The news that the London Excel Conference Centre is to be converted into a 4,000-bed field hospital, led by the military, for patients with Covid-19 has been in the headlines this week. It comes despite larger hospitals in London rapidly expanding both their intensive care capacity and their general bed pool, and speaks of the enormity of the task before the NHS. Chris Hopson, CEO of NHS Providers, suggested that smaller district general hospitals (DGHs) in London are considering concentrating their intensive care staff, resources, and patients into larger units, such as the Excel, sooner rather than later.
Where London leads, the rest of the country tends to follow, especially in terms of health policy. But is it sensible for smaller, rural remote hospitals in the United Kingdom to follow suit?
It certainly may be an option for other urban areas, such as Manchester, Birmingham and other parts of the Midlands, where there is a mix of large teaching hospitals and smaller DGHs in close proximity. There may also be benefits for multi-site trusts converting smaller hospitals into convalescent facilities.
The centralisation of acute and/or intensive care services, however, makes much less sense for more rural and remote hospitals. People living in the countryside tend to be older and have more co-morbidity than their urban counterparts, and are precisely the group shown to be more heavily impacted by Covid-19 infection. Smaller rural hospitals are therefore likely to see substantially more patients who are sicker and in probable need of intensive care than elsewhere, making the case for urban centralisation less strong.
The closure of any type of acute services is likely to cause confusion, if not outright panic, in the local population. As happened when some emergency departments were converted into walk-in centres, patients are likely to continue to present, but find their local hospitals less equipped than before to deal with their problems.
Most ambulance trusts are already under heavy strain, so the impact of either diverting ambulance services to other centres, or increasing the numbers of inter-hospital transfers should not be underestimated. Smaller emergency departments in England see around 45,000-60,000 patients per year. Even if the increase in time for each diversion was only 15-20 minutes, this multiplied by 3,500 patients per month, rapidly adds up to thousands of extra hours on the road. Inter-hospital transfers are also deceptive in terms of time – although the journey between hospitals may be short, critical care transfers tend to take four hours on average. Each vehicle would then need a deep clean afterwards, again putting substantial strain on the service.
Time also matters when conveying sick patients, and the emerging evidence is that patients with the coronavirus are particularly prone to rapid deterioration. So the movement of people across longer distances, whether by ambulance or private transportation, is likely to lead to poorer outcomes for patients.
If smaller hospitals are to remain open, there are specific emerging issues that will need to be considered and addressed in any further planning.
Most smaller hospitals already suffer from substantial staff shortages, and some are already reporting that up to 50% of their workforce are self-isolating. So far, this appears to have had little impact on the ability to deliver direct patient care. Concerns are much more over the ability of non-clinical staff continuing to keep wards well-stocked and scrupulously clean, as well as meeting the massive increase in logistical and managerial work posed by the pandemic.
The pandemic has also, in some places, laid bare the problems of outsourcing essential services such as catering and maintenance. With food no longer cooked on the premises of many hospitals, and instead reliant on a just-in-time supply, problems similar to those seen in supermarkets are likely to occur in the face of increase in demand. Concerns are also emerging about responsiveness to maintenance of critical equipment. While alternatives to both of these issues could be found, there is little logistical or managerial capacity to allow that to happen.
The downsides of centralising acute services have also been not fully explored. Working in unfamiliar environments substantially increases the risk of error – a risk that will be magnified with clinicians being required to work outside of the boundaries of their usual specialty. Trust is also highly important in disaster scenarios, and the literature suggests that utilising existing networks of trust and information can be more efficient than configuring new networks in times of high stress.
Looking to the military is still instructive. But rather than building large hospitals, what is needed are small teams that can supply logistical support to rapidly reconfigure and expand services (which may include the setting up smaller field wards), reinforce supply chains, carry out maintenance, and set up large kitchens. This should be bolstered by multi-purpose teams who can work across boundaries and have permission to solve problems on the ground. Such teams could also oversee the large numbers of volunteers willing and able to support in the NHS. Once better disease surveillance is in place, there is scope to deploy such teams to the areas where outbreaks are beginning to emerge. This is likely to be more efficient and cause less confusion to NHS staff and the public alike than the mass movement of health care workers into central locations.
The problems of smaller hospitals in rural and remote areas are not the same as their larger urban counterparts. The response to the coronavirus pandemic cannot be one-size-fits all. Thoughtful tailoring of additional support to allow clinical teams to continue to meet the needs of their local communities may be the best response for the most vulnerable communities.
This blog was originally published in the BMJ on 27 March and is reproduced with permission.
Vaughan L (2020) “Coronavirus response must consider smaller hospitals”, Nuffield Trust comment.