Richard North, 23/04/2020  
 


As a preparation for the Covid-19 epidemic, most of the NHS hospitals throughout the land have been converted into treatment centres. ICU availability has been ramped up, operating theatres have been turned into ICUs and much of the hospital service has effectively been repurposed.

The use of such facilities for this purpose is heavily contraindicated by Chinese experience, not least because of the difficulties in controlling nosocomial infection in environments not specifically designed or equipped to process highly infectious patients with a disease for which there is no cure, no available prophylaxis and no vaccine.

Thus, it seemed an entirely logical, if not a somewhat delayed, response of the government to commission a network of so-called Nightingale Hospitals to provide care for Covid-19 patients. It also seemed to accord with the Chinese practice of using purpose-built "shelter hospitals".

Furthermore, this appeared to conform with the principles set out in the WHO checklist for influenza pandemic preparedness planning, published in 2005. This advised members to determine potential alternative sites for medical care, such as schools, gymnasiums, nursing homes, day-care centres or tents in hospital grounds.

Members were also to determine the level of care that might be provided in alternative healthcare facilities, and to develop a contingency plan for providing these alternative facilities with the equipment and supplies adequate for the level of care that would be provided.

It turns out, though – and not for the first time – that the UK was singing to its own tune. Rather than the Nightingale Hospitals being treated as alternative sites, keeping infection out of the existing hospitals, they have become overspill units, with the NHS hospital service still taking the brunt of referrals.

Thus we have CMO Whitty, at yesterday's press conference, happily declaring that the "minimal use" of the Nightingale Hospitals around the country is "a sign of success". He says he is "delighted" that some of them have not had to be used. Rather than being used as alternatives, they had been built to give the country "flexibility" and to give us "a number of options".

It would seem, therefore, that the chief medical officer is not only content but "delighted" that the service (as well as patients and staff) should bear the brunt of hospital infection that inevitably arises from the use of premises not fit for purpose, and quite evidently has no concern that this puts staff and patients at risk, giving rise to increased and unnecessary mortality.

In addition, because of their effective repurposing, hospitals are no longer able to deliver the medical services for which they were originally designed and furnished and nor, for many vulnerable patients, is it safe for them to attend units which have become major reservoirs of infection in the community.

With cancer sufferers particularly at risk, with fears that many thousands will die unless given timely treatment, on the back of early diagnosis where necessary, we now have a bizarre situation developing. To avoid their patients being exposed to potentially fatal infection from the SARS-Cov-2 virus, a number of hospital trusts have opened Covid-19-free "cancer hubs" in specialist sites, some in the private sector, outside the established hospital system.

Under the aegis of the chief medical officer, therefore, we have a situation where district general hospitals are being used as isolation hospitals, to deal with an epidemic of the most infectious disease the service has experienced in recent times, while more suitable facilities are under-used.

Then, on the other hand, because the district general hospitals can no longer be used for the purposes for which they are designed, other less suitable facilities are having to be made available – which are being used.

These, however, cannot accommodate patients at risk of dying from strokes, heart attacks or other life-threatening acute illness, or those who suffer accidents which need hospital-based treatment. As a result, it is estimated that an extra 2,600 people a week are dying from non-Covid-19 causes, either because (rightly) they are shunning A&E departments for fear of acquiring infection, or because there is no longer the capacity to deal with them.

Given these Alice in Wonderland contradictions, some might pause to consider whether the current chief medical officer is fit for his post, although they might also wonder whether the system is even capable of acting in a coherent manner.

That might certainly be the case, given the current political direction of the service, under the tutelage of secretary of state Hancock. This man is now happily chirping that Britain has reached the peak of the Covid-19 epidemic and that the NHS "will now reopen for routine care". He insists that people must seek medical help if they need it, telling the Commons that routine surgery will resume shortly as the NHS has 10,000 free beds and the outbreak is no longer worsening.

Never mind that the cases reported yesterday ran to 4,451, with 759 deaths, and a cumulative total of 18,100 deaths for the UK, and cases running at 133,495 – many of whom are still in hospital. And with an emergency ambulance sitting outside my office window as I write (picture), one takes protestations that the crisis is under control with a pinch of salt.

As long as Covid-19 patients are being treated in any hospital, uninfected patients in the same building are at risk – and more so if the NHS cannot resolve its ongoing supply problems and equip its staff with the necessary protective equipment.

However, this has not stopped Hancock declaring a "victory" in the battle to stop the NHS being overwhelmed. Currently, there are 3,000 free intensive care beds, three times more than at the start of the outbreak, even before counting the (under-used) Nightingale Hospitals.

"Within very short order we will start to restart the NHS", he says, possibly unaware that this will inevitably trigger a rise in hospital infection and associated mortality, even if some of the more vulnerable patients are still excluded from attending "normal" hospitals.

One small piece of good news, though – paraded on the front page of The Times - is that an "army of thousands" is to be recruited to assist in the process of contact tracing, in order to speed the relaxation of the lockdown.

Council staff and civil servants, we are told, are to be drafted in as part of a three-tier system to ensure that as many infected people as possible are detected and isolated. Hancock has promised that contact tracing will be in place on a "very large scale", before the lockdown is relaxed.

The bad news is that the original mobile app proposed by Hancock is being tested, suggesting that the Department of Health is still committed to its use. But, once we see the details of the full contact tracing scheme, it may be possible to be more confident that we might be getting a workable system.

But even the so-called experts can't get it right. Prof Allyson Pollock, of the Newcastle University Centre for Excellence in Regulatory Science, tells the BBC that: "We don't need fancy expensive apps where people are going to be exposed to issues of data privacy". We should, she says, "be following... a low-tech model, using people and telephone [interviews]".

This academic has obviously never done the job, and clearly hasn't talked to anyone who has. Had she done so, she might have learnt that those on the ground have already discovered that the low-tech telephone interview has serious limitations. Unfortunately, there is no substitute for face-to-face interviews, preferably from local government personnel. Their peoples are more likely to be trusted than civil servants, who may be suspected of being tax or immigration officials.

But then, it occurs to me that some of the reluctance of the government to do the job properly might mean even more demands on a creaking protective equipment supply service. That "army" of contact tracers will need equipping, stretching supply chains even more.

Nothing, it seems, is working for the government, even if the Guardian is on the case. The paper is telling readers that it is "investigating how the UK government prepared for – and is responding to – the coronavirus pandemic", and wants "to learn more about recent decisions taken at the heart of government". It is inviting whistle-blowers or sources "with new information" to contact it via a dedicated e-mail.

This is typical of the media which is obsessed with "secret squirrel" stuff, when all it has to do is read the published documentation going back to 2005 and before, whence it will learn all it needs to know about why the decision-making process went so wrong.

It seems, though, that the media is as inept as the government, a terrifying combination that will ensure that most people remain ill-informed about the perils they face.






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