NHS and other professional bodies’ response to the Sunday Times, 25 October 2020

26 Oct 2020 01:36 PM

The Sunday Times ran a story alleging that frail and elderly patients were denied care by clinicians in wave one of the coronavirus pandemic, in part because clinicians drafted a triage tool for use if the NHS was overwhelmed.

The response from the NHS, along with the other professional bodies referenced in the Sunday Times story, and responses to case studies cited by the newspaper, is below, together with detailed factual explanations for why the Sunday Times’ claims are demonstrably wrong.

Dr Alison Pittard, Dean of the Faculty of Intensive Care Medicine, recently said:

“Throughout the first wave of Covid-19 the NHS did not run out of critical care capacity, which remained available to everybody who would benefit from it.

“As we learned more about Covid-19 treatment changed as it became clear that oxygen therapy, that can be delivered on general wards, is often more beneficial than being on a ventilator.

“The Faculty of Intensive Care Medicine has been clear throughout that doctors should make decisions about patients’ treatment just as they normally would.”

Professor Stephen Powis, NHS national medical director, recently said:

“These untrue claims will be deeply offensive to NHS doctors, nurses, therapists and paramedics, who have together cared for more than 110,000 severely ill hospitalised Covid-19 patients during the first wave of the pandemic, as they continue to do so today.

“The Sunday Times’ assertions are simply not borne out by the facts: it was older patients who disproportionately received NHS care – over two thirds of our Covid-19 inpatients were aged over 65.

“The NHS repeatedly instructed staff that no patient who could benefit from treatment should be denied it and, thanks to people following Government guidance, even at the height of the pandemic there was no shortage of ventilators and intensive care.

“We know that some patients were reluctant to seek help, which is why right from the start of the pandemic the NHS has urged anyone who is worried about their own symptoms or those of a loved one to come forward for help.”

Dr Katherine Henderson, President of the Royal College of Emergency Medicine, recently said:

“Emergency Departments have been open throughout the pandemic and our top priority has always been patient care and safety.

“While the pandemic has demanded some practical changes to the way we treat patients and we had to learn at pace about how to manage a completely new illness, we did not need to change the critical clinical decisions about the emergency care we offered.

“We want to remind patients that we are here for them and they should not hesitate to seek urgent and emergency care if they need it as one of the serious concerns of the first wave was patients staying away through fear.”

Professor Sir Jonathan Montgomery, co-chair of the Moral and Ethical Advisory Group, recently said:

“We were asked to look at the issue of a Covid-19 triage tool, however, it wasn’t needed.

“Clinicians have been focused throughout the pandemic on assessing the individual needs of their patients and then providing the care that will benefit them best.

“The rapid expansion of critical care capacity ensured that our initial concern that the NHS might be unable to meet all its patients’ needs proved unfounded.”

A spokesperson for the Intensive Care Society recently said:

“The decision-making guidance is derived from work commissioned from an expert group for consideration by Government, which was subsequently stood down on 28/29 March 2020, without DHSC or NHS implementation, after a review of capacity and pandemic trajectory.

“It therefore remained in draft and unpublished at this point.

“Subsequently the draft document was further adapted and refined for release as an independent professional and academic publication.

“The final version, which does not include numerical scoring, was issued for release by the Society on 28 May 2020 with endorsement by other professional bodies across the 4 nations, and carries the status of clinical guidance.

“No interim versions were released, published, endorsed or authorised by the Society or any of the above bodies before 28 May 2020.

“As a professional body, the Intensive Care Society forms guidance to support those working within intensive care.

“Implementation of guidance is the responsibility of individual Trusts.”

The facts 

• NHS hospitals did not run out of intensive care beds, so there was never a need to refuse anyone treatment on the basis of NHS capacity.
• Clinicians make decisions about the best course of treatment for their individual patient, based on that person’s specific needs, and wherever possible with relatives, carers or next of kin. That is what happened throughout this pandemic; there was categorically NO blanket national decision to refuse care to any group of people, including on the basis of their age.
• The optimal therapy for most hospitalised Covid-19 patients has turned out to be oxygen therapy, which can be given in a general ward, rather than the patient being sedated on a mechanical ventilator in intensive care, and latest data show that of all Covid-19 patients receiving any form of oxygen therapy, the majority of them were indeed aged 65 or older.
• Older people were not denied admission to ICU during the first wave; actually they comprised the majority of patients admitted to ICU with Covid-19, throughout. This has remained true irrespective of the overall number of patients of any age in England’s ICUs being treated for Covid-19. 

Hospital treatment and intensive care has been available to any individual who clinicians determined would benefit from it throughout the pandemic as it normally would be.

Throughout the Covid-19 pandemic there has in fact always been ICU capacity available. As the National Audit Office have confirmed, around the peak of Covid-19 hospital admissions on 14 April, NHS providers in England had 6,818 ventilator beds operational, of which: 2,849 (42%) were occupied by Covid-19 patients; 1,031 (15%) were occupied by other patients; and 2,938 (43%) were unoccupied.

Data from the Intensive Care National Audit and Research Centre (ICNARC) show that it is not true that older people were denied care. Over half of patients admitted to ICU with Covid-19, throughout the pandemic, have been aged 60 or over. This proportion has remained steady irrespective of the overall number of patients of any age in England’s ICUs being treated for Covid-19. This is also consistent with patterns of ICU admissions before the pandemic. ICNARC analysis makes clear the age profile of Covid-19 patients being admitted to ICU is the same as for the most similar other condition—viral pneumonia—between 2017 and 2019. For viral pneumonia the average age of a patient in ICU is 58.

Far from rationing ICU beds, NHS England and NHS Improvement wrote out to the health service very early in the pandemic to say that all patients should receive the best available care regardless of concerns about future pressures. The Speciality Guide Adult Critical Care v2 sent to the medical directors, Covid-19 leads, Trust heads of service and clinical leads for critical care and emergency care on April 8 stated, in terms: “All patients should be treated respectfully and equally and should receive the best available care. Patients should not be treated differently because of anticipated future pressures: it is important to focus on current clinical demands and available resources. Assess what care is likely to provide benefit to the patient, taking into account the best available evidence on factors that predict this and applying it to the specific situation of the patient being treated.”

No intensive care national triage tool was issued by the NHS. Early work on a triage tool was commissioned when modelling suggested two million people here could require hospital treatment and hospitals in northern Italy and Spain were being overwhelmed. This was not completed let alone issued because it became clear that, thanks to the efforts of the public in following Government guidance, the number of patients would be kept within NHS capacity. As the Moral and Ethical Advisory Group (MEAG), which was involved in developing a draft, noted: “The specific draft discussed by the MEAG was not progressed any further as it became clear it was not needed.” NHS E/I have not adopted published or relied on any such tool and our logo has not be authorised for use on any such tool.

NHS England and NHS Improvement have urged patients to come forward for treatment as they normally would throughout the pandemic. At a Downing Street press conference on April 4, just two weeks into lockdown,  Professor Stephen Powis, the NHS national medical director, said: “if you have any emergency condition, whether it’s a sick child, whether it’s a mother, or a mother in pregnancy who’s worried about the movements of the baby, you should be seeking emergency services just as you always have done. They are there for you and although we are focusing on Coronavirus, it’s important that we also continue to focus on other emergency conditions.”

NHS England and NHS Improvement have repeatedly instructed the NHS and clinicians that blanket DNACPR are inappropriate, formally writing to clinicians and the NHS three times (March 24, April 3, April 7) to say they should only ever be applied with the appropriate consents. The April 7 letter (attached) from chief nursing officer Ruth May and national medical director Professor Stephen Powis, for example, stated: “The key principle is that each person is an individual whose needs and preferences must be taken account of individually.” NHSE/I also issued a joint position statement with Baroness Jane Campbell on May 20 (also attached) repeating that blanket DNACPR s are “totally unacceptable”. Having a care plan in place for frail and elderly patients, which is not the same as a DNACPR, is best practice. The Coordinate My Care system allows patients, their families and their doctor to log their urgent care plan. It does not mean a DNACPR is in place.

There was no NHSE/I policy of denying care home residents dying of Covid-19 access to hospitals. As stated above, NHSE/I told clinicians that “All patients should be treated respectfully and equally and should receive the best available care” and repeatedly said that blanket DNARs were inappropriate.”

It has never been the case that the Nightingale hospitals were “mainly equipped” to treat young patients. More than three quarters of those admitted to Nightingale hospitals were over 65. They were created as an insurance policy which NHS England hoped never to use. However, London and Manchester took patients in wave one, Harrogate and Exeter have been used for diagnostics since they were opened and three Nightingales in the North are now preparing to take patients in wave two should it be needed.

The NHS operates a freedom to speak up policy to protect NHS staff who want to speak out. It states:

“Speaking up about any concern you have at work is really important. In fact, it’s vital because it will help us to keep improving our services for all patients and the working environment for our staff. You may feel worried about raising a concern, and we understand this. But please don’t be put off. In accordance with our duty of candour, our senior leaders and entire board are committed to an open and honest culture. We will look into what you say and you will always have access to the support you need.”

In addition to this a letter sent to Chief executives of all NHS trusts and foundation trusts, CCG Accountable Officers, GP practices, Primary Care Networks Providers of community health services and NHS 111 providers and copied to NHS Regional Directors, Chairs of ICSs and STPs Chairs of NHS trusts, foundation trusts and CCG governing bodies, local authority chief executives, directors of adult social care and Chairs of Local Resilience Forums on April 29 stated:

“Now more than ever a safety and learning culture is vital. All our staff should feel able to raise concerns safely. Local Freedom to Speak Up Guardians are able to provide guidance and support with this for any concerned member of staff. As we know, diverse and inclusive teams make better decisions, including in the Covid19 response.”

Responses from individual NHS provider and commissioner organisations cited by the Sunday Times.

Case study one: Raymond Austin, who was in the care of East Surrey hospital.

Dr. Ed Cetti, Medical Director, Surrey and Sussex NHS Healthcare Trust recently said:

“We offer our heartfelt condolences to Mr Austin’s family for their loss. At no point was there any delay to Mr Austin’s care or was he denied the care he needed. No patient in our care is ever forced to accept a DNACPR order and this has been the case throughout the pandemic. We twice confirmed with Mr Austin his personal DNACPR decision.”

Background points responding to journalist questions:

• Chaldon Ward is a dedicated ward for patients over the age of 75 and is led by specialists in elderly medicine. It provides acute care including the provision of high flow oxygen.
• There were high temperatures on the ward as a result of guidance that restricted the use of fans and open windows for infection control purposes.
• Nursing records show that food and drink was regularly provided and that the patient’s appetite fluctuated however we have acknowledged and apologised to Mr Austin’s family for the times when his drink was out of reach.
• Many factors inform whether a patient would benefit from intensive care admission, high flow nasal oxygen treatment or non-invasive ventilation. These include prognosis from the acute illness, frailty and other underlying medical conditions. In this patient’s case, it was agreed that Mr Austin would benefit from high flow oxygen, delivered via a mask on a medical ward and he was provided with this alongside other medical treatments.
• Patients who have capacity to make their own decisions about their care, including decisions around resuscitation or intensive care admission, do so together with their clinical team’s advice and support. We understand that these decisions can be difficult and upsetting for families. Mr Austin had capacity to make the decision with his clinical team.
• To respond to the pandemic the trust quadrupled its critical care capacity to care for COVID patients and this would have been available to Mr Austin if clinically appropriate.
• There were plans in place across the South East and London to use available intensive care capacity if needed. This included access to the London Nightingale Hospital if necessary.
• Mr Austin was provided with high flow oxygen without delay and this was increased in line with his clinical need.

Case study two: Betty Grove, 78, who was in the care of Whipps Cross Hospital, and subsequently the Barts Health Rapid Response Team.

Dr Heather Noble, medical director of Whipps Cross Hospital, recently said:

“We extend our deepest sympathies to Betty Grove’s family at this difficult time. We are working closely with them, and are carefully looking into all aspects of the care Mrs Grove received.

“However, throughout the pandemic we continued to treat all our patients according to their clinical need, and following our normal medical procedures and practices.”

Background

• The care Mrs Grove received is being reviewed as is usual following a complaint.
• Since the pandemic began the hospital has successfully treated and discharged 112 Covid-19 patients aged 90+

Case study three: treatment offered during the pandemic by Buckinghamshire Integrated Care Partnership.

A spokesperson for Buckinghamshire Integrated Care Partnership recently said:

“Every patient who needed admission to Buckinghamshire Healthcare Trust was admitted, and those who required critical care received it, with more than half aged over 70.

“Throughout the first wave of COVID-19 we had sufficient capacity to care for patients admitted to hospital, including critical care and over a four month period, March to June, 275 patients were admitted with COVID – with over 50 per cent of these aged over 70 years old.”

Background points

• Patients are always assessed by clinicians to determine the most appropriate treatment and care for them and this has remained the case for all patients in Buckinghamshire during the pandemic.
• The purpose of these assessments is to offer patients and their family’s choices about their care, and together in agreement, identify the most appropriate care package for them which doesn’t always include hospital admission.
• The framework was developed to ensure processes were in place during the first wave of the pandemic, if presented with large patient numbers and at full capacity, and that point was never reached.

Case study four: care offered during the pandemic by NHS Sutton Clinical Commissioning Group.

Dr Dino Pardhanani, local GP and GP lead for Sutton recently said:

“Supporting patients to talk about their wishes for how they are cared for if they become unwell is long established best practice and the Covid-19 outbreak did not change that.

“All planning, including what treatments someone does or does not want or whether or not they want to go to hospital, especially at the end of life, is always done in consultation with the patient and their family.”

Background

• Covid-19 has not changed the long established best practice around decisions and planning on treatment and care. All planning, especially around the end of life, is done in consultation with the patient and their family.
• National guidance is available on the NHSE/I website, as you can see the document covers guidance on all operational procedures and as mentioned on the phone it is regularly updated, so you need to talk to NHSE/I directly about the content – https://www.england.nhs.uk/coronavirus/primary-care/general-practice/.
• There is also a relevant letter to the system which is available here – https://www.england.nhs.uk/coronavirus/publication/maintaining-standards-pressurised-circumstances/
• Supporting patients to talk about their wishes and what matters most to them and how they are cared for if they become unwell is standard and a voluntary process
• Advance care plans provide direction to healthcare professionals when a person is not in a position to make and/or communicate their own healthcare choices.
• This has shown to be particularly important in COVID, when dying patients may be at risk of being separated from their loved ones in hospital.