London Eye: The capital prepares for a second peak

The new capacity

It feels like a long two weeks since London had to get its homework in on how it proposed to align itself with Sir David Sloman’s “journey” to a new system. Especially as people work through the implications of a “new normal” with a much lower elective capacity.

Aside from the non-urgent-procedures-might-have-to-wait-two-years problem, system leaders are concerned they might have to cancel the lists they have been asked to restart as a second spike comes through.

Broadly, the consensus of senior managers is that this is likely to happen and they have been asked to plan for a scenario where it hits in July (electives are supposed to start roughly around 8 June).

However, London Eye understands the NHS London regional team actually predicts a second peak in November — shortly before flu season normally hits.

With those timescales in mind, where is the permanently expanded ICU capacity referred to in Journey to a New Health and Care System likely to be?

System leaders had to set this out for each ICS in the response to Journey.

Clockwise from the Nightingale in Newham, the Royal London’s two new floors are going to be retained for this purpose. I’m curious to know what kind of deal has been struck with the PFI provider, as levels 14 and 15 have lain unused for some time for reasons of not wanting to increase the unitary payment. Once this is up and running there is the hope for keeping St Bartholomew’s mostly covid-free (although the options being examined for achieving this confirm it will be laborious and uncertain, rather than a guaranteed fast-running elective service).

In the south east, King’s College Hospital at Denmark Hill and St Thomas’ are looking to expand their ICU capacity. For a while it had looked like KCH’s £100m ICU beds would never open but they did just in time for a lot of work to come in.

St George’s looks to be the ICU centre for south west London and had already been promised a significant slug of capital funding after years of asking (it appears a Legionella problem with the trust’s water supply – which it has refused to answer questions about – may have finally become the spur, before the covid-19 outbreak).

London Eye understands the hasty conversion of some theatres into ICU space has uncovered even more issues with some of its clinical space.

In north west London, Imperial College Healthcare Trust and Chelsea and Westminster Hospital Foundation Trust will be expanding their provision. At Chelwest it will be interesting to see if this involves sacrificing other services at the Chelsea site or taking a (presumably hefty) financial hit to expand services at West Middlesex University Hospital, which it runs but is on a PFI deal.

In NWL, London North West University Hospitals Trust was for a long period in the early stages of the outbreak the big outlier in mortality numbers. It put this down to factors like the size of Northwick Park’s accident and emergency, the co-morbidities and age of its population, and the size and expertise of its infectious diseases unit. It’s A&E had recently been rebuilt.

The Guardian recently reported that a single trust had dragged the national average of covid-19 cases acquired in hospital from between 5 and 7 per cent across most trusts to a 20 per cent national average overall, “because one trust was known to have poor infection control procedures in place”.

Infection control is a mix of a few different factors, human and logistical, but some of it is estate-related – ie, do you have the facilities to isolate people?

This could end up being an important factor in the rushed business case going into the centre for more capital funding.

In north central London, University College London Hospitals looks to be expanding critical care capacity too.

NCL’s covid response prompts questions about how much its service configuration will return to its pre-covid picture.

What if, for example, NCL’s paediatrics in large part stays at Great Ormond Street? And how much cancer work continues to get done at the Wellington? The Hospitals Corporation of America is going to start wanting to charge more than just NHS tariff prices before too long.

So while expanded critical care facilities are uncontroversial, the knock-on effects on other services may provide plenty for “citizens juries” to wrestle with, whatever they are.