-skilled staff with critical care skills will be needed “at base” and taking them elsewhere this time will probably be a step too far in terms of staffing.
These extra beds could be useful as rehabilitation units but, again, skilled staff that are not overly common already will be needed and may require “cross border” working from agencies who may be locality based. If this circle can be squared these staff need to be activated, but I worry it is already too late for the hardest pressed areas.
Nosocomial infection is a major risk; most years we have stories of crowding and “corridor care,” but this year it is not only the “usual” risks to safety and dignity, but also the risk of covid cross infection that needs considering.
Fundamentally, however, the success or otherwise of the lockdown will be down to a) clear leadership in messaging of the rules from the government b) people acting in accord with these rules and c) the time afforded from a lockdown being used to fix the processes in place that have not worked to date, such as an adequate testing system.
These three things are the absolute minimum we owe NHS staff as we enter another period of immense strain on every single person who works in our NHS.
Nick Scriven, immediate past president of the Society of Acute Medicine
Competing interests: none declared.