Thread by @fascinatorfun

So good from ⁦@xtophercook⁩ and ⁦@tortoise⁩ about why the NHS and public services need built in resilience - spare capacity, saxritficed on the altar of “efficiency”.

Because politicians & services CANNOT plan for everything.

The curve balls members.tortoisemedia.com/2020/03/30/chr…

There is a list of nightmares all risk assessed. A flu pandemic was amongst them, one of many and was assessed as high risk and almost as high Impact.

It even noted it could have a 2% fatality rate. 600k deaths

It is why they “war game” in Operation Cygnus”

They have a warehouse full,of Tamiflu ready to go at a secret location.

But CV19 is not flu.

SARS was an earlier similar but crucially NOT the same and experienced most severely in Asia, leading those countries to prepare for another outbreak with more resilience.
It felt real

One of the bigger problems insufficiently acknowledged is that the asymptomatic spread of CV19 was not known or planned for not least because the Chinese authorities (but not their medics & scientists) hid these data
They did not include asymptomatic +ves in their returns to WHO

It was not until weeks after CV19 spread outside China that there was a dawning realisation around the world and by the WHO that their estimate of 1-3% and not asymptomatically contagious was well under what other countries were finding.

And what the WHO found in their China delegation when they reported later in February.

This was a massive curve ball. The thought that, like SARS, you could test symptomatics and containment went out the window. But too late.

SARS was contained at ⬇️ 9k cases and ⬇️800 deaths

So. Not only had the response in the U.K. to the repeat failures revealed in Operation Cygnus war gaming remarkably relaxed by Government, but they were planning for Flu or the possibility of a SARS style outbreak.

CV19 ‘s deadly gift is the scale of asymptomatic transmission

Our great big stores of TamiFlu and Relenza were no use against CV19

And we had little resilience not just in the NHS but in PHE to engage in massive scale testing and contact tracing for a massive greyhound race already with traps up and racing away.

Part of any disaster response planning is to include a generalised ability to absorb the unforeseeable.

The way the U.K. has been run for at least three decades is to push it in the opposite direction.

“We started this crisis in a weak position.

We built a fragile state.”

From a flu point of view this was a mild winter. Despite that the NHS was still under extreme pressure, with a repeated failure to have the capacity to meet really important A&ar targets. 95% to be seen within 4 hours.

Fatalities increase measurably with further delays.

He goes on to look at A&E slippage which, by February, just as COVID started pushing resources, already was down to just 70% of patients being seen within 4 hours.

A good barometer of capacity. And this has been slipping for years

Foreseeable and foreseen.

Big London hospitals p, where COVID has hit most brutally p, were already at 95% capacity before those patients started dislodging “normal” work.

A senior doctor at Imperial Hospital Trust :-

“Every junior doctor/consultant rota life will be affected and changed. ....

“...Our definitions of safe are being redefined, our need to relearn forgotten skills can make for uncomfortable times...this feels like a career and life defining experience”

It will never be the same.

Just as the human body has built in resilience with two kidneys, lungs, arterial systems, neural systems) so the NHS and public service need it too.

Even relatively small adjustments (eg clawing back the 14k beds lost since 2010) and bigger Public Health teams can buy time.

Just more space literally means it is more possible keep infectious and non infectious patients apart.

Mor staff capacity means more time to be meticulous about taking self protective measures, and preventative especially when there is adequacy of PPE so much under discussion

We have seen how the additional capacity at all levels, public health, labs, medical personnel, emergency services, hospital beds in other countries such as S Korea and Germany has enabled them to slow the spread and buy time to pull in resources & prepare.

Needed at ALL levels

This is what is being done to create capacity but at a real cost to general care. Patients who really do need treatment having to wait. We know not how long.

The shortage of ventilators is but one problem

Only a quarter of over 70s survive once put on ventilators.

The U.K. is, in fact, a low spender on capital projects. Whilst other countries have seen on average a 44% increase...look at the UK. Lower than it was in 2000 whilst seeing many more patients.

We are talking about failures to repair to prevent “catastrophic failure, major disruption to clinical services or deficiencies in safet which are liable to cause serious injury and/or prosecution”

Let alone beds

⬇️⬇️⬇️

Maybe a redesign of hospitals and admission processes is needed.

Medical assessment units act as a “safe” holding space to try and prevent pressure on specialist units and wards.

But COVID is demonstrating that it is time to create more capacity (beds, personnel and specialised equipment) and reduce pressure on A & E and MAUs.

There comes a time when supposed “efficiency savings” and faster and faster throughput is, in fact, increasing inefficiency.

But it isn’t just beds. Or a failure to expand ventilator stock for surges in need. Or even PPE

As we have seen Lab capacity curtailed since 2006. And all the hollering for more testing cannot cure that as there has to be spare capacity, now being addressed.

Expensive batch processing equipment for RT-PCR testing has to be procured PLUS lab technicians employed & trained in the process and scientists to supervise.

Because capacity has been squeezed & hospital labs couldn’t expand until now to accommodate.

https://twitter.com/fascinatorfun/status/1244580757651238912?s=21

It doesn’t stop there. Mortuaries, waste services, medicines, palliative care drugs , drug & product production all need “slack” to cope with the curve balls and ramp up in emergencies

Staff. Trained.

Coroner’s offices will be hugely over stretched

Community care

All needed

GP and primary care. All under huge pressure with 1/3rd if GOs over 50 yrs old. We can see it coming.

After the dissection & Inquiries.

Gavin Kelly, former advisor to Brown
“Maybe this will be so epoch-changing that you can frame things differently for a long period of time”