Revealed: The trusts hit hardest by covid

There’s no way to calculate precisely which trusts were hardest hit by covid. Is it tougher to expand an eight-bed critical care unit at a general hospital by 300 per cent, or to carry out a major reconfiguration across a four-site trust, including opening entire additional floors of intensive care beds?

Is it more damaging to go through two very extreme but relatively brief peaks; or to see lower peaks, or to suffer interminable months on end of lower but significant covid admissions, while many other areas had become quieter? 

Is it easier to cope as a hospital in London – with more support close by and an “all in it together” regional mood – or as an island in a region where neighbours saw substantially less covid, but perhaps were less understanding and geared up to help? How did the experience compare between the pre-vaccine period, with much more severe illness and death, to the period since, when ongoing pandemic pressures have combined with much higher non-covid demands?

It would take many more conversations and analysis to try to take all factors fully into account and it might be futile and perhaps wrong to seek an absolute answer.

There are also questions about the accuracy of the only data which can be used, which was (and still is) submitted in daily sitreps to NHS England. Hospitals have often said the figures underestimated the share of their beds occupied by covid patients, partly because many were out of action due to infection control.

However it is possible and I think appropriate to look across several different methods to show, using the data trusts submitted, that a set of them were particularly heavily affected.

Four trusts had more than five months at more than 20 per cent covid occupancy

When considering covid bed days in proportion to the size (bedbase) of the trusts, many of those most heavily hit were smaller providers: There are four trusts which spent more than five months – 150 days, or a fifth of the total time – between 20 March 2020 and 30 April 2022, with at least 20 per cent of their beds occupied by patients with covid: Croydon and Whittington in London, Sandwell and West Birmingham in the West Midlands, and Countess of Chester in the North West.

For 35 trusts, covid occupancy was at 20 per cent or higher on at least one in 10 days during that period.

Also listed below are the hardest-hit trusts measured by: Total covid bed days as a ratio to the trust’s pre-covid bed base — and a heatmap showing all hospital trusts on this measure; crude total covid bed days; total mechanical ventilation covid bed days as a ratio to the trust’s pre-covid critical care bed base; and estimated maximum critical care surge.

I have also spoken to chief executives of four of the trusts at or near the top of several of these tables and asked them to reflect and share observations, recommendations and lessons from their experience — both for preparation for future major incidents, and for running the day-to-day NHS.

One strong message was that the NHS needs to go further in sharing their waiting lists and scheduling patients’ treatment across systems and regions. You can hear much more of what they said in two HSJ Health Check podcasts we’ve just published.

Although the CEOs’ observations were not all about acute care, this analysis is about the acute hospitals most affected. Obviously other parts of the health and care system were and are hit very heavily too.

Total covid bed days relative to pre-covid total bed capacity 

The gradient of trusts’ lines in the chart below shows how pressure mounted on them at different times, with a steeper increase showing higher occupancy. 

For example, Countess of Chester was particularly pressured from summer 2020 and through the rest of 2020; Medway was sharply hit in November and December 2020; Sandwell and West Birmingham severely affected through much of 2021; and Croydon and Whittington had higher occupancy than others during winter 2021-22 and through to the end of April this year.

 Absolute total covid bed days

 Mechanical ventilation bed days relative to pre-covid critical care capacity 

Critical care surge

Looking at the maximum numbers of covid patients receving mechanical ventilation at a trust, over and above their normal critical care capacity, shows how the largest trusts opened up, and used, many additional beds.

It does not show the full critical care surge at the time because it does not include non-covid patients still in intensive care. Nor does it take account of reconfigurations across sites — such as Barts effectively closing some critical care at Barts hospital, in order to open additional floors at the Royal London.

In percentage terms, the figures suggest – again – that the smallest trusts stretched the furthest. However, this involved opening small absolute numbers of critical care beds, relative to the large regional centres.