Ten years ago the UK was experiencing the last pandemic to be declared by the World Health Organization. Between April 2009 and March 2010, over 800,000 people in England contracted swine flu (or H1N1), of whom just under 26,000 were hospitalised and 342 died. The UK’s response to the pandemic was described as “highly satisfactory”, with Dame Deirdre Hine’s independent review praising levels of planning and communication, with the NHS and public health services across the country considered to have responded “splendidly”.
Pandemics – which the WHO defines as a “worldwide spread of a new disease” – are somewhat predictable events. While their exact timing won’t be known, we can say with a reasonable degree of confidence they will continue to occur as diseases evolve. The UK government’s National Risk Register shows the risk of pandemic influenza as the most significant risk facing the country – even ahead of other risks such as extreme weather events.
So far, the WHO has not declared the spread of the coronavirus Covid-19 to be a pandemic, and the numbers of people affected so far in the UK are low. But what would happen to the NHS if they increased to the levels seen in that swine flu pandemic of a decade ago?
Managing the response
The first place to look is NHS England’s ‘Operating Framework for Managing the Response to Pandemic Influenza’, which sets out the roles and responsibilities across the wider system and which was informed by learning from swine flu. We’re now in the ‘Detect and Assess’ phase, with Public Health England taking the lead and seeking to understand what any pattern of spread might look like.
At the time of writing, 5,549 people in the UK had been tested for Covid-19 – nine positively. But if numbers do increase rapidly, we will move to the ‘Treat and Escalate’ phase, where the NHS takes the lead and local organisations consider enacting business continuity plans.
Every NHS organisation has such a plan in the event of a major incident. We tend to think of major incidents as sudden events such as a rail disaster, but they can also be things that build up over a period of time – described as a ‘rising tide’ incident by emergency planners. And that includes pandemics. The NHS England Emergency Preparedness, Resilience and Response Framework sets out the expectations of each part of the health system in a major incident. A pandemic would be classified as Alert Level 4 – the most serious – where “NHS England (national) may take command of all NHS resources across England. In this situation, direction from the national team will be actioned through the regional teams.”
What might this mean in practice? Trusts have already been told to establish ‘pods’, where people who suspect they’ve been exposed to the virus are isolated for testing (and ‘uncapped’ capital has been allocated to support this). We’re also seeing ‘swab squads’ established to test people in their own homes. So far, any pressure on the NHS comes from testing those who are concerned, rather than treating those who are ill. But what if this changes?
Cause for calm
Pandemics are clearly unpredictable in their severity, but we can draw some comparisons with what happened 10 years ago. Although 26,000 people hospitalised over a year sounds a lot, it’s a tiny proportion of NHS activity in a year.
In 2018/19, there were 6.3 million unplanned admissions to hospitals in England, so even if the number of people hospitalised with coronavirus were double that of swine flu – and there is no reason to suppose it would be – that still represents less than a 1% increase in activity. The NHS has seen year-on-year increases in emergency admissions over the last decade in significant excess of that – without a pandemic to explain it.
Indeed, every year the NHS comes under pressure from the impact of seasonal influenza. Although it's not directly comparable with Covid-19, if we look at seasonal flu statistics for 2017/18 (the last full year figures available), there were an estimated 26,408 deaths associated with influenza in England – over 70 times the number killed by swine flu. A concerted public effort to improve flu vaccine uptake rates across all age groups, and among health care workers, would free up much needed resources to cope with the existing pressures on services as well as the impact of Covid-19 or other future pandemics.
A more immediate concern is the pressure that is beginning to be seen in emergency departments and GP practices, as concerned individuals present themselves for testing rather than following official advice to call 111. We have already seen several temporary GP practice closures, which creates a pressure for the whole health and care system, not simply the response to Covid-19.
In the event of Covid-19 being declared a pandemic, the way the service is affected will clearly be dictated by that pandemic’s severity. In any pandemic, the NHS will prioritise patients who need emergency care. That could mean a national agreement to delay admissions for people who need planned operations to ensure that beds – particularly intensive care beds – are available. Other non-critical activity could also be curtailed to ensure that hospitals have appropriate accommodation to isolate patients with a highly infectious disease. That happened in some places 10 years ago, but the overall impact on waiting times was negligible (as shown here).
A pandemic would not only increase demand on the NHS from people who are ill, it could also affect the availability of staff. Not only could they become sick or unavailable for work through being quarantined, any impact on schools and public transport could also mean they are unable to get to work.
Given the high level of vacancies within the NHS and social care, a Covid-19 pandemic would exacerbate the pressure on the service. Unlike in 2009/10, the NHS is already struggling to cope with demand on services, and is missing all key performance targets. It is possible therefore that the impact might be more marked this time around, and we could see a further increase in waiting times for planned care, together with longer waiting times for urgent care for people with less serious conditions.
Should we be concerned? Time and again the NHS has proven itself well able to respond in a crisis. But while the health service will be well prepared for Covid-19, its resilience is threatened by 10 years of underfunding and failure to address staffing problems. While the new money already announced for the NHS is welcome, we have already said that it will do no more than halt the current decline in performance.
The forthcoming budget provides an opportunity for the government to set out its plans to invest further in NHS staff, and to support the social care system. The threat of Covid-19 simply underlines how important that investment will be.
Buckingham H (2020) "Coronavirus: how will the NHS cope?”, Nuffield Trust comment.