2. Ensuring sufficient physical infrastructure and workforce capacity
ENSURING SUFFICIENT PHYSICAL INFRASTRUCTURE AND WORKFORCE CAPACITY is crucial for dealing with the COVID-19 outbreak, as there may be both a surge in demand and a decreased availability of health workers. The section considers the physical infrastructure available in a country and where there are shortages, it describes any measures being implemented or planned to address them. It also considers the health workforce, including what countries are doing to maintain or enhance capacity, the responsibilities and skill-mix of the workforce, and any initiatives to train or otherwise support health workers.
2.1 Physical infrastructure
Initially tests for COVID-19 were usually organised by emergency care, but this soon became unsustainable and isolation became more challenging. All swabs were processed in one laboratory and separate forms were required from different stakeholders to authorise testing, which increased reporting errors. The swabs used for the COVID-19 tests are the same as for flu and while test kits were initially in fruitful supply, was a global shortage of both reagent and swabs for some time. Lab testing has been under strain, with initial waits of up to 3-4 days for results, though this has improved in some places. There is also an expected strain on other allied health care resources including X-Ray, CT scanning and phlebotomy.
Following chronic underfunding and a period of austerity, general acute hospital bed capacity has fallen in the last 20 years in the UK. Prior to the COVID-19 pandemic, hospitals frequently ran at 92% occupancy and often over 95% occupancy in winter, which is well over the capacity deemed to be safe (https://www.kingsfund.org.uk/publications/nhs-hospital-bed-numbers).
To create extra capacity, the NHS planned to free up 30,000 English NHS beds and 100,000 general and acute beds, discharging many patients to care homes where possible. This has now received considerable criticism as many believe that this seeded the virus into care homes. This is particularly important because most patients were not tested and early guidance did not advise isolation of these residents unless they developed symptoms. Testing is now mandatory on discharge to a care home but this is still reported by some homes to be quite patchy. Hospital bed shortages were predicted but did not generally cause widespread disruption.ICU beds in the UK usually run at >80% capacity and there were <5,000 critical care beds at the start of the crisis. There was expected to be an imminent shortage and some hospitals in London and other major cities are under extreme pressure already. In response, several new temporary hospitals were built in several major cities to provide surge ITU capacity where demand was most likely to be required. The London Nightingale hospital has been operational since the first week of April, with capacity to treat 4,000 patients, with 500 beds equipped with ventilators and oxygen. Strict admission criteria preclude high numbers of admissions to Nightingale, which is not running at capacity. In fact for the duration of the crisis, most of these units have been run at extremely low bed occupancy. The Intensive Care National Audit and Research Centre estimates that as of 15th May2020, there had been 8,699 cases admitted to 252 critical care units and 5,109 were mechanically ventilated within the first 24 hours. Currently, there is no centralised IT system for shared electronic health records in the UK and data on the % patients who are hospitalised for COVID-19 and are subsequently discharged is unknown.
Personal Protective Equipment:
There is a global shortage of personal protective equipment (PPE) as China has slowed exports of this equipment since the epidemic began.
Local hospital stocks of PPE ran low after the initial stages of the outbreak during which full PPE was used during testing. Some individual trusts reported shortages of PPE (acknowledged by the Chief Medical Officer in 19th March 2020 press briefing), particularly equipment that was not previously in common use including goggles, FFP3 masks, respirators and hoods. Many trusts report having to use different brands of FFP3 masks, which with the legal requirement to fit-test each brand of mask for each user presenting many challenges.
Until the 17th April, the Department for Health and Social Care stated that there was currently sufficient stock of PPE in the UK. In March 2020, the government mobilised the national pandemic influenza stockpile and recruited the army to distribute it to health and social care providers. The government announced that there was a national shortage of surgical gowns on 17th April and advised that gowns could now be reused in certain instances. Some of the influenza stockpile was also sold to mainstream suppliers to maintain the supply chain for social care and facilitate access and local resilience forums in local councils are now trying to support care homes to access PPE where they are unable to, with varying success. The NHS has also announced that it will roll out an automated data-driven PPE distribution service that will calculate the amount of PPE required in each setting and deliver it automatically. This has been promised and awaited for over a month. There is also a dedicated helpline and email address for providers to source emergency PPE.
On the 28th March, the Business Secretary also eased regulations on companies wishing to produce and distribute hand sanitiser and PPE to facilitate and hasten supply to NHS staff (https://www.gov.uk/government/news/regulations-temporarily-suspended-to-fast-track-supplies-of-ppe-to-nhs-staff-and-protect-companies-hit-by-covid-19). Controls have also been imposed to prevent the export of PPE outside of the European Union (https://www.gov.uk/government/publications/personal-protective-equipment-ppe-export-control-process).
Guidance issued by government on 10th April stated that any care workers in both care homes and in delivering home care “who are within two metres of a possible or confirmed Covid-19 patient should wear an apron, gloves, surgical mask and eye protection, based on the risk of transmission” (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/879221/Coronavirus__COVID-19__-_personal_protective_equipment__PPE__plan.pdf). The guidance references current and future PPE provision to social care, coordinated through the CQC and Local Authorities to registered providers in England. Associated PHE guidance sets out appropriate PPE guidance for social care settings, advocating for sessional, rather than only single use of masks and goggles and in subsequent updates staff were advised to wear facemasks during contacts with all residents rather than just those with symptoms, as the UK is experiencing sustained community transmission (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/879111/T4_poster_Recommended_PPE_additional_considerations_of_COVID-19.pdf). However, the guidance did not initially define how the term ‘sessional use’ should be interpreted in the social care environment. The Social Care Action Plan pledged that Public Health England would offer an explanation on how the term ‘sessional use’ should be interpreted and this was finally published on April 17th, using scenarios and FAQs to explain who should take what precautions and in what settings for care homes and for domiciliary care (see: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/881329/COVID-19_How_to_work_safely_in_care_homes.pdf and https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/884165/Domiciliary_guidance_England.pdf)
There have been major challenges in supplying all social care providers with adequate and sufficient PPE in a timely manner. Social care settings do not stock facemasks and googles routinely and few providers had established supply chains in place given that these items are not usually required to deliver most social care. Moreover, very early PHE guidance advised social care providers not to use facemasks, even for residents with suspected COVID-19 and so these organisations did not stockpile. As a result of the sudden increase in demand, many providers experienced shortages in supply and increased costs. Without a centralized system of distribution as exists in the NHS, individual providers have been required to access their own PPE, paying high prices on the market. The Action Plan stated that it had undertaken an ‘emergency drop’ of 7 million items and released 23 million items to wholesalers for onward sale to providers, but many wholesalers maintain that many of these supplies have been requisitioned back to the NHS.
A further challenge in the sector is that few staff have had training in when and how to use PPE so online videos have been released by Public Health England (https://www.gov.uk/government/publications/covid-19-how-to-work-safely-in-care-homes/covid-19-putting-on-and-removing-ppe-a-guide-for-care-homes-video). In England, other training has been developed by workforce support partner Skills for Care and government-funded improvement agency the Social Care Institute for Excellence, which have now been publicised on a new CARE workforce app for ease. At the time of writing, there are still major concerns within the sector about the supply of and access to PPE.
Other Hospital Equipment:
It is expected that there will also be a shortage of hospital equipment including ventilators and extracorporeal membrane oxygenation (ECMO). There have been calls to industry to support the response by repurposing to manufacture ventilators, expanding laboratory capacity, and potentially using hotels as hospital bed space. Guidance on the fast-track approval of non-CE marked medical devices such as ventilators have been issued for the duration of the outbreak.
Pharmaceutical supplies are also expected to be in short supply including oxygen, antivirals, and possibly inotrope medicines. Teams within NHS England have been deployed to ensure the viability of the supply chain.
There has been a shortage of IT infrastructure has also been scaled up to facilitate staff in Public Health England, the Department of Health and Social Care and NHS England to work from home to support the response.