I used to work as the medical registrar at one of the busiest hospitals in the country, at one of the worst ever winters recorded in the NHS. The medical registrar sees all the sickest patients being admitted to the hospital and on one particular day my pager beeped so frequently it had its own rhythm. We admitted 60 patients in 12 hours. Several went to intensive care and two had to be transferred out for emergency specialist care. I remember feeling physically beaten. The next day and nearly every day after was exactly the same. That was three years ago.
Since then things have only gotten worse. By every metric, the NHS is running well beyond maximum capacity as it is: A&E waiting times, bed occupancy, operation waiting times. It was a four-week wait to take my daughter to see our GP.
For several winters now we have been “lucky” with the other major determinant in emergency admissions: influenza. Meanwhile, the background infrastructure has eroded away. The whole system has inched closer and closer to the edge, just waiting to tip. And now comes Covid-19, colloquially known as coronavirus.
We’ve seen scary viruses before, SARS and MERS for example. I’ve personally seen only the latter in a young man flying in from Saudi. Covid-19 looks worse. It reportedly has a long period between catching the virus and it causing any symptoms (up to 24 day incubation period) but is still infectious. That means many people have no signs of illness, and can still infect others, making it very difficult to track and quarantine. Up to 80% will have symptoms so mild they might not even recognise them anyway. It could also survive on surfaces for up to nine days, according to some reports, again making its spread to others harder to halt.
“There is no cavalry coming. The cavalry has been propping us up for years already.”
So far, the bulk of the UK cases have been limited to import from elsewhere, but the front has marched closer already: from China to Singapore and now Italy and Tenerife.
Right now, on the ground, coronavirus is a spectre on the horizon: we had a “mask fitting” at my trust a few weeks ago, we’ve discussed it in passing, but for now, it’s just on our minds, not on our wards.
A few years ago we had a spate of a virus-related heart disease called myocarditis, three or four cases that came in nearly at the same time, and it really felt like we were in the midst of an epidemic. Only two survived. With only those four patients, our ITU reached capacity. In retrospect, it didn’t take much at all.
There has been a lot of comparison to flu and in some ways that is useful: an infectious virus with a small risk of death and critical respiratory illness. Flu is a serious problem every year in hospitals, and many healthcare workers dutifully get the vaccine each year, myself included. But coronavirus has a 2-3% mortality rate, around 20-30 times the rate of influenza (0.1%), and there is currently no vaccine. Around 5% of reported cases need intensive care, predominantly older adults with existing health conditions.
The problem is, despite our best efforts, even a modest rise in demand for intensive care will completely overwhelm the NHS. We have some advantages: as a national organisation we can coordinate well between hospitals, and our staff are incredibly dedicated. I’m sure we could try to fill extra shifts to create more capacity. But we already have one of the lowest numbers of intensive care beds in the developed world at around 4,000 adult beds in England, and some of the fewest doctors and nurses. Many of these departments are run at 80% capacity routinely and regularly utilise “bank” nurses and doctors to fill long-term staff gaps. We can’t fly them in, we can’t train them “quick”, we can’t magic them up. There is no cavalry coming. The cavalry has been propping us up for years already.
At worst, some estimates show up to 60% of the UK could be infected with Covid-19 – that’s 42 million people, with 2.1 million needing intensive care. That’s the mother of all nightmare scenarios.
A much more hopeful 1% estimate would mean less than 700,000 people would be infected, and 35,000 would need intensive care – that’s still nine times as many beds as we have now. That’s still a nightmare scenario.
Even at a probably unrealistic 0.1% national infection rate, we would still need double our current bed numbers, in a system already running at over 80%. To contain the initial outbreak, China built a 1,000-bed hospital in Wuhan in just 10 days. Resources we could never come close to mobilising.
The only way the NHS could be “ready” for coronavirus is if the pandemic is contained to just a handful of cases and we went back in time and rebuilt the infrastructure we have lost, the capacity we should be offering in extreme emergencies. We aren’t ready for coronavirus and we never would have been. Wash your hands, stay home if you are sick, wash your hands again, and don’t travel needlessly. That’s all we’ve got right now.
The government certainly can’t be blamed for a coronavirus pandemic, but I couldn’t imagine a worst starting point to try to deal with it. Perhaps this crisis might highlight how far and deep cuts to the service have gone, and what we need to do to start to fix it.
Dr Dominic Pimenta is a cardiology registrar in London and writer. His book, P A R T S, is out now.