NHS in crisis – abdication of leadership

In 2017, NHS England submitted one of the most significant documents in its history to the Chief Medical Officer – the NHS Surge and Population Triage briefing paper.

Population Triage – what’s the big deal?

Why was this document so important? Following Exercise Cygnus, Dame Sally Davies – the former CMO – had realised that NHS capacity, after years of depletion and bed closures by successive governments, would be easily overwhelmed by a major pandemic, and that a plan was needed to decide what would happen when very sick patients vastly outnumbered NHS resources. 'Dame Sally Davies realised NHS capacity would be easily overwhelmed by a major pandemic, and a plan was needed to decide what would happen when very sick patients vastly outnumbered NHS resources.' Click To Tweet

Some argue that the NHS makes choices about what and who to treat all the time. This is an incorrect argument. Population triage is not “normal” for the NHS, it isn’t the same as the NHS denying a treatment which is ineffective or too costly. Population triage is where the NHS denies an intervention which could easily save a patient’s life at no great cost, because its “surge” capacity has been degraded to the point where it cannot withstand any significant excess in demand. 

We already know from recent research carried out at University College London that increasing ICU bed occupancy to above 85% results in significantly increased mortality, but population triage raises the question: What happens when ICU bed occupancy hits 100%? 'We already know that increasing ICU bed occupancy above 85% results in significantly increased mortality, but population triage asks the question: What happens when ICU occupancy hits 100%?' Click To Tweet

An ethical and legal minefield for healthcare professionals

Clearly the Population Triage document of 2017 had enormous ethical implications for NHS healthcare professionals. We have been trained to promote equality by providing high quality care for all, but population triage capsizes the normal ethical framework which guides NHS practice. 

For instance, what will doctors do when a patient with 60% chance of survival occupies a ventilator, if all ventilators in a unit are taken and that ventilator is urgently required by three patients with 80% survival? Will we withdraw life-saving care from a patient who could reasonably be saved? Will we hold a lottery to decide which of the three patients then occupies the ventilator? What will the ethical implications and legal consequences of such decisions be?

We know that NHS England’s Emergency Preparedness, Resilience & Response team met with the BMA Ethics Committee in December 2016 and discussed these important questions. 

The results of these secret discussions were never shared with the fee-paying members of the BMA – doctors who would have to deal with the clinical consequences of an overwhelming pandemic – even after a series of novel viruses (SARS, MERS, H1N1, Ebola) had emerged over the last 20 years, and even though the BMA knew that a pandemic was listed as our most likely civil emergency.
'NHS England met with the BMA Ethics Committee in December 2016 to discuss population triage. These secret discussions were never shared with BMA members – doctors who would have to deal with the clinical consequences of an overwhelming pandemic.' Click To Tweet

Playing politics during a national healthcare emergency

However, if the BMA’s involvement in the population triage protocol raises questions, what can we say about the conduct of NHS England and the Department of Health? The guideline for the most serious and most likely threat to the NHS was disgracefully kept secret from the people who fund the NHS – the British taxpayer. There was no excuse for this secrecy. Even the Government’s own guidelines on civil emergencies reads “research shows that the public have an appetite for information and are more likely to be alarmed if they feel that they have insufficient information“. 

The decision to keep the Population Triage document under wraps, like the decision to keep the findings of Exercise Cygnus secret, had no rationale based on the public good. It simply covered up the systematic degradation of our national healthcare infrastructure, for instance obscuring the fact that we had less than one third intensive care capacity as compared to Germany.

'The decision to keep the Population Triage document and the findings of Exercise Cygnus under wraps had no rationale based on the public good. It simply covered up the systematic degradation of our national healthcare infrastructure.' Click To Tweet

An abdication of leadership

In the absence of national leadership, it has fallen to small groups of experts to propose their own triage protocols. For instance, a group from the Royal United Hospital Bath NHS Trust have published a structured process of fair allocation of critical care resources in the setting of insufficient capacity. This is an intelligent and well-intentioned effort to address a pressing need, but it is not even official policy for Bath NHS Trust, and it cannot replace the need for a national framework to address the pandemic. 

For instance, the team at Bath NHS Trust cannot re-allocate intensivists or ventilators or PPE supplies or vaccines from regions of low COVID prevalence to regions of high COVID prevalence, nor can they redraw ethical and legal frameworks. It is worth noting that only one of the authors of this BMJ paper appears to have legal training. The Lancet has recently published a proposal for “triage committees” to provide hospital policies which integrate egalitarian and utilitarian principles. The Lancet paper again appears to be dominated by clinicians, but Population Triage is not only a clinical question: it raises fundamental questions of ethics and economics. 'In the absence of national leadership, it has fallen to small groups of clinicians to propose their own triage protocols… but Population Triage is not only a clinical question: it raises fundamental questions of ethics and economics.' Click To Tweet

Essentially, this represents a colossal abdication of leadership at the top of both the Department of Health and NHS England. The Nuffield Council of Bioethics has called for a national policy and offers some useful imperatives: the policy needs to be coordinated, communicated clearly to healthcare professionals and the public, authoritative, clear and definitive, robust, transparent, consistent across the healthcare service, and triage decisions should be seen to be both fair and credible. 

Perhaps the most incomprehensible aspect of this act of self-inflicted national incompetence is that Exercise Cygnus identified a need for a triage policy, the Government has asserted that it has taken forward actions on all of Cygnus’s 22 recommendations, we have documented evidence that a policy was submitted to the Chief Medical Officer in 2017, but our political leaders lack the courage to admit to that policy’s existence. 'This represents a colossal abdication of leadership at the Department of Health and NHS England. A policy was submitted to the Chief Medical Officer in 2017 but our political leaders lack the courage to admit even to its existence.' Click To Tweet

The consequences of secrecy

Jeremy Bentham once said, “Secrecy, being an instrument of conspiracy, ought never to be the system of a regular government”. The trouble with concealment built on political cowardice is that it inexorably leads down a road of deception upon deception. First the findings of Exercise Cygnus were kept secret. The Population Triage document which followed then had to be concealed. Then even when it became clear that a major pandemic had spread to British shores, a decision was made to deprive healthcare professionals of data from a national exercise which had been carried out precisely to prepare the UK’s emergency pandemic response. 

Even today the Department of Health has “declined to respond” to calls for national guidance, as has NHS England. Inevitably the Government cannot free itself from the shackles of secrecy it has locked itself into, as we see close to 10,000 COVID deaths in one week and NHS intensivists facing triage decisions in the complete absence of national leadership.  Just as the Dossiers on WMD in Iraq irreparably damaged the reputation of the last government, so the Cygnus Reports will lay bare this government’s abdication of leadership. 'Just as the Iraq Dossiers irreparably damaged the reputation of the last government, so the Cygnus Reports – when revealed in full – will lay bare the abdication of leadership by this government.' Click To Tweet

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