Stresses and strains

Was the government too complacent?

The outbreak of Covid-19 will go undoubtedly down as one of the most traumatic social and economic upheavals of our time. At the time of writing, more than 200,000 people worldwide are recorded as having died and the true figure is undoubtedly higher. More will undoubtedly succumb. But as tragically high as these figures are, it is possible to imagine a far worse pandemic. A typical pandemic would be expected to strike more evenly across the age spectrum than Covid-19 which has predominantly impacted on those aged over 50. You do not have to be a virologist to imagine an even more terrifying disease which is more virulent and infectious than Covid-19. Indeed, the threat of such a pandemic is one of the natural disasters which form a key element in national disaster planning across the world.

Fortunately, such outbreaks are rare but precisely because of that it is so easy to become complacent about the risks which they pose. However, in what now seems like propitious timing, a year before we had even heard of Covid-19, a group of epidemiologists conducted a study to assess the preparedness of global health systems in the event of a global epidemic. They constructed an Epidemic Preparedness Index (EPI) covering 188 countries and based on five key metrics:  overall economic resources; public health communications; infrastructure; public health systems and institutional capacity. According to the authors, “the most prepared countries were concentrated in Europe and North America, while the least prepared countries clustered in Central and West Africa and Southeast Asia.”

All countries have expressed concerns that the outbreak of the disease would overwhelm their health systems, which is why they have imposed a lockdown to spread out the incidence of infections. Health experts are unanimous in their belief that containment and mitigation strategies are the first line of defence to combat a pandemic. Italy was one of the first countries, aside from China, to implement a lockdown on 9 March. At that time it had recorded 7,375 cases and 366 deaths. As of today, it has recorded 197,675 cases and 26,644 fatalities. The UK imposed a lockdown two weeks later than Italy, on 23 March, at which time it had recorded 5,683 cases and 281 fatalities. Almost five weeks later it has recorded 148,377 cases and 20,319 fatalities.

The debate in the UK focuses very heavily on the fact that the government was too late in implementing the lockdown and that it should have learned from the Italian experience. By the time it adopted this strategy, when its figures were similar to those in Italy two weeks previously, it was already too late and the path of the disease was effectively predetermined. There certainly does appear to be a lot of evidence to suggest the British government was reluctant to take such a dramatic measure although others suggest that the scientific advisers were slow to respond.

Either way it appears that the delay in implementing the lockdown played a role in allowing Covid-19 to become more widespread than it need have been although it is easy to be wise after the event. Indeed when Germany implemented a lockdown on 23 March, it had recorded 24,774 cases (more than either the UK or Italy at the same stage) but just 94 fatalities. It is thus likely that future research will concude that some governments were too slow to deploy their first line of defence. But this is not the whole story.

Or is it the lack of spending?

National health systems act as the second line of defence, offering options ranging from testing to intensive care. At this point the degree of funding provided to the health system really starts to come into its own. According to data compiled by the OECD, the UK had fewer medical staff per 1000 of population than many other European nations (see chart below). Although the proportion of doctors is below the OECD average, it is not too far out of line with other EU countries. But the number of nursing staff is somewhat lower. This might partially explain, for example, why the UK has been so slow in rolling out mass testing. To the extent that a shortage of trained medical staff at a time of emergency puts pressure on existing staff as overstretched resources are stretched more thinly, there is some evidence to suggest that funding constraints over the last decade have added to the strains facing the British NHS in recent weeks. Indeed, despite making great play of the fact that a number of temporary hospitals have been opened to add additional capacity to the health system, there have been complaints that there are simply not enough trained staff to provide the requisite services.

I have noted the strains on various parts of the public sector on numerous occasions in recent years and have pointed out the issues facing NHS funding (here, for example). In theory, of course, the NHS was protected from the worst of the austerity but there was still a slowdown in the rate of funding which meant that the supply of health care has not kept pace with demand. In terms of what the service offers, it can be regarded as efficient in an international context. For example, the NHS operates its critical care facilities with an 84% utilisation rate (higher than all other OECD countries bar Ireland, Israel and Canada, see chart below). But this also means that there is limited spare capacity to cope with emergencies. When it comes to the overall capacity of the system, the UK also has fewer intensive care beds per head of population than the OECD average.  

It is hard to avoid the conclusion that the NHS entered the Covid-19 crisis with the bare minimum of resources. For anyone who doubts the strains that the medical profession operate under in normal times, I highly recommend the book by former doctor Adam Kay, This is Going to Hurt, which is a litany of the humorous, bizarre and tragic circumstances routinely encountered by the medical profession. Anecdotal evidence gathered from my own discussions with medical personnel in recent years suggests that the strains intensified during the worst of the government’s austerity programme.

On the basis that demand for health services is infinite, some serious questions will have to be asked once the crisis is over as to what we require of health services in future and how we expect to pay for  them. It is pretty certain that no government will be able to deny funds to the NHS in the near future. Therefore, either spending in non-health related areas will have to be cut or taxes will have to rise. I even suggested a couple of years ago that a hypothecated tax to fund health spending might be something we need to consider. Whatever options we finally choose, the public will accept nothing less than a new deal for the NHS. The era of austerity is over although the question of how to pay for it all will be the subject of future posts.