Could a swine flu surge see a slump in targets?

The NHS is heading for a long, hard winter with a sustained outbreak of swine flu putting pressure on intensive care, accident and emergency and the ambulance service - and the threat of a third peak.

In any worst case scenario there is bound to be an impact on the quality of care we can deliver

That is the pessimistic reading of the latest figures on swine flu, which show a decrease in the number of cases but little reduction in the numbers requiring hospital treatment or intensive care. Chief medical officer for England Sir Liam Donaldson has warned that doctors have been unnerved by the severity of the cases they are seeing and how fast patients’ condition declines.

Over the last few weeks the proportion of patients in hospital who require critical care has increased: last week 173 out of 785 were in critical care - more than 22 per cent compared with 12 per cent earlier this year. Under fives have been particularly badly affected.

But what does this mean for the NHS’s flu planning? Rather than the nationwide peak which brings public services to a standstill, the NHS may have to cope with months of elevated levels of flu (both swine flu and, potentially, normal seasonal flu) and high demand for critical care beds.

This could bring extra pressures: if there was an outbreak with hospitals being swamped with cases, then it is generally expected that the NHS would be on a “war footing”, with normal targets suspended and the service’s focus shifting to treating thousands of critically ill swine flu patients. Elective care and outpatient appointments would be put to one side for a time, staff shifted around hospitals to cope with the pressure and former staff asked to return to work.

But a long period of sustained pressure has different consequences. NHS Confederation policy director Nigel Edwards says: “There is a concern that people working in the NHS will get worn down.”

Trusts are also concerned that they may not be given leeway on targets such as 18 weeks referral to treatment and four hours in A&E, or indeed funding for extra staff, even though the cumulative effect of weeks of pressure may be as difficult to cope with as a “short sharp” epidemic. Mr Edwards hopes the Department of Health will make an “intelligent interpretation” of the pressures after the event - but says it is unlikely to announce too much in advance.

Head of emergency preparedness at NHS London Andy Wapling says: “If the predictions are right it will be equal to a bad seasonal flu winter. We will be under pressure. We are not looking to suspend any target. We would expect that with planning trusts could manage to sustain the 18 week target.”

NHS East Midlands director of flu resilience Phil DaSilva warns the main danger now is complacency: assuming that because we are not in the middle of a major spike, there is nothing to worry about.

Aspects such as seasonal flu jabs and encouraging patients to use the right “stream” to access urgent care may become more important in a longer outbreak, as they could offer ways to reduce the pressure. Vaccination of “at risk” groups - already under way - could reduce the number of cases but a proportion of patients won’t fall into these groups and can’t be predicted.

Finding extra beds

The NHS is in a far better position to cope with the demands on critical care than it was a few months ago. An article in Anaesthesia in July highlighted the potential shortage of critical care beds - with demand outstripping supply by up to 60 per cent at the peak of a pandemic - and strong regional variations. Paediatric critical care beds would be quickly exhausted, the authors warned.

Since then proposals have been crystallised in all SHA areas to at least double the number of beds for the most seriously ill patients. These extra care beds have been found from upgraded beds used for less seriously ill patients and, in some cases, by identifying beds such as theatre recovery that could also be used. Clearly this could only be done if elective operations were cancelled.

Some areas have also made significant investments in equipment: in the North East alone, 34 additional ventilators have been bought. Extra equipment could avoid ventilators in operating theatres being used for swine flu cases and stopping elective work.

If the system comes under pressure, children are likely to be nursed in adult critical beds in district general hospitals rather than in specialist paediatric beds, which exist only in a few centres. Decisions about the age and weight of children to be treated in this way are being taken locally but in some areas it is envisaged children as young as 15 months could be in adult beds, although five years is more common. Staff in adult critical care units dealing with children would be able to access paediatric advice, often from specialist centres. In London, the expertise of staff at Great Ormond Street Hospital has been used to train staff elsewhere.

Expanding critical care capacity is as much about workforce as about physical beds. Trusts have identified staff who could provide critical care if numbers treated rose: in part these are critical care trained staff who are not working in that area at the moment; other staff could be trained to assist.

SHAs are looking at situations where specialist staff-patient ratios could move to 1:2 or even 1:3 at moments of great pressure, rather than the 1:1 that is normal for the sickest patients. NHS North West, NHS South West and NHS Yorkshire and the Humber say ratios could move to one senior critical care nurse for three patients in the event of a “severe surge”. In the North East a critical care nurse could oversee two to four patients, although there would be a minimum of one nurse per patient.

Maximum benefit

This will be necessary to ensure the maximum number of people benefit from intensive care, but it will have consequences. 

“If you drop the nurse-patient ratio you drop safety levels,” says Bruce Taylor, a consultant at Portsmouth Hospitals and one of the authors of the Anaesthesia report. “Intensive care is run in a way that the patients are safe. They are closely supervised and monitored. But if a nurse is looking after four patients - helped by people with little experience - and two patients become ill at the same time, you have a problem.”

Royal College of Nursing acute care adviser Alan Dobson expects to see staff across hospitals being asked to work in different areas.

“In any worst case scenario there is bound to be an impact on the quality of care we can deliver,” he says. “Under those circumstances care would be compromised. But we are talking about a situation in which a large proportion of the population would be ill.” 

Up to now intensive care units have not been swamped, although almost all areas have seen more people come into hospital with swine flu needing intensive care. Why this should be happening is a bit of a mystery but it does seem to echo what happened in the southern hemisphere during their winter a few months ago.

“It probably will not stretch our capacity as much as we thought,” says Linda Sheriden, NHS East of England swine flu lead. “The total numbers going into critical care are not as huge as we anticipated - but they are pretty sick.”

Dr Sheriden points out that only a very small proportion of those coming into hospital have had antiviral drugs - which suggests that these are limiting the extent of the disease, provided they are taken at the right time. Making them widely available may well turn out to have been the right policy.

But Dr Taylor points to the question of why some of the sickest people had not had antivirals - did they become ill so rapidly they came straight to hospital or did something else prevent them starting the drugs?

To date, SHA regions have managed without needing to transfer many people out of their regions, although some severely ill patients have been moved to the few centres that offer ECMO (extracorporeal membrane oxygenation), where the patient’s blood is oxygenated outside the body. But given the patchy nature of swine flu across the country, if it does get worse it is likely that inter-region transfer will be used extensively. 

The changing picture has forced SHAs to go back over their plans and ask other NHS organisations to refresh them. Dr Taylor is one of many who believes the NHS has been lucky so far. The outbreak has been more regional than expected, so pressure has not come at the same time across the country, and the total number affected has been fewer than expected, possibly helped by mild weather.

This may have allowed the vaccine programme to make a difference, both in protecting the known at risk groups and protecting staff. Although there has been concern that overall take-up among hospital staff is relatively low, Dr Taylor suggests this will be higher among intensive care staff. He believes there could also be an opportunity to wipe swine flu out by a mass vaccination programme.

“We can’t be sure there won’t be a third peak,” he says. “But I think it is likely we will have a long, slow period.”