NHS: A cold Covid winter ahead?

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With Covid rates remaining stubbornly high and a huge pent-up demand for hospital care, the UK’s National Health Service faces a tough winter. Intensive care wards are the canary in the mine, reports Rachael Jolley.

Mark Toshner: We can make beds, but what we can’t make are specialised staff to run those beds. The accident and emergency department needs a very specific skill set. And once you run out of their capacity, you don’t really have anywhere to turn.

The winter is going to be tough. I think that nobody’s envisaging anything other than a really difficult winter and how difficult that is, I think we don’t know, but it’s going to be difficult.

If you hear people from intensive care, telling you things are tough, that’s a really important canary down the mine, because these people are the SAS of clinical staff. And if they are telling you it’s tough, you should be listening.

Andrew Conway Morris: My unit is about a third full of COVID. We have spilled out into our higher independency area and we are ventilating patients in the high dependency area.

Rachael Jolley: Welcome to Pod Academy. My name is Rachael Jolley. I’m a journalist and podcast producer. In this episode, we look at the challenges for the National Health Service as it faces COVID in winter 2021.

With Welsh hospitals reporting some of the longest waiting times ever and the Scottish government calling in the army to help drive ambulances are we as prepared as we can be for the winter ahead?

And what does it feel like inside one of the UKs most famous hospitals right now? In September Prime Minister Boris Johnson said further restrictions could be put in place if the NHS is threatened this winter. By the end of the month COVID hospitalisations were already at a high level. To find out more and see how different this winter might be from the last one I spoke with two doctors who work at Addenbrooke’s Hospital in Cambridge.

We talked about how they’d coped so far and how they’re preparing for this winter and what their biggest worries were. I spoke with Mark Toshner, an academic at Cambridge University, who is also a pulmonary physician, a specialist in illnesses relating to the lungs, at Addenbrooke’s. While Mark doesn’t normally work in intensive care last year, he was called into help out during the worst of the emergency. And Pod Academy also heard from Andrew Conway Morris, a clinical scientist at Cambridge University and a consultant working in intensive care at Addenbrookes.

First we heard from Mark Toshner.

Mark, if I were the Secretary of State for Health, what would you be asking me to do right now?

Mark Toshner: The first thing I would be asking is for our really honest acknowledgement that we’re in a difficult place and that we have just under, I think we might even have topped 8000 people in hospital now and we’ve had that for weeks now, between about 7000 and 8,000 and that this was supposed to be our period of rest, or quiet time, during the summer. In actual fact we’ve seen almost historic highs of healthcare utilisation.

That’s a really tough start to then go into winter for, and, so we’re in a really vulnerable position.

Rachael Jolley: And Andy, what is it like in intensive care right now?

Andrew Conway Morris: My unit is about a third full of COVID. We have spilled out into our higher independency area and we are ventilating patients in the high dependency area

Mark Toshner: I’ve got plenty of colleagues who’ve essentially just been the coal face now for the better part of a year and a half or longer, and you can see the toll that it’s taken on some of them. And it has a pretty heavy toll. And so the winter is going to be tough. I think that nobody’s envisaging anything other than a really difficult winter and how difficult that is I think we don’t know, but it’s going to be difficult. We start off with one of the lowest ratios of doctors to population any way.

Rachael Jolley: One of the lowest isn’t it? One of the lowest in Europe?

Mark Toshner: I think we’re second or third [lowest] or something like that, depending on how you measure it.

Rachael Jolley: Mark, you spent some time working in intensive care last year in the middle of one of the busiest periods. What was that like?

Mark Toshner: I’m not an intensive care doctor for a very simple reason. I couldn’t hack it as an intensive care doctor. It’s just one of the hardest jobs in the hospital because, on a daily basis, you’re dealing with patients at the edge of life and death and so you need to be a really unique and special and resilient type of person to be able to cope with that day after day after day. And I’m probably not it. And I have the self knowledge about that. So when I worked in intensive care for a couple of months it was really tough, even for a couple of months. There were nights where I was just completely sleepless after these events, and even just the physical being in the PPE the whole time, the stress of the whole environment it takes such a stark, quite profound toll on you.

If you hear people from intensive care, telling you things are tough, that’s a really important canary down the mine because these people are the SAS of clinical staff. And if they are telling you it’s tough, you know, you should be listening.

Rachael Jolley: Andy what would you say are the lessons you’ve learned from last winter and COVID?

Andrew Conway Morris: It’s been challenging and I think that’s probably fairly obvious to everybody that intensive care has been on the front line of COVID. We have seen unprecedented numbers of patients coming to us, to the extent, if I give an example from my own hospital, you know, we started with, 40 intensive care beds and at the peak of the second wave, which is the worst it’s got so far and hopefully won’t get that bad again, we were up to around 120 beds, so, you know, a tripling of our capacity.

And of course it goes without saying that we didn’t have a tripling and capacity of intensive care consultants, intensive care nurses, pharmacists, physiotherapists and all that. Specialists who we rely on in intensive care.

And when it first came, we thought this is like Ebola, you know, super, super dangerous and highly, highly transmissible. And there’s almost no protection against it. And as time has gone on we’ve learned that actually that isn’t so much the case and taking appropriate precautions, and as long as those people who are coming into hospital are at least aware of the risks that they’re taking and so forth, and clearly with people being vaccinated, it changes things.

I would say that the biggest things that I think are going to help us this winter and why I genuinely think that this winter will not be as bad as last winter is that we have the vaccines and to my mind that has made a bigger difference than pretty much anything else that we’ve done.

We also have effective treatments that we didn’t have previously.

We understand what we’re dealing with much better, and we have better stockpiles of kit.

Rachael Jolley: To both of you, what are your fears for the winter ahead?

Andrew Conway Morris: There’s going to be COVID over the winter, then there’s going to be the usual winter viruses. And of course, we’ve got this massive backlog of work, which, you know, does need to be done.

Mark Toshner: My guess is that we’ll always manage to stay open and that we’ll find a way . And then it’s about how many beds you have downstream in the hospital. And again, we’re in exactly the same position with that, we have limited capacity on that front.

It’s a mixture of physical capacity and the staff. So the physical capacity does become important then, because if you don’t have a bed it’s very hard to admit a patient. And so then that has a knock on effect on the scheduled work. So all the routine or non-urgent stuff can get basically stopped .

Rachael Jolley: There’s no extra people out there who you can go, “Oh, well I’ll just ring them up and they can come in.”

Mark Toshner: That’s right. And it’s not just doctors, nurses, incidentally, the hospital has all the ecosystem of support staff and they’re all just as important.

So, you know, to pick an example, you can’t run a radiology department without radiographers. So if you have a limitation of radiographers, you might not be able to process all the patients that need scans. You may have lots of machines sitting empty.

So the really important thing about intensive care is that it has a really unique mixture of both routine, non-emergency work and everything is kind of down wind of that. And so if you’re having your cancer operation and you need an intensive or high dependency bed, or if you’re having an aorta repaired or if you’re having a valve done, or if you’re having a coronary artery bypass, then you need a higher level of care in the immediate postoperative period. If the hospital is just filling up with COVID patients, all that stuff has to be stopped.

There aren’t very many of us who don’t know somebody who goes to the hospital or who needs hospital care, who has an operation coming up. So actually, this is us. I think that the phrase that really wound most of the clinical staff up during the wave one and two was this idea of “protect the NHS” because it made it sound that the NHS was a thing that we were protecting, but actually it’s the other way around the NHS protects you from illness, from disease and from all manner of things.

Andrew Conway Morris: The staff are tired, I do worry, especially about those who were redeployed in the first two waves. I think the psychological toll that it took on them was probably greater to some extent than on those of us who’ve chosen to work in an ICU in the first place.

And I wonder how willing they will be to come back. I wonder how willing my colleagues will be to step up again and take on the supervisory roles and so forth. I don’t know. I mean, you know, they’re all professionals and watching everyone pull together was one of the highlights of the whole experience.

You know, that there was a sense of camaraderie, a sense that we were in it together and we were all going to try and do our best. But I, I think we mustn’t close our eyes to the the casualties of that.

Rachael Jolley: And final words from both of you.

Mark Toshner: People are just cracking on as if none of this was happening and that the pandemic was over and the pandemic is not over. So if I had any influence at all, I’d be trying to change the messaging. And I’d be making it clear that additional steps may be needed.

Andrew Conway Morris: I think the only thing that is likely to make a major difference to our winter would be a willingness to reimpose restrictions on people’s freedoms rapidly and in time and not dither when it’s needed. So pay close, close attention to the data and be prepared to take unpopular decisions because the alternative is a really, really, really unpleasant winter in the health service, but actually it’s not us that’s going to have the really unpleasant time, it’s the patients.

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