Covid rationing plan advises doctors at major NHS hospital to pick which severely-ill patients to save by ‘lottery’ or based on ‘how much they contribute to society’
- Protocol calls for patients to be prioritised based on contriubutions to society
- For those who can’t be separated in other ways, medics told use ‘random lottery’
- Guidance drawn up by specialists at trust in Bath in absence of national protocol
Doctors may have to decide which severely ill patients to treat based on a ‘lottery’ if the NHS is overwhelmed this winter under draft Covid rationing plans.
The guidance also advises medics look at patients’ potential to contribute to society or their likelihood of surviving the treatment as a way to prioritise whose lives should be saved.
The protocol says that for patients who are in similar health and cannot be separated in other ways, a ‘random allocation, such as a lottery, may be used’.
The document, published in the Journal for Medical Ethics in November, was drawn up by experts at a major NHS Trust in Bath in an attempt to come up with a system for rationing care in the event there are not enough resources to treat everyone.
It being widely circulated among NHS specialists, according to the Telegraph, as some trusts struggle to deal with a tsunami of coronavirus patients with the new, highly infectious strain of the disease.
Medical, legal and palliative care specialists at the Royal United Hospital Bath NHS Trust (RUHBT), who drafted the protocol, stressed the health service has not yet reached the tipping point at which care needs to be rationed.
But two-thirds of trusts in England are now treating more Covid patients than they were in April, and on Monday the Chief Medical Officers from the four home nations raised the national alert level to number five, meaning there is ‘a material risk of the NHS in several areas being overwhelmed over the next 21 days’. It forced Boris Johnson into putting the country in its third national lockdown on Monday.
Dr Kevin Fong, consultant anaesthetist and national clinical adviser to NHS England’s emergency response team for Covid, who was not involved in the protocol, said today he had ‘never seen anything like’ the levels of patients currently in hospitals.
Professor Tim Cook, a consultant in anaesthesia and intensive care medicine at RUHBT who helped come up with the protocol, told the Telegraph it was intended to be used as a ‘practical guide’ for doctors working at speed in overcrowded Covid wards and ICUS in the event they run out of resources. He stressed it was a draft protocol and was not to be taken as policy.
The authors say they were forced to come up with the protocol due to a lack of national guidance from the Department of Health or NHS England.
There were disputed claims the NHS was rationing beds and denying older coronavirus patients intensive care treatment during the height of the first wave of the pandemic, even though hospitals were not pushed to the brink in the spring.
Doctors may have to decide which severely ill patients to treat based on a ‘lottery’ if the NHS is overwhelmed this winter under draft Covid rationing plans drawn up by experts at a major NHS Trust in Bath
The guidance also advises medics look at patients’ potential to contribute to society or their likelihood of surviving the treatment as a way to prioritise whose lives should be saved (file)
Dr Kevin Fong, consultant anaesthetist and national clinical adviser to NHS England’s emergency response team for Covid, who was not involved in the protocol, said today he had ‘never seen anything like’ the levels of patients currently in hospitals
‘This document is explicitly and only for use in times of inadequate resource, during which we need to change approach, and need a strong ethical framework in order to make fair decisions’, says the protocol.
‘When resources are sufficient, decisions are based solely on what is best for each individual patient.
‘When resources are insufficient, decisions need to include a broader view on what is ethically fair for the wider community (society).
‘This means factors such as fairness to others are included in decision-making’.
It adds: ‘The protocol aims to enable structured, explicit, transparent decision-making in a situation we all hope will never arise.
‘This document has been produced locally as there is no explicit national guidance’, says the document.’
A spokesperson for Royal United Hospital Bath NHS Foundation Trust described the draft protocol as a ‘research document for the purposes of discussion’.
It was not ‘trust policy and as such there is no related protocol at the RUH’, they told the Telegraph.
Almost two thirds of hospitals in England had more Covid-19 patients at the end of December than they did on April 12, which was the worst day for England as a whole during the first wave.
The worst-affected hospitals now are mostly in the South of England, but NHS trusts in the North experienced similar spikes in patients at the start of the second wave in the autumn.
Hospital trusts listed below had the biggest difference between total patient numbers in April and December, measured in raw numbers not adjusted for hospital size.
Hospital trust name
Covid patients on April 12, 2020
Covid patients on Dec 29, 2020
Mid/South Essex
East Kent
Maidstone
Portsmouth
East Sussex
Barking, Havering
Frimley Health
North Midlands
Dartford
Hull University
374
143
85
130
68
171
276
134
79
44
785
415
299
342
257
356
453
304
241
191
The protocol says a ‘four-stage process’ should be followed to decide who should get treatment in the event the NHS is overwhelmed.
Doctors are advised to carry out a health assessment which takes into consideration the patient’s survival chances and whether they have underlying health conditions, including if they are an alcoholic.
They are then told the speak with the patient and their family to get consent about their treatment path.
The document says medics must then consider ‘ethical factors’ with the aim being to ‘save more lives and more years of life’. It adds that for patients who are in similar health, a ‘random allocation, such as a lottery, may be used.’
‘Other ethical considerations are more complex and opinions differ considerably. Some judge that an individual’s potential to contribute to maintenance of the critical infrastructure throughout the epidemic may be considered in determining priority for allocation of ICU care.
‘Others have proposed that people who participate in research to improve treatments or vaccines during an epidemic should be given some priority for treatment’.
A final check is then to be carried out by a senior clinician not directly involved in the patient’s treatment.
There were disputed claims the NHS was rationing beds and denying older coronavirus patients intensive care treatment during the height of the Covid-19 pandemic, even though hospitals were not pushed to the brink in the spring.
Those aged over 80, and some over 60s, were not given potentially life-saving treatment because health officials were concerned the NHS would be overwhelmed, according to reports.
It is claimed documents called a ‘triage tool’, drawn up at the request of England’s chief medical officer Professor Chris Whitty, were used in preventing elderly Covid-19 patients from receiving ventilation in intensive care.
As part of an investigation, the Sunday Times says the tool was used to create a ‘score’ for patients based on their age, frailty, and illness.
Under the original system, over-80s were automatically excluded from ICU treatment due to their age. Even over-60s considered frail and with pre-existing health conditions, such as heart disease, could have been over the intensive care threshold.
The tool was never formally published, nor was it official NHS policy. But the newspaper, which carries claims by doctors who say the tool was used in their hospitals, said the documents were widely circulated among health care professionals.
Earlier this year NHS chiefs hit back at the accusations and said they were false, while ‘deeply offensive to NHS doctors, nurses and paramedics’.
Officials say that while early work on an intensive care national ‘triage tool’ did take place, it was ‘not completed’ and never issued.
Graph shows the NHS hospital trusts that have the highest number of Covid-19 patients now compared to in April, with many hospitals seeing three or even four times as many people with the disease than they did at the height of the first wave
Meanwhile, Dr Fong told BBC Radio 4’s Today programme the third national lockdown gave the NHS a fighting chance of not being overwhelmed this winter.
Cancer crisis hits hospitals: Fears for patients and heart victims as doctors are forced to axe urgent surgery amid Covid-19 surge
Urgent cancer surgery is being cancelled as hospitals do not have space for non-Covid patients.
Soaring admissions mean bosses in London and Kent say they had no choice but to take the drastic step so they can deal with emergency virus cases.
In London, where hospitals are close to being overwhelmed, surgical theatres and recovery wards usually be used for operations have been turned into Covid wards.
Doctors fear heart attack and stroke patients could also become collateral victims of the new lockdown, with a huge fall in the number of non-virus patients attending A&E. The first lockdown was blamed for tens of thousands of excess non-Covid deaths.
The NHS had pledged to keep cancer treatment going throughout the winter but patients have had operations cancelled at the last minute.
Surgery would require an intensive care bed for the patient to recover in – but in many hospitals all ICU beds are taken up treating Covid. Operations classed as Priority Two – deemed so urgent they must be done within 28 days – have been called off at hospitals including King’s College London. It said: ‘A small number of cancer patients due to be operated on this week have had their surgery postponed, with patients being kept under close review by senior doctors.
‘Due to the large increase in patients being admitted with Covid-19, including those requiring intensive care, we have taken the difficult decision to postpone all elective procedures, with the exception of cases where a delay would cause immediate harm.’
Any delay to cancer surgery risks the tumour growing and the disease spreading, reducing survival chances.
The Health Service Journal reported that cancellations were ‘rife’ across London, with almost all non-emergency surgery scrapped.
Thousands of elective operations, such as knee and hip replacements, had already been called off. Professor Neil Mortensen, president of the Royal College of Surgeons, told Times Radio: ‘Over the weekend we talked about a slow-motion car crash, but I think it’s getting much worse than that now.
‘My colleagues in London report that there are problems with staff numbers on the wards, staff numbers in theatres.’
Sara Bainbridge, head of policy at Macmillan Cancer Support, said: “We still must make sure that cancer doesn’t become “the forgotten C”. It is imperative that people expecting tests and treatment face minimal disruption.’
Kruti Shrotri, Cancer Research UK’s head of policy, said: ‘It’s extremely concerning to hear that cancer surgery is being delayed in some parts of the country, and this shows just how much the NHS is struggling to cope. We know NHS staff are doing everything they can. We’re doing all we can to support the NHS to protect cancer services.
‘Anyone who thinks they might have signs or symptoms of cancer, please go and see your GP – the NHS is still open to see you.’ Meanwhile, Royal College of Emergency Medicine vice president Dr Adrian Boyle said attendances at A&E by non-virus patients has fallen by up to 30 per cent.
‘We worry about the missing patients,’ he said. ‘People with heart attacks and strokes can be too scared to come to hospital. People are coming more severely ill because they have waited too long to get help. We want to get the message out that if you do go to hospital we will do everything we can to look after you.’ He warned that the surge in Covid patients is having a knock-on impact, with trolley waits in A&E at their worst level for a decade.
Professor Ravi Mahajan, the president of the Royal College of Anaesthetists, said: ‘If we do not take decisive action to tackle this virus now, we will see increasing waiting lists which may take years to get under control.’
A spokesman for NHS England said: ‘Trusts continue to treat as many elective patients as possible, and are prioritising those who have been waiting the longest, whilst maintaining cancer and urgent treatments. Howev
He said: ‘I think what we’ve got coming up now are the most dangerous four to six weeks of the whole pandemic and we need this last push to get us through, and we need everybody’s help… to help choke off the supply of these cases coming through.
‘We need the public to help us, we’re out there to help you. We need you to help us.’
He said ‘the whole country is busy at the moment – don’t let anyone tell you otherwise, we’re running super hot.’
‘I think my colleagues in intensive care are out at full stretch, they have been for some time now, and this is as hard as I’ve ever seen the teams work.
‘We are grateful that the lockdown has come. It gives us a fighting chance, but I have never seen anything like it.
‘We have been working flat out across Christmas doing everything we can to address the surge in cases of Covid-19.’
He said ‘staffing is a problem because of isolation – people having to go into isolation because of contacts – people being sick themselves, and just the staff being exhausted really’.
He added: ‘So yes, all of these pressures are building up in the system.
It comes as MailOnline’s analysis of NHS figures showed two thirds of hospitals in England currently have more Covid patients than they did on the country’s worst day in April last year when the pandemic first exploded.
There were a record 26,000 infected patients in hospital beds across England on January 2, the most recent day data is available for, and doctors warn admissions are still accelerating as the second wave rages on.
On Monday London reported 828 new coronavirus patients were admitted to hospital on January 2, in the highest daily toll for nine months and close to the record of 883 back in March.
And analysis of official statistics shows some hospitals in hard-hit areas such as Kent and East Sussex are seeing up to three times as many coronavirus patients as they did on April 12, the point of the first wave at which patient numbers were highest.
NHS staff from across the country say caring for surging numbers of people is becoming more and more difficult, with one London hospital last week declaring it was in ‘disaster’ mode.
One doctor said medics in some badly hit areas are already having to decide how to ration ventilators for intensive care patients and face ‘horrifying’ choices at work.
Chief of healthcare union NHS Providers, Chris Hopson, said the spike in Covid inpatients since Christmas alone was enough to fill 18 hospitals.
And the Royal College of Surgeons’s president, Professor Neil Mortensen, warned that patient numbers are now so high that cancer operations may have to be sidelined again.
There was chaos in spring when non-urgent ops were cancelled and the NHS is now fighting its way through a backlog of thousands.
NHS England statistics show that, in the most recent data from December 29, 81 out of 127 major hospital trusts had more Covid patients than on April 12.
Many of the worst affected are in the South East and London, where the new fast-spreading variant of the virus has taken hold, with those regions now making up a majority of the daily positive tests being reported.
Hospitals in the North West, which endured the full force of the second wave earlier in the autumn, have now seen patient numbers drop to more manageable levels. The new strain of the virus is not yet spreading as widely in the North of the country.
NHS figures show that on the worst day in the first wave, April 12, there were 18,974 people with Covid-19 in England’s hospitals.
On December 29 this was 21,787. It has since spiralled to 26,626 but hospital-by-hospital data is not yet available for the extra 5,000 patients.
December’s data shows that London has the greatest number of Covid patients in hospital – in part because it has the biggest population – but there have been far sharper rises in the South East and the East of England.
In the East of the country, inpatient numbers are 74 per cent higher than they were in the spring, with 2,922 patients on December 29 compared to 1,679 on April 12.
There were 62 per cent more in the South East – 3,796 compared to 2,342.
In London, the Midlands and the South West, there were between eight and nine per cent more patients at the end of December than at the country’s peak in April.
But the North East, North West and Yorkshire all now have fewer inpatients than they did nine months ago.
Many hospitals in the North, however, experienced the same spiralling pressures now being seen in the South at the start of the first wave in September, October and November, when cases were still low in other parts of the country.
Mid and South Essex NHS trust, which runs hospitals in Southend, Basildon and Chelmsford, is one of the ones to have seen the biggest spike in patients during the second wave. On December 29 it had 785 people on wards with Covid-19, which was 411 more than double the 374 on April 12, England’s peak.
East Kent Hospitals has seen admissions almost three times as high, with 415 patients compared to 143, while the Maidstone and Tunbridge Wells trust had 3.5 times as many patients in December: 299 compared to 85.
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